(a) Epigastric pain—The most common cause of this pain is "peptic ulcer syndrome". This is described in the text books as "non-ulcer dyspepsia". Often it is described as burning pain ("Haraara" by Gulf patients and "Horgaa" by Yemenis). At other times it is a dull pain or ache. So often the pain has 'no' relation to fasting or an empty stomach. Though consumption of Chillies ("filfil") definitely increases the pain, many patients, specially Bahrainis, Qataris and Saudis would say that they hardly ever consume Chillier. Use of lemon ("Lemoon") often increases the symptoms in majority of Arab patients—especially Yemenis. Often the symptoms increase after consumption of food. Though the patients complain of the pain having been present for a few months or even "years" (specially in Yemenis) there is no history of a definite remission. Most of the patients have a "fear" of ulcer ("Garhaa") and keep on asking the doctor during history taking whether in his opinion they have an ulcer. Often the radiologist in the patient's country has reported an ulcer-l ike appearance on Barium meal examination. It is important to elicit this history. In case there is a positive history, nothing less than an endoscopic examination relieves them of their "fear" of ulcer (not the symptoms!).

In more than ninety percent of such patients, endoscopy is either normal or findings mentioned under "Hyperacidity" are noted. In the rest of them few "erosions" are noted. Although, the gastroenterologists would put the incidence of chronic duodenal ulcer in the above type of patients at about 5 to 10 per cent, in my experience this incidence is not more than 1 or 2 per cent! It is also worth noting that complications of chronic duodenal ulcer like haemorrhage, perforation and gastric outlet obstruction are uncommon in Arabs (especially the last two complications). Majority of above patients, specially Yemenis also complain of retrosternal burning and water brash ("Homodaa").

Most male patients are heavy smokers and consume plenty of Chillies (especially Yemenis). Also they consume as many as 20 to 30 helpings of tea or more often "Qahwah". A few Bahrainis consume alcohol—which is not more than 2 to 3 times a week. Also a few take beer—2 to 3 cans per day in the afternoon. Yemenis invariably give history of consuming "Qat" at least twice a week. A few Yemenis consume alcohol "after" Qat.

Except smoking, omission of which relieves many of fhe symptoms, I wonder what is the role of other stimulants. This is because when I hear the complaints from "female" patients surprisingly these are absolutely same if not "more" in severity. Although, a few elderly Arab ladies do smoke Hooka ("Sheesha"), it is usually the young and middle aged non-smokers who complain more.

The only common feature to all these patients is "tension" ("Taab" or "Tafkeer") which could be a strong etiological factor.

(b) High Epigastric pain in the area of Xiphoid process

This is of two types—

(i) The patients go on pressing the Xiphoid process and then "wince", impressing the doctor that they have definite pain (see fig. alongside). And this tenderness bothers them more than the pain itself. If there are no associated symptoms of "peptic ulcer syndrome", I would diagnose this pain as chondritis of the Xiphoid process and treat it accordingly. But often there are associated symptoms of peptic ulcer syndrome and many other functional symptoms of the gastrointestinal tract which overshadow the above symptom.

(ii) "Fooaat" discomfort in epigastrium is often heard of in Omani patients. When asked as a leading question, some patients from Yemen, U.A.E., Saudi and Qatar also do complain of it. This symptom is the exact counterpart of Indian Muslim women complaining of "Kaleja mein Takleef"—which literally means discomfort in the liver—but the patients use this phrase for discomfort in the anatomical area of "epigastrium" especially high epigastrium.

Though most of the Arabs associate this symptom with "heart" ("Gulb"), in my experience, interestingly the most common cause of this symptom is "epigastric pulsations of Abdomina/ Aorta", which is equivalent to "palpitations" when one becomes conscious of heart beating. If you ask the details, these patients go on poking the epigastrium and feel for the pulsating aorta ("Arg Dam") which increases their suspicion and fear of disease! ! Many patients are satisfied if you tell them that the heart ("Gulb") is OK! Others are not still happy and would like to hear that liver ("Kaibid") and stomach ("Maidaa") are normal.

(c) Pain in the right hypochondrium—Many patients, especially Yemenis would use the word "Pain" in the liver area ("Kaibid") or over the gall bladder ("Marrarra"). Surprisingly their knowledge of anatomy is very good which makes "neurosis" more common in them. Although, after investigations, some patients are found to have gall stones, in majority of them, liver and gall bladder "imaging" results are normal.

Then what do these patients suffer from? Often I elicit tenderness of hepatic flexure—"associated" with a tender descending colon and may be caecum as well. Also I find that many of these patients complain of other bowel symptoms which are due to Irritable bowel syndrome".

(d) Pain in the upper abdomen—Many patients complain of pain over the area of "floating ribs" and Costar margin. This is a very common symptom in Yemeni population. The pain over the right side may be confused with right hypochondriac pain. On the left side, the pain of splenic flexure syndrome can be simulated. Often the patients press on their ribs and demonstrate tenderness at the time of giving history. X-ray chest and abdominal investigations are found to be normal. These patients thus suffer from "Rib tip Syndrome" discussed elsewhere in the book.

(e) Pain over the "Kidney" area (Kilyae)—is often complained of on both sides—and more in the anterior part of the loin. Although, kidney stones are common in Arab population, moment the patient uses the word "Kidney", more often he has no kidney stones. If positively questioned, they do even describe the so-cal led "radiation" of the pain posteriorly, but usually the pain does not radiate down like a ureteric colic. "Bilateral" pain is also against the diagnosis of stones because even if the stones are bilateral, the symptoms are often unilateral. Also the tenderness (elicited more often by the Yemeni patients) goes in favour of musculo-skeletal pain.

Investigations like X-ray K.U.B., IVP (intravenous pyelography), and urine culture have to be done, before you can say with confidence to the patient that his kidneys are normal.

(f) Periumbilical pain—is often complained of. A few Yemenis use the word pain over the "Pancreas" (pronounced as "Paancreas"). Many patients with umbilical pain would come forward with the history that in the past, during an "acute attack" some local paramedical person had pushed back and manipulated the "umbilicus" thereby proving that the change in position of the umbilicus was the cause of the pain! My impression is that in most of these patients, it is the spasm of the irritable transverse colon which causes severe umbilical pain (even Pancreatitis is a rare disease in Arab patients, may be because alcoholism is still not widespread). And surely the "massage" of this area is one of the best treatment to give relief.

(g) Pain in the right iliac fossa—if such a patient approaches a surgeon first, invariably his appendix will be removed. Acute appendicitis is a very common entity in Arabs and in practice I see a number of patients having a scar for appendix ("DoodZaida") surgery done in their country for acute pain in the right iliac fossa.

But I am not content to diagnose "chronic" appendicitis clinically because most of the times the pain is in the form of a "dull ache" (present all the time) and not spasmodic pain. Also most of these patients suffer from the following—

• Pain elsewhere in the colon
• Severe constipation or other symptoms of irritable bowel syndrome
• Tenderness of the descending colon or the transverse colon— meaning thereby that the tenderness in the right iliac fossa is "caecal" and not appendicular
• Associated multiple complaints involving many other systems and finally
• Symptoms of neurosis.

The surgeon would not like to take a chance and allow this foreign visitor to go back with his appendix intact, which may one day create a near-fatal emergency. Granting that many of the Arab patients are "happy" with appendix "out" rather than "in", I am not convinced about the high frequency of "chronic" appendicular disease. Unfortunately, at present we have no method (e.g. "imaging") available to confirm this diagnosis before the surgery is undertaken. The "non-filling" and/or the filling defects in appendix reported on X-rays are non-specific. The tenderness mentioned by the radiologist while doing barium study is often of the caecum and not of the appendix.

Rarely in Arab patients a ureteric stone is the cause of pain in the right iliac fossa.

(h) Pain in the left iliac fossa—is often due to irritable bowel syndrome or a ureteric calculus, the former being much more common. A few female patients have tubo-ovarian masses (confirmed on) sonography), but such gynaecological causes are not very common in Arab population.

(i) Hypogastric pain—is often complained of by patients with cystourethritis syndrome, which is common in Arab population and is discussed elsewhere. It is more common in males— especially Yemenis.

(j) Generalised abdominal pain—demonstrated by the patient by passing his hand all over the abdomen is surprisingly very uncommon in Arab population, though, it is very common to see a patient having nearly half or 3/4th abdomen affected by pain experienced in different areas e.g. epigastrium, right hypochondrium, left iliac fossa etc. This is mainly because diseases like parasites (round worms) or Koch's abdomen are not so common in this population.

(k) Pain in midline of the abdomen—This is a very interesting rare site of pain complained of by Yemenis. These are highly neurotic patients, and they are convinced that they have all "midline" organ diseases. The symptoms start with watering of nose, sneezing, sore throat, retrosternal burning etc.

(I) Pain in one half of the body—Unlike the above group, there are patients, who rarelycomplain of thistypeof pain. These patients suffer from root pains of cervical and lumbar spondylosis more on one side—and then the chest and abdomen on that side gets "involved".

(m) Pain over the upper opening of the Inguinal canal—Some male patients complain of this type of pain. I find no evidence of a hernia. If these patients approach a surgeon first, the only method of relieving them is to do surgery to strengthen the inguinal canal. To my surprise they do get relieved!!

(n) Proctalgia fugax ("Vajaa Daakhal Khurooj")—This is more often heard of in a few Yemeni patients, having symptoms of irritable bowel syndrome, though overall incidence of it is less. You can pick up many such patients, if you ask leading questions.

I use simle words—pain ("Waaja") inside the rectum ("Daakhal Khurooj"). This pain is one of the most severe pains in the body and the Yemenis show the severity, with facial gestures and the type of cutting pain with gestures of hands, demonstrating cutting with knife.

I had an opportunity to see one of these patients during an attack. Although on most of the occasions Arab patients love to undergo a rectal examination and their sphincters and anal canal are relaxed to receive your fingers or proctoscope, in this patient, there was so much temporary spasm that it was impossible to put a finger or a proctoscope. Of course all these patients suffer from symptoms of severe irritable bowel syndrome.

Finally a word about the radiation of abdominal pain to the back. In Arab patients especially Yemenis, the radiation of all abdominal pains to the back is very common! Pain of ulcer, irritable colon, and most of the other musculoskeletal system radiate—so that "this" history becomes misguiding.

It is interesting to note that while Bahrainis, Qataris and Saudis come, more often than not, presenting with "Peptic ulcer syndrome", Yemenis frequently have a combination of the above with irritable bowel syndrome with superadded symptoms of psychoneurosis referable to other systems.

On many occasions (during his daily ward rounds) any clinician can be embarrassed by the Yemeni patients who often go on "changing" the site of abdominal pain during their stay in the hospital. And yet they are so sure of their symptoms.

They would usually "borrow" your hand and press the area of pain and then wince with the facial expression which is pitiable. As the saying goes "they are fishing for sympathy". That is the time a doctor feels helpless—you would like to help such a patient but it is a difficult situation—a combination of visceral and musculoskeletal pains supplemented by fear, anxiety, suspicion and neurosis—a picture you would hardly ever see in any other population !

Other abdominal complaints

Abdominal Distension

This is one of the most common abdominal symptoms in Arab population. After meals, the whole abdomen puffs up ("Inthfukk"). A typical Yemeni always gives history by speaking with "gestures". In this case he puffs up both the cheeks to show the puffing up of the abdomen after meals (see fig alongside). Most of these patients show no evidence of any organic illness of the abdomen. Often, symptoms of hyperacidity, aerophagy, peptic ulcer and irritable bowel syndrome are associated.

Aerophagy

Belching ("Gashaat") excessively is a common symptom in Arabs though less common than in Indian population. The incidence of this problem is seen in the increasing order of frequency from Bahrain, Qatar, Saudi Arabia, Dubai, Oman to Yemen,—the last country having the highest incidence.

Constant belching gives the patient the impression that the food is not being digested. Thus, he develops more anxietv which leads to more air swallowing.

Hyperacidity ("Hararaa"- "Homoda")

So common is this symptom (burning of the chest) that in one series, I found that out of 100 consecutive Arab patients, 60 complained of it as one of the leading symptoms, 30 said 'yes' when asked about it and another 10 were not sure that they 'never' suffered from this symptom!! Interestingly the severity of this symptom varies increasing in order of frequency from Bahrain to Yemen as described above under aerophagy. Although, "smoking" appears to be the most common aetiological factor, the other reasons are excessive use of "caffeine", alcohol etc. Finally tension may also be responsible for this symptom. Even these factors cannot explain the very high incidence of hyperacidity in female Arab patients. When endoscopy of upper G.l tract was done on one group of hundred such young and middle aged patients (done by different endoscopists), it was interesting to note that 5 to 10 patients had slight peptic oesophagitis. About 20 to 30 patients had gastrooesophageal reflux without presence of oesophagitis. And yet majority of the rest of the patients had normal oesophagus with no gastro-oesophageal reflux! This makes me feel that it is the sensitivity of the oesophagus of the Arabs, which over-reacts to, may be, intermittent regurgitation of normal stomach acid. When fractional test meal gastric analysis of many of these patients was done, I was surprised to find that most patients had no evidence of hyperacidity. Also many of these patients did not consume any chillies or spices in their food and the women never smoked.

Milk intake relieves many of these patients, but in some of them, it increases borborygmi possibly because of presence of lactase insufficiency. Some patients need 2 hourly administration of large doses of antacids to control the symptom of hyperacidity! Water brash ("Homodaa") is an extremely common symptom complained of maximum by Yemeni patients. Interestingly it is a rare complaint of a Bahraini and a Qatari. It is very difficult to explain the reasons for this. Although, associated hyperacidity is present in many patients, I have also seen patients without symptoms of hyperacidity having predominant complaint of "Homodaa"— leading to "Abyaat Moyee"—sudden water brash with appearance of white watery contents in the mouth! Is it that their gastro-oesophageal sphincter is very incompetent? Routine endoscopic pressure and dynamic studies have not been done.

Vomiting or nausea—("Loa" "Tarash" "Zoa"—"Gatyan") are extremely common symptoms in all Arabs but especially in Yemenis. At times the doctor gets the feeling that the patient is mixing up the symptoms of water brash with vomiting. But if details are asked, many of them are suffering from both! The vomit is usually small and is often associated with other symptoms e.g. hyperacidity or aerophagy. Nausea ("Zoa" or "Gatyan") may or may not be complained of. If a Bahraini complains of vomiting, often, a history of migrainous headache preceding it can be elicited. In some instances, an attack of "migraine" presents with vomiting only. This has been discussed elsewhere. Whereas, a Bahraini complaining of vomiting, is a well-fed, overweight patient (more often a female), a Yemeni is an underweight ill-looking patient. All investigations done to find out the cause of vomiting usually turn out to be normal.

PoorAppetite ("Shahiyaa")—is a symptom commonly encountered in Yemeni patients who are mostly underweight. Often there is no organic cause (like Kochs) for this symptom. How much is "Qat" responsible for this symptom is difficult to say. But rest of the habits of smoking, alcohol, tea, Qahwah are present equally in other countries of Qatar, Bahrain etc. where people eat more and are overweight! Also endoscopic examination of these patients is normal and shows no evidence of gastritis! (Routine gastric biopsy is not being done).

Constipation ("Maemshi" or "Batan Imsoek" or "Ma Albraaz")— is a very common symptom in all Arab patients. Again the frequency of this complaint increases in order of frequency from Bahrain, Saudi, Qatar, U.A.E. to Yemen in that order. There are patients who have a bowel evacuation only after 4 to 5 days or even after 8 to 10 days or more! Many of them (especially Yemenis) complain of very hard stools ("Yeboosa"). Most of the common laxatives and purgatives (when given in the usual doses) do not work on them. Diet possibly plays a role in the etiology of this condition. Arabs are rice and meat eaters. They are reluctant to eat vegetables. Also, although they drink more water because of increased sweating, this is not enough. The role of personal habits is to be kept in mind. Drug abuse of Mandrax, Mogadon, tranquillisers in Qatar, Bahrain and "Qat" in Yemen could be contributory factors. Finally sedentary life might have some bearing. Surprisingly the incidence of diverticulosis in elderly Arabs is very very low. In fact constipation is present in younger Arabs more than in older ones. Irritable bowel syndrome seems to be a very common cause.

Gastrocolic reflex—is one of the less common symptoms. The patient views this symptom as a very serious condition because he feels that whatever he eats, gets evacuated immediately and thus he has severe indigestion. Most of the patients have irritable bowel syndrome as the cause of this complaint.

Chronic Diarrhoea ("Ishaal")— is rare. "Acute" diarrhoea is more common especially in children. After coming to Bombay, some of them experience "Traveller's diarrhoea". These patients however consider it as a very serious condition. Though chronic diarrhoea is a rare symptom, increased frequency of bowel movements due to incomplete evacuation of a spastic colon is often seen. Also mucous colitis bothers many patients (who are fond of looking at the stool) and the sight of mucous upsets them! They often explain this symptom by rubbing their fingers, and comparing it to the white discharge ("Abyaat Moyee") of a nasal cold! It is interesting to note that a number of patients especially Yemenis have suffered from Bilharzia, Giardia or amoebic dysentery in the past. Many of them would use the word "Doodh" for big worms and small worms of the above diseases. After ordering for hundreds of stool examinations, sigmoidoscopies, barium enema examinations and serological tests for amoebiasis, especial stool examinations for Bilharzia infestation, my impression is that except Giardia and sometimes entamoeba histolytica and perhaps an occasional round worm it is rare to find other parasites. Malignancy of the colon is extremely rare in this part of the world

Although I have treated amoebic liver abscess in three Arabs who were seamen by profession, I have yet to see a strongly positive serological test for amoebiasis in an Arab patient! This is inspite of the fact that many of them now make frequent trips to Bombay and stay for a couple of days every time.

Borborygmi ("Gargaraa")—is a very common symptom especially in Yemenis whose stool examination and barium meal X-rays are all normal. Theoretically one could say that giardia infestation as its cause could be missed by stool examination but we could not be missing it in so many patients. The fact is that no evidence of organic bowel disease is found. Many of them have other symptoms of irritable bowel syndrome. In a few, lactase insufficiency could be contributory factor, because symptoms are increased by consuming milk.

More interesting is the complaint of gurgling in "upper abdomen". This symptom of localised gurgling is especially complained of by Yemenis. These patients have no evidence of upper gastrointestinal obstruction! May be, this shows the degree of attention these people give to normal functions of the body including the normal peristalsis!

Dryness of mouth ("Iyaabus")—is an extremely common complaint in Arab population. Often it is not complained of as a leading symptom. But if questioned, only very rarely does the patient not oblige you. The frequency of this symptom increases from Bahrain to Yemen in the same order. In certain patients it is a presenting symptom and yet when they open the mouth, the tongue and the buccal mucous membrane appear normal and moist! Often I am not able to connect it with consumption of "Qat" or other intoxicants or drugs which are consumed only once a week.

It is interesting to note that in Arab population, the symptoms or the signs of gereralised glossitis are very uncommon. The degree of alcoholism being less, B-complex deficiency is rare. Even in wasted Yemenis with poor food habits, glossitis is seldom seen. Similarly although some Yemenis do complain of local pain over the tongue and have aphthous ulcers, the incidence of this disease is strikingly low in Arab population!

Loss of taste ("Taam")—This is a very common complaint. Often it is associated with loss of smell ("Shaam"). Most of the times all the investigations are normal and do not point to any disease which could be its cause.

Jaundice ("Abu Usfaar")—Although sickle cell disease, G6PD deficiency, gallstones and Bilharziasis (in Yemenis) are fairly common causes of this symptom, it is noteworthy that hepatic causes of jaundice are very rare. In fact, Chronic liver disease is very rare in this population. Past history of viral hepatitis is sometimes present.