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Little gems: how hot are you on digestion?

Test your knowledge for the nMRCGP with this little GEM from GP Notebook


Question Which of these accompanying clinical features are regarded as alarm symptoms signifying dyspepsia requires urgent review?

•Chronic gastrointestinal bleeding

•Macrocytic anaemia

•Fresh rectal bleeding

•Epigastric mass

•Persistent vomiting

Answer It is advised that urgent referral for endoscopy, or to a specialist, is necessary for patients of any age with dyspepsia and any of the following:

•chronic gastrointestinal bleeding


•progressive unintentional weight loss

•persistent vomiting

•iron deficiency anaemia

•epigastric mass

•suspicious barium meal result.

Also refer urgently for endoscopy patients aged 55 and older with unexplained and persistent recent-onset dyspepsia alone. NICE guidance defines unexplained dyspepsia as 'a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the primary care professional after initial assessment of the history, examination and primary care investigations (if any)'. In the context of this recommendation, the primary care professional should confirm that the dyspepsia is new rather than a recurrent episode and exclude common precipitants of dyspepsia such as ingestion of NSAIDs.

Abdominal pain

Question Left upper quadrant pain may result from various pathologies. What causes should you consider?

Answer Possible causes include:

•gastric ulcer


•acute pancreatitis

•spontaneous splenic rupture

•leaking splenic artery aneurysm

•acute perinephritis

•subphrenic abscess

Question Apart from gastric ulceration, what other pathologies are associated with abdominal pain that is precipitated by food?

Answer Other pathologies include:

•biliary colic, which patients find is most commonly precipitated by fatty foods

•chronic mesenteric ischaemia

•rarely, gastric carcinoma


Question If a mother has had a home delivery and requests a visit for her eight-day-old

baby, what causes should be considered?

Answer Consider the age of the neonate. Causes of early neonatal vomiting


•feeding problems, including overfeeding

•systemic infection

•cerebral anoxia or hypoxia

•subdural haematoma


•renal disease such as urinary tract infection, renal insufficiency

•neonatal intestinal obstruction

Causes of vomiting which are seen from the end of the first week of life, in addition to the above, include:

•hiatus hernia

•necrotising enterocolitis

•congenital adrenal hyperplasia

•inborn metabolic errors

•cow's milk protein intolerance

This fortnightly series is based on GPnotebook Educational Modules (GEMs) The full version is available via GPnotebook Plus, a service free to UK medics at

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