What's the next step in managing a 48-year-old woman with sudden onset of sharp, constant upper abdominal pain, nausea, vomiting, and a history of peptic ulcer disease (PUD), taking famotidine, presenting with hypertension, tachycardia, tachypnea, and a distended abdomen with diffuse tenderness?

Management of Acute Abdominal Pain in a 48-Year-Old Woman with PUD

Immediate CT scan with IV contrast is the next step for this patient with suspected perforated peptic ulcer, followed by surgical consultation and preparation for emergency surgery. 1

Initial Assessment

This patient presents with classic signs of peritonitis and possible perforated peptic ulcer:

• 12-hour history of sudden-onset upper abdominal pain
• Sharp, achy, constant pain that worsens with movement and deep breathing
• History of peptic ulcer disease (PUD) on famotidine
• Vital sign abnormalities: hypertension, tachycardia, tachypnea
• Abdominal examination revealing distension, diffuse tenderness, and hypoactive bowel sounds

These findings strongly suggest a surgical emergency, most likely a perforated peptic ulcer given her PUD history.

Diagnostic Approach

Imaging

1. CT scan with IV contrast is the recommended first-line imaging modality:

   • High sensitivity (90-95%) for detecting perforation and other abdominal emergencies 1
   • The World Journal of Emergency Surgery guidelines strongly recommend CT scan imaging for suspected perforated peptic ulcer 2
   • Can detect free air, fluid collections, and other complications

2. If CT is not immediately available:

   • Chest and abdominal X-rays should be performed, though they have limited sensitivity (30-85%) for detecting perforation 2, 1
   • Consider water-soluble contrast studies if perforation is still suspected despite negative plain films 2

Laboratory Tests

• Complete blood count (already showing leukocytosis)
• Serum creatinine and electrolytes
• Inflammatory markers (C-reactive protein, procalcitonin, lactate)
• Arterial blood gas analysis 2

Management Algorithm

1. Immediate Resuscitation:

   • Establish IV access with two large-bore IVs
   • Begin fluid resuscitation with crystalloids
   • Place nasogastric tube for decompression
   • Administer supplemental oxygen if needed

2. Diagnostic Confirmation:

   • Obtain CT scan with IV contrast
   • Surgical consultation while awaiting imaging

3. Antimicrobial Therapy:

   • Start broad-spectrum antibiotics to cover gram-negative and anaerobic organisms 2

4. Surgical Management:

   • For confirmed perforated peptic ulcer, emergency surgery is indicated 2
   • Laparoscopic approach is preferred if expertise is available and patient is stable
   • Simple closure with omental patch is the standard procedure for most perforations

5. Damage Control Surgery:

   • Consider if patient develops hemodynamic instability, severe peritonitis, or septic shock 2
   • This approach involves abbreviated laparotomy with planned second-look procedure

Surgical Considerations

The patient's vital sign abnormalities (hypertension, tachycardia, tachypnea) and abdominal findings (distension, diffuse tenderness) are concerning for peritonitis. According to the World Society of Emergency Surgery guidelines, these are alarming clinical signs that should prompt immediate surgical evaluation 2.

The presence of tachycardia, tachypnea, and diffuse abdominal tenderness are significant predictors of peritonitis requiring surgical intervention 2. The guidelines specifically recommend against delaying prompt diagnostic work-up and surgical exploration in patients with persistent abdominal pain and gastrointestinal symptoms 2.

Pitfalls to Avoid

1. Delayed diagnosis: Relying solely on plain radiographs can miss perforations in up to 70% of cases 1

2. Misdiagnosis: Elevated amylase can be seen in multiple conditions, including mesenteric ischemia and perforated peptic ulcer, not just pancreatitis 1

3. Inadequate resuscitation: Patients with peritonitis require aggressive fluid resuscitation before surgery 2

4. Overlooking sepsis: The combination of tachycardia, tachypnea, and abdominal findings should raise concern for developing sepsis 2

This patient's presentation with sudden-onset severe epigastric pain, diffuse tenderness, vital sign abnormalities, and history of PUD strongly suggests a perforated peptic ulcer requiring immediate surgical intervention. The standard of care is CT imaging followed by emergency surgery if perforation is confirmed.