What is the first priority in managing a patient with emesis (vomiting) accompanied by acute abdominal pain?

Management of a Patient with Emesis and Acute Abdominal Pain

The first priority in managing a patient with emesis accompanied by acute abdominal pain is to rule out peritonitis, as this condition represents the most immediate life-threatening emergency that requires urgent surgical intervention. 1

Initial Assessment Algorithm

When evaluating a patient presenting with emesis and acute abdominal pain, a systematic approach is necessary to identify potentially life-threatening conditions:

1. Assess for peritonitis first:

   • Look for signs of peritoneal irritation: rebound tenderness, guarding, rigidity
   • Check for fever, tachycardia, and tachypnea (the triad that strongly suggests peritonitis or anastomotic leak) 1
   • Evaluate for hypotension, which may indicate septic shock from peritonitis

2. Evaluate for bowel obstruction:

   • Assess for abdominal distention, high-pitched bowel sounds, and absence of flatus
   • Note that bowel obstruction accounts for approximately 15% of hospital admissions for acute abdominal pain 1
   • Determine if there's a history of previous abdominal surgery (85% sensitivity, 78% specificity for adhesive small bowel obstruction) 1

3. Consider blockage of hollow viscus:

   • Persistent vomiting and nausea are alarming signs suggesting internal hernia, volvulus, gastrointestinal stenosis, or intestinal ischemia 1
   • Assess for colicky/crampy pain pattern typical of obstruction

Evidence-Based Rationale

Peritonitis must be ruled out first because:

• It represents a surgical emergency with high mortality if not promptly treated
• The open abdomen approach is indicated for emergency surgery patients with severe peritonitis and septic shock 1
• Damage control surgery is necessary for hemodynamically unstable patients with severe peritonitis 1

Bowel obstruction requires urgent attention but typically follows peritonitis in priority because:

• Small and large bowel obstructions account for ~20% of cases needing acute surgical care 1
• Obstruction can lead to ischemia, perforation, and peritonitis if not addressed 1
• However, peritonitis represents a more immediately life-threatening condition

Laboratory and Imaging Considerations

• Laboratory evaluation should include complete blood count, CRP, procalcitonin, serum lactate levels, and blood gas analysis 1
• Leukocytosis and lactic acidosis are frequently present in intestinal ischemia 1
• CT scanning is preferred over conventional radiography, which lacks added value in acute abdominal pain 2
• Ultrasound may be used as first imaging modality, with CT following if results are negative or inconclusive 2

Common Pitfalls to Avoid

1. Delaying surgical consultation: In patients with persistent abdominal pain and vomiting, especially with fever, tachycardia, and tachypnea, prompt surgical consultation is essential 1

2. Overlooking referred pain: Symptoms of acute abdomen may be caused by extra-abdominal pathology such as lower lobe pneumonia or cardiac conditions 3, 4

3. Withholding analgesia: Administration of opioids for pain relief does not affect the accuracy of physical examination and should not be delayed 2

4. Missing intestinal ischemia: "Pain out of proportion to physical findings" is classic for mesenteric ischemia, which requires rapid diagnosis and treatment 1

In conclusion, while all options in the question (ruling out bowel obstruction, peritonitis, and blockage of hollow viscus) are important, peritonitis represents the most immediate threat to life and therefore should be the first priority in the assessment algorithm of a patient with emesis and acute abdominal pain.