What is the initial management for a patient with nausea, vomiting, suprapubic and left iliac fossa tenderness, normal pregnancy test, normal urine dipstick, and normal white blood cell (WBC) count?

Initial Management of Patient with Nausea, Vomiting, and Abdominal Tenderness

The initial management for a patient with nausea, vomiting, suprapubic and left iliac fossa tenderness, normal pregnancy test, normal urine dipstick, and normal WBC count should be abdominal CT (option B).

Diagnostic Approach Rationale

Assessment of Clinical Presentation

• Patient presents with:
  • Nausea and vomiting
  • Suprapubic and left iliac fossa tenderness
  • Normal pregnancy test (ruling out ectopic pregnancy)
  • Normal urine dipstick (ruling out urinary tract infection)
  • Normal WBC count (no obvious inflammatory response)

Diagnostic Imaging Selection

CT imaging is the preferred initial management for several important reasons:

1. Superior Diagnostic Accuracy: CT is the imaging modality of choice for determining the presence of intra-abdominal infection and its source in adults not undergoing immediate laparotomy 1. It provides comprehensive evaluation of the abdomen and pelvis.

2. Broad Diagnostic Capability: The patient's presentation could represent several conditions including:

   • Bowel obstruction (small or large bowel)
   • Sigmoid volvulus (especially with left iliac fossa pain)
   • Diverticulitis (despite normal WBC)
   • Early appendicitis (despite location and normal WBC)
   • Intra-abdominal infection with localized peritonism

3. Evidence-Based Approach: According to the World Journal of Emergency Surgery guidelines, CT imaging is essential when the diagnosis is in doubt or if ischemia or perforation is suspected 1. The patient's localized tenderness raises concern for possible bowel pathology.

Why Other Options Are Less Appropriate

Option A: Abdominal X-ray

• Limited sensitivity and specificity for many abdominal conditions
• While X-rays can detect some cases of bowel obstruction or volvulus showing the "coffee bean sign" 1, they miss many pathologies and provide less information than CT
• According to radiological guidelines, "the use of conventional radiography has been surpassed; this examination has only a possible role in the setting of bowel obstruction. However, CT is more accurate and more informative in this setting as well" 2

Option C: Diagnostic laparoscopy

• Too invasive as an initial management step
• Should be reserved for cases where imaging is inconclusive or patient deteriorates
• Not indicated without prior imaging in a hemodynamically stable patient

Option D: Analgesia and discharge

• Inappropriate given the concerning symptoms of localized peritonism
• The World Journal of Emergency Surgery guidelines recommend that "patients with abdominal pain, constipation and vomiting" require thorough evaluation 1
• Discharging without diagnosis could miss serious pathology like bowel obstruction, which accounts for approximately 15% of hospital admissions for acute abdominal pain 1

Management Algorithm

1. Initial Stabilization

   • Rapid restoration of intravascular volume if needed 1
   • IV fluid therapy when intra-abdominal infection is suspected 1

2. Diagnostic Imaging

   • Proceed with abdominal CT with IV contrast
   • CT findings will guide subsequent management decisions

3. Post-Imaging Management

   • If CT shows obstruction: appropriate surgical consultation
   • If CT shows infection: initiate antimicrobial therapy 1
   • If CT shows other pathology: disease-specific management

Important Clinical Considerations

• The absence of leukocytosis does not rule out serious intra-abdominal pathology
• Left iliac fossa pain could indicate sigmoid pathology (diverticulitis, volvulus) which is best evaluated with CT
• Normal pregnancy test is important to note, as ectopic pregnancy can present with similar symptoms and requires different management 1
• Localized peritonism is a concerning sign that warrants thorough investigation rather than discharge

By choosing abdominal CT as the initial management, you provide the most comprehensive evaluation that will guide appropriate subsequent treatment for this patient with concerning abdominal symptoms.