What is the initial management for a female patient presenting with nausea, vomiting, suprapubic and left iliac fossa pain and tenderness, with a negative pregnancy test, normal urine dipstick, and normal White Blood Cell (WBC) counts?

Initial Management for Female Patient with Abdominal Pain, Negative Pregnancy Test, and Normal Laboratory Findings

The most appropriate initial management for a female patient with nausea, vomiting, suprapubic and left iliac fossa pain and tenderness, negative pregnancy test, normal urine dipstick, and normal WBC counts is abdominal CT scan with contrast (Option B).

Diagnostic Approach for Acute Abdominal Pain in Females

Clinical Assessment and Initial Considerations

• The patient presents with:
  • Nausea and vomiting
  • Suprapubic and left iliac fossa pain and tenderness
  • Negative pregnancy test (ruling out ectopic pregnancy)
  • Normal urine dipstick (making UTI less likely)
  • Normal WBC count (atypical for acute inflammatory processes)

Imaging Selection Rationale

1. CT Abdomen and Pelvis with Contrast

   • The 2020 World Journal of Emergency Surgery guidelines strongly recommend cross-sectional imaging for patients with normal investigations but non-resolving abdominal pain 1
   • CT is the preferred modality when ultrasound findings are negative or inconclusive 1
   • CT can effectively differentiate between various causes of lower abdominal pain including:
     • Appendicitis (even without leukocytosis)
     • Diverticulitis (which can present with left iliac fossa pain)
     • Epiploic appendagitis (which can mimic appendicitis) 2
     • Gynecological conditions (ovarian cysts, adnexal torsion)

2. Why not other options?

   • Abdominal X-Ray (Option A): Limited sensitivity for soft tissue pathologies and gynecological conditions
   • Diagnostic Laparoscopy (Option C): Too invasive as initial management; guidelines recommend cross-sectional imaging before surgery 1
   • Analgesia & Discharge (Option D): Inappropriate given localized tenderness and concerning symptoms without a clear diagnosis

Diagnostic Algorithm

1. First step: Abdominal CT with contrast

   • Provides comprehensive evaluation of abdominal and pelvic organs
   • Can identify both gynecological and non-gynecological causes
   • Particularly valuable when clinical presentation is atypical (normal WBC)

2. If CT is inconclusive:

   • Consider pelvic ultrasound for better visualization of gynecological structures
   • Consider diagnostic laparoscopy if symptoms persist despite negative imaging 1

Important Clinical Considerations

Differential Diagnoses to Consider

• Gynecological causes:
  • Pelvic inflammatory disease (can present without leukocytosis)
  • Ovarian cyst complications (rupture, torsion)
  • Endometriosis
• Non-gynecological causes:
  • Appendicitis (can present with normal WBC in 8.4% of cases) 1
  • Diverticulitis (can present with left-sided pain) 3
  • Epiploic appendagitis (can mimic appendicitis) 2

Common Pitfalls to Avoid

• Don't assume normal WBC excludes serious pathology: Appendicitis and other inflammatory conditions can present with normal WBC counts 1
• Don't dismiss localized tenderness: Rebound tenderness and guarding are significant physical findings requiring investigation
• Don't overlook gynecological causes: Left iliac fossa pain in females requires consideration of both gynecological and gastrointestinal etiologies

CT imaging provides the most comprehensive initial assessment for this clinical scenario, allowing for appropriate diagnosis and management planning while avoiding unnecessary invasive procedures or premature discharge.