GI History
OSCE Guide
GI histories can present in lots of ways: abdominal pain, vomiting, diarrhoea, constipation, dysphagia, rectal bleeding, weight loss or a change in bowel habit.
What this Station is Testing?
In a GI history station, the examiner wants to see that you can:
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Explore the main symptom clearly
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Work out whether the pattern is upper GI, lower GI, hepatobiliary, obstructive or systemic
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Ask about vomiting, bowel habit, bleeding, weight loss and dysphagia
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Screen for red flags such as melaena, haematemesis, rectal bleeding, jaundice or obstruction symptoms
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Cover relevant PMH, surgery, medication, family history, diet and travel
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Recognise when urgent assessment or further investigation is needed
Explore the Main Symptom
“Can you tell me what has brought you in today?”
If the main symptom is abdominal pain, use SOCRATES:
SITE
- “Where exactly is the pain?”
ONSET
- “When did it start? Was there any injury or trigger?”
CHARACTER
- “What does it feel like — sharp, burning, cramping or dull?”
RADIATION
- “Does it move anywhere else?”
ASSOCIATED SYMPTOMS
- “Any vomiting, diarrhoea, constipation, blood in the stool, black stools, urinary symptoms, fever or weight loss?”
TIMING
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“Is it constant or does it come and go? Is it worse in the morning or at night?”
EXACERBATING AND RELIEVING FACTORS
- “What makes it better or worse? Does eating, fatty food, opening your bowels or antacids affect it?”
SEVERITY
- “On a scale of 0 to 10, how bad is it?”
Also ask about impact:
“Is it stopping you eating, sleeping, working or moving around?”
For symptoms such as vomiting, diarrhoea, constipation, bloating, dysphagia, rectal bleeding or weight loss, use a simple structure:
ONSET
“When did it start?"
PROGRESSION
“Is it getting better, worse or staying the same?”
EXACERBATING & RELIEVING FACTORS
“Is anything triggering it, such as food, stress, antibiotics or travel?”
ASSOCIATED SYMPTOMS
“Are there associated symptoms, such as pain, fever, blood, mucus, weight loss or waking at night to open your bowels?”
If the Main Symptom is not Pain:
Pain Location
Pain Location can help guide your thinking.
Site:
Epigastric
Possible Causes:
Reflux, gastritis, peptic ulcer disease, pancreatitis, atypical MI, AAA
Site:
Left Iliac Fossa
Possible Causes:
Diverticulitis, ulcerative colitis, gynaecological causes
Site:
Right Upper Quadrant
Possible Causes:
Gallstones, cholecystitis, cholangitis, hepatitis
Site:
Flank
Possible Causes:
Renal colic, pyelonephritis, AAA
Pain location does not give you the diagnosis by itself, but it helps you decide what to ask next.
Upper GI Symptoms
Ask about nausea, vomiting, reflux, dyspepsia, dysphagia and haematemesis.
Useful questions include:
“Have you felt sick or vomited?”
“What does the vomit look like?”
“Is there any blood, or does it look like coffee grounds?”
“Do you get heartburn, acid reflux or indigestion?”
“Is the pain related to eating?”
“Have you had any difficulty swallowing?”
“Is that with solids, liquids or both?”
“Is it getting worse over time?”
Progressive dysphagia, haematemesis and coffee-ground vomit are important red flags.
Epigastric pain can also mimic cardiac pain, so consider chest pain, exertional symptoms and cardiovascular risk factors where relevant.
Pain Location
Lower GI Symptoms
Start by asking what is normal for the patient:
“What is normal for your bowels?”
“Has that changed recently?”
Then clarify:
“Are you going more often or less often than usual?”
“What does the stool look like?”
“Any blood, mucus or black stool?”
“Any urgency, accidents or feeling of incomplete emptying?”
“Does it wake you at night?”
“Is it affecting work, sleep or leaving the house?”
For diarrhoea, ask about frequency, duration, stool type, blood, mucus, fever, weight loss, travel, antibiotics and sick contacts.
For constipation, ask about frequency, straining, hard stool, abdominal distension, vomiting and whether they are still passing wind.
For bleeding, clarify whether the blood is bright red or dark, whether it is on the paper, coating the stool or mixed in, and whether there is black, sticky or tar-like stool.
Blood mixed with stool, melaena, change in bowel habit or weight loss should be taken seriously. This could represent GI malignancy, or a GI bleed requiring admission.
Abdominal Distension
Ask whether the abdomen feels swollen or bloated, whether this is constant or comes and goes, and whether the patient is vomiting, opening their bowels or passing wind.
Distension with vomiting and absolute constipation should make you think about bowel obstruction.
RED FLAGS
GI red flags
Important GI red flags include:
Unintentional weight loss, fever or night sweats (Systemic signs of malignancy)
Dysphagia (Oesophageal disease: Achalasia/Stricture/Malignancy)
Persistent vomiting/Haematemesis (Mallory Weiss Tear)
Coffee-ground vomit/Melaena (Upper GI bleed)
Rectal bleeding (Lower GI bleed/Haemorrhoids)
Change in bowel habit (GI malignancy)
Iron deficiency anaemia (GI malignancy)
Abdominal mass/Jaundice (Pancreatic/Biliary/Liver malignancy)
Severe or worsening abdominal pain (Colitis/Bowel Ischaemia/Obstruction)
Abdominal distension with vomiting and not passing stool or wind (Obstruction)
These symptoms do not give you the diagnosis by themselves, but they should make you take the presentation seriously.
Site:
Right Iliac Fossa
Possible Causes:
Appendicitis, Crohn’s disease, renal or gynaecological causes
Site:
Suprapubic
Possible Causes:
UTI, urinary retention, pelvic inflammatory disease, pregnancy-related causes, testicular torsion
Past Medical and Surgical History
Ask about general medical history, then focus on GI conditions.
Relevant conditions include GORD, peptic ulcer disease, gallstones, pancreatitis, inflammatory bowel disease, coeliac disease, diverticular disease, bowel cancer, liver disease and previous bowel obstruction.
Ask about previous abdominal surgery, endoscopy or colonoscopy.
Surgical history is important because previous abdominal surgery can increase the risk of adhesions and bowel obstruction.
Drug History and Allergies
Ask about regular medications, over-the-counter treatments and allergies.
Specifically ask:
“Are you taking anything for the pain?”
“Is it helping?”
Relevant medications include NSAIDs, opioids, steroids, methotrexate, biologics, anticoagulants and recent antibiotics if tendon pain is suspected.
Always clarify allergies and the reaction.
Family History
Ask about family history of bowel cancer, Crohn’s disease, ulcerative colitis or coeliac disease.
If a relative had bowel cancer, ask sensitively about their age at diagnosis.
Social History
GI symptoms can have a big impact on confidence, work and social life.
Ask about:
Smoking/Alcohol/Diet
Recent travel/Sick contacts
Work and daily activities
Ability to leave the house
Impact on sleep, mood and confidence
Useful questions include:
“What would you eat in a typical day?”
“How much fluid do you drink?”
“Have you travelled recently?”
“Has anyone around you had similar symptoms?”
“Is this affecting your work, sleep or ability to leave the house?”
“Do you ever avoid going out because you are worried about needing the toilet?”
Pregnancy and Gynaecological History
In patients where pregnancy is possible, especially with lower abdominal or pelvic pain, ask sensitively:
“Is there any chance you could be pregnant?”
If relevant, ask about periods, contraception, vaginal bleeding and vaginal discharge.
Pregnancy-related causes, including ectopic pregnancy or miscarriage, should always be considered in abdominal or pelvic pain.
OSCE TALK TIP
Female patients with unexplained abdominal pain should always have pregnancy considered, as missing an ectopic pregnancy could be life threatening.
Gynaecological causes such as ovarian cyst/torsion should be considered also
Explore the Patient’s Ideas, Concerns and Expectations.
Example Summary:
“Mr Jones is a 58-year-old man presenting with a six-week history of change in bowel habit, with looser stools and increased frequency compared with his normal baseline. He has noticed intermittent bright red blood mixed with the stool and reports unintentional weight loss of around half a stone. He denies vomiting blood or black stools. He has no previous diagnosis of inflammatory bowel disease, but there is a family history of bowel cancer in his father. Overall, I would be concerned about a lower GI cause for his symptoms, including colorectal cancer, and would want to examine him and arrange appropriate investigations.”
Ask Naturally:
“Had you any thoughts yourself about what might be going on?”
“Is there anything in particular you are worried about?”
“What were you hoping we might be able to do today?”
Patients may be worried about cancer, inflammatory bowel disease, needing surgery or embarrassment around bowel symptoms.
Acknowledge this:
“I can understand why bleeding or a change in your bowels would worry you. We’ll take it seriously and work through what might be causing it.”
GI Patterns to Recognise
Upper GI Bleed:
Think about upper GI bleeding if there is haematemesis, coffee-ground vomit or melaena.
Ask about NSAIDs, aspirin, anticoagulants, alcohol use, liver disease and previous ulcers. These patients can be risk stratified using Glasgow Blatchford Score.
Bowel Obstruction:
Think about obstruction if there is abdominal pain, distension, vomiting and constipation, especially if the patient is not passing wind. This is commonly caused by adhesions, cancer, hernia.These patients need NG Tubes, bowel rest, and sometimes surgical input.
Bowel Cancer:
Bowel cancer becomes more concerning with change in bowel habit, rectal bleeding, blood mixed with stool, weight loss, iron deficiency anaemia, abdominal mass or family history. An MDT of Surgeons/Oncologists will help to guide management.
Inflammatory Bowel Disease:
IBD may present with diarrhoea, blood or mucus, abdominal pain, weight loss, fatigue, mouth ulcers, joint symptoms, eye symptoms or perianal disease. These patients need systemic steroids and input from the GI/Surgical Team.
Gastroenteritis:
Gastroenteritis is more likely with acute diarrhoea, vomiting, fever, sick contacts, recent travel or food exposure. Often IV fluids and electrolyte management will allow these patients to recover.
Pancreatitis:
Pancreatitis may cause severe epigastric pain radiating to the back, nausea and vomiting. Alcohol and gallstones are important risk factors. Admission is required for IV fluids, anti emetics, and some may require ICU/HDU.
Biliary Disease:
Gallstones or cholecystitis may cause right upper quadrant pain, especially after fatty food, with nausea, vomiting or fever. Patients can become septic, require IV antibiotics, MRCP/ERCP, and possible surgical input.
Possible Examiner Questions & Model Answers
Q1: What are your top differential diagnoses?
This depends on the presenting symptom and pain location.
For right iliac fossa pain, consider appendicitis, Crohn’s disease, renal colic and gynaecological causes.
For epigastric pain, consider gastritis, peptic ulcer disease, pancreatitis and atypical MI.
For change in bowel habit with rectal bleeding and weight loss, be concerned about colorectal cancer, while also considering IBD or diverticular disease.
Q3: Why is surgical history important?
Previous abdominal surgery can lead to adhesions, which can cause bowel obstruction.
It becomes especially relevant if the patient has abdominal pain, distension, vomiting and constipation.
Q4: What medications are important in a GI history?
NSAIDs, aspirin, anticoagulants, opioids, antibiotics, iron tablets, steroids and immunosuppressants.
Q2: What red flags would you ask about?
Important red flags include weight loss, dysphagia, persistent vomiting, haematemesis, melaena, rectal bleeding, change in bowel habit, iron deficiency anaemia, abdominal mass, jaundice, fever and night sweats.
Quick MSK History Structure
A focused GI history can be structured around:
Explore the main symptom
Ask upper GI symptoms
Ask lower GI symptoms
Screen for red flags
Ask about PMH, surgery and medications
Ask about family history
Cover social history, diet and travel
Explore ICE
Key Message
A strong GI history is about pattern recognition.
Explore the main symptom, then ask targeted questions about upper GI symptoms, lower GI symptoms, bleeding, bowel habit, systemic symptoms, medications, surgical history and social impact.
Do not miss weight loss, dysphagia, haematemesis, melaena, rectal bleeding, change in bowel habit, jaundice or obstruction symptoms.