Management of Dengue with Abdominal Pain
Patients with dengue presenting with abdominal pain should receive symptomatic management with acetaminophen for pain relief, careful fluid management based on hemodynamic status, and close monitoring for warning signs of progression to severe disease. 1, 2
Assessment of Abdominal Pain in Dengue
- Abdominal pain in dengue may indicate progression to severe disease and requires immediate attention as it could be a warning sign of plasma leakage, organ impairment, or hemorrhage 1, 2
- Evaluate for other warning signs including persistent vomiting, lethargy, mucosal bleeding, liver enlargement, and increasing hematocrit with decreasing platelet count 2
- Consider ultrasonography to detect early signs of plasma leakage such as gallbladder wall thickening, which has a positive likelihood ratio of 2.14 for detecting early plasma leakage 3
- Rule out complications such as acute acalculous cholecystitis, which can present as sharp abdominal pain in dengue patients 4
- In rare cases, rectus sheath hematoma may occur after extreme retching and vomiting, presenting as severe right upper quadrant pain 5
Pain Management
- Acetaminophen (paracetamol) at standard doses is the recommended first-line analgesic for pain relief in dengue patients 1, 2
- Avoid aspirin and NSAIDs under all circumstances due to increased bleeding risk, especially with the thrombocytopenia commonly seen in dengue 1, 2
- For pregnant women with dengue fever, acetaminophen remains the safest analgesic option 1
- In children, acetaminophen dosing should be carefully calculated based on weight 1
Fluid Management
- For patients without shock, ensure adequate oral hydration with more than 2500ml daily 1
- For patients with signs of shock (including severe abdominal pain with other warning signs), administer an initial fluid bolus of 20 mL/kg crystalloid with careful reassessment afterward 1, 2
- Avoid overhydration, which can lead to pulmonary edema, particularly during the recovery phase 2
- Monitor for clinical indicators of adequate tissue perfusion, including normal capillary refill time, absence of skin mottling, warm and dry extremities, and adequate urine output 2
Laboratory Monitoring
- Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 2
- Rising hematocrit (>20% increase from baseline) with rapidly falling platelet count suggests plasma leakage and potential progression to severe dengue 2
- Monitor liver function tests as dengue can cause hepatic involvement 1
Management of Complications
- For significant bleeding, blood transfusion may be necessary 1, 2
- For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1, 2
- In cases of severe dengue with refractory shock, consider early albumin administration for crystalloid-refractory shock 6
- Monitor for symptomatic abdominal compartment syndrome, which may require invasive percutaneous drainage in severe cases 6
Common Pitfalls to Avoid
- Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2
- Delaying fluid resuscitation in patients with dengue shock syndrome 2
- Administering excessive fluid boluses in patients without shock, which can lead to fluid overload and respiratory complications 2
- Misdiagnosing abdominal pain as a common gastrointestinal issue rather than a warning sign of severe dengue 4
Special Considerations
- In critically ill children with severe dengue, targeted interventions including early albumin for crystalloid-refractory shock and proactive monitoring for abdominal compartment syndrome have shown improved outcomes 6
- The incidence of dengue is increasing worldwide due to climate change and global mobility, making prompt recognition and management essential 7