Gastrointestinal history taking requires a systematic approach to ensure you don’t miss anything important. This guide structures the history in parallel with the structure of the GI system, beginning at the mouth and working downwards. Over time you will stop using this approach and only ask a smaller more focused subset of these questions which are relevant to the given presenting complaint, but it takes time to become competent at this, so this is a good starting point. Check out the gastrointestinal OSCE mark scheme here.
Opening the consultation
Introduce yourself – name / role
Confirm patient details – name / DOB
Explain the need to take a history
Ensure the patient is comfortable
It’s important to use open questioning to elicit the patient’s presenting complaint
“So what’s brought you in today?” or ”Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presenting complaint if required
“Ok, so tell me more about that” ”Can you explain what that pain was like?”
History of presenting complaint
The following questions should be asked for each symptom the patient is experiencing.
Onset – when did the symptom start? / was the onset acute or gradual?
Duration – minutes / hours / days / weeks / months / years
Severity – e.g. if symptom is weight loss – how much weight loss?
Course – is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. increasing dietary intake
Associated features – are there other symptoms that appear associated (e.g. fever/malaise)
Previous episodes – has the patient experienced this symptom previously?
Key gastrointestinal symptoms:
- Dysphagia / odynophagia – solids vs liquids
- Nausea / vomiting – triggers/ colour of vomit / haematemesis
- Reduced appetite / weight loss
- Gastroesophageal reflux
- Abdominal pain – SOCRATES
- Abdominal distension
- Altered bowel habit – constipation / diarrhoea / fresh blood / malaena
- Systemic symptoms – jaundice / fever / malaise / fatigue
Upper gastrointestinal tract symptoms
Mouth – Pain / Ulcers / Growths
Dysphagia – Onset / Progression / Solids and/or liquids
Odynophagia – pain on swallowing – oesophageal candidiasis
Progressive dysphagia (difficulty swallowing solids at first, then eventually difficulty with liquids) suggests the presence of a malignant stricture. Especially in elderly patients with associated weight loss and iron deficiency anaemia.
Nausea and vomiting
Frequency and volume – high frequency and volume increases risk of dehydration
Projectile vomiting – obstruction
What does the vomit look like?
- Undigested food – pharyngeal pouch / achalasia / oesophageal stricture
- Non-bilious vomit – pyloric obstruction (i.e. pyloric stenosis)
- Bilious vomit/ faecal matter – lower GI obstruction (i.e. severe constipation)
- Fresh red blood – undigested – acute bleed – Mallory Weiss tear / oesophageal variceal rupture
- Coffee ground – digested – bleeding peptic/ duodenal ulcer
Preceded by forceful retching? – Mallory Weiss tear
How much weight over how long? – always suspect malignancy – especially in the elderly
Decreased appetite – may suggest malignancy, or in younger patients possibly anorexia nervosa
Is pain localised to a specific area of the abdomen?
- Right iliac fossa – appendicitis / Crohn’s disease
- Left iliac fossa – diverticulitis
- Epigastric – gastritis/oesophagitis
- Right upper quadrant – cholecystitis/hepatitis
- Flank – pyelonephritis
- Suprapubic – cystitis
Is the pain intermittent or continuous?
- Intermittent – e.g. renal colic/biliary colic/bowel obstruction
- Continuous – e.g. cystitis/peritonitis
Use SOCRATES to gain more details about the pain.
Common causes of abdominal distension:
- Fat – obesity
- Flatus – paralytic ileus/obstruction
- Faeces – constipation
- Fluid – ascites
- Fetus – pregnancy
Altered bowel habit
Consistency – how formed is it? (Bristol stool chart)
Mucous – Inflammatory bowel disease (IBD) / Irritable bowel syndrome (IBS)
Blood – Fresh red blood (anal fissure/haemorrhoids/IBD). Melaena (upper gastrointestinal bleed)
Recent antibiotics? – C. Difficile
Recent suspect food? – food poisoning
Duration of constipation
Absolute constipation? – not passing flatus – obstruction
Colour of the stool
Black (Melaena) – peptic ulcer / duodenal ulcer / malignancy
Fresh red blood – anal fissure / haemorrhoids / IBD / polyp / lower GI malignancy
Pale (steatorrhoea) – biliary obstruction (gallstones / malignancy)
Yellowing of the skin and sclera
Causes of jaundice:
- Infectious – hepatitis B and C / malaria
- Malignancy – pancreatic cancer / cholangiocarcinoma
- Alcoholic liver disease
- Autoimmune – autoimmune hepatitis / primary sclerosing cholangitis
- Congenital – Gilbert’s syndrome (benign)
If pain is a symptom, clarify the details of the pain using SOCRATES
- Site – where is the pain
- Onset – when did it start? / sudden vs gradual?
- Character – sharp / dull ache / burning
- Radiation – does the pain move anywhere else?
- Associations – other symptoms associated with the pain
- Time course – worsening / improving / fluctuating / time of day dependent
- Exacerbating / Relieving factors – does anything make the pain worse or better?
- Severity – on a scale of 0-10, how severe is the pain?
Ideas, Concerns and Expectations
Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient:
- What you have covered – “Ok, so we’ve talked about your symptoms”
- What you plan to cover next – “Now I’d like to discuss your past medical history”
Past medical history
Gastrointestinal disease – inflammatory bowel disease (IBD) / irritable bowel syndrome / malignancy / gastroesophageal reflux (GORD)
Other medical conditions
Surgical history – e.g. appendectomy / colectomy / c-section
Any recent hospital admissions? – when and why?
Local food? – e.g. salmonella poisoning
Insect bites? – malaria
Contact with dirty water? – campylobacter / shigella / giardia
- Proton pump inhibitors
- H2 receptor antagonists
- Sodium alginate/calcium carbonate e.g. Gaviscon
Regular medications – NSAIDS / Steroids /Bisphosphonates – (Gastroduodenal erosions)
Over the counter drugs – NSAIDS / laxatives
Contraception? – consider gynaecological causes of abdominal pain – ectopic pregnancy / miscarriage
Gastrointestinal disease – malignancy / IBD / GORD
Hereditary bowel conditions – HNPCC / FAP
Other significant medical conditions
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – be specific about type / volume / strength of alcohol
Recreational drug use – IV drug use is a risk factor for hepatitis
Sexual history – important if considering blood-borne viruses – e.g. hepatitis
- Lack of fibre – constipation
- Gluten – coeliac disease
- Fatty foods – may be associated with upper abdominal pain – cholecystitis
- House / flat – stairs / adaptations
- Who lives with the patient? – important when considering discharging home from the hospital
- Any carer input? – what level of care do they receive?
Activities of daily living:
- Is the patient independent and able to fully care for themselves?
- Can they manage self-hygiene/housework/food shopping?
- Is the illness interfering with the patient’s ability to do the above?
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. erythema nodosum in inflammatory bowel disease).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Musculoskeletal – Bone and joint pain / Muscular pain
Dermatology – Rashes / Skin breaks / Ulcers / Lesions
Closing the consultation
Summarise the history