What is the management for a patient with dengue fever (DF) presenting with abdominal pain?

Management of Abdominal Pain in Dengue Fever

For patients with dengue fever presenting with abdominal pain, immediate assessment for warning signs of severe dengue is essential, followed by appropriate supportive care including acetaminophen for pain relief, careful fluid management, and monitoring of vital signs and laboratory parameters. 1, 2

Assessment of Abdominal Pain in Dengue Fever

• Abdominal pain in dengue fever can represent either a common symptom of the disease itself or a warning sign of severe dengue/complications 1, 2
• Carefully evaluate for warning signs including persistent vomiting, increasing abdominal pain, abdominal tenderness, hepatomegaly, mucosal bleeding, lethargy, and rising hematocrit with falling platelet count 2
• Abdominal pain may mimic surgical conditions such as acute appendicitis, acute cholecystitis, or acute pancreatitis without actually requiring surgical intervention 3, 4

Diagnostic Approach

• Obtain daily complete blood count to monitor platelet counts and hematocrit levels 1, 2
• Consider abdominal imaging (ultrasound or CT scan) to rule out surgical complications if abdominal pain is severe, localized, or associated with peritoneal signs 3, 4
• Look for thrombocytopenia with leucopenia, which can help differentiate dengue from surgical conditions like acute appendicitis (which typically presents with leukocytosis) 5
• Confirm dengue diagnosis with PCR (early in disease) or IgM capture ELISA (after 5-7 days of symptoms) 1, 2

Management Protocol

Pain Management

• Administer acetaminophen (paracetamol) at standard doses (10-15 mg/kg every 4-6 hours, not exceeding 4 g/day in adults) for pain relief 6, 2
• Strictly avoid aspirin and NSAIDs due to increased bleeding risk 1, 6, 2
• Monitor liver function tests when using acetaminophen, particularly in patients with pre-existing liver disease or signs of hepatic involvement 6

Fluid Management

• Ensure adequate oral hydration with more than 2500ml daily for patients without shock 1, 2
• For patients with signs of dehydration, administer oral rehydration solution 6
• For dengue shock syndrome, administer an initial fluid bolus of 20 mL/kg crystalloid with careful reassessment afterward 1, 2

Monitoring

• Monitor vital signs, urine output, and signs of fluid overload 1
• Continue daily complete blood count monitoring to track platelet counts and hematocrit levels 1, 2
• Watch for progression of abdominal pain, which may indicate development of complications 2

Management of Specific Complications

• For suspected acute pancreatitis complicating dengue, provide supportive care including fluid resuscitation, pain management with acetaminophen, and close monitoring 7
• For rectus sheath hematoma or other bleeding complications, consider blood transfusion if significant bleeding is present 8, 1
• Surgical intervention should be avoided unless absolutely necessary, as dengue-related coagulopathy increases surgical risks 3, 5
• If surgical intervention becomes necessary, correct coagulopathy with platelet transfusions and ensure multidisciplinary team involvement 3

Special Considerations

• Dengue may mimic an acute abdomen without any true surgical complications - maintain high suspicion in endemic areas 4, 5
• Unnecessary surgical intervention in dengue patients with abdominal pain has been associated with poor outcomes 3
• In endemic areas, early dengue antigen testing and abdominal imaging before surgical intervention may help avoid unnecessary surgery 3, 5
• Multidisciplinary team involvement with case-by-case decision-making is needed for optimal care 3