How to manage abdominal pain in dengue fever?

Management of Abdominal Pain in Dengue Fever

Abdominal pain in dengue fever should be managed with supportive care while monitoring for potential serious complications, including careful fluid management and appropriate pain control with acetaminophen.

Clinical Presentation and Assessment

• Abdominal and gastrointestinal symptoms are present in approximately 67% of patients with dengue fever, with nausea (52%), abdominal pain (36%), vomiting (29%), and diarrhea (17%) being the most common manifestations 1
• Abdominal pain in dengue can mimic acute abdomen conditions, making diagnosis challenging and requiring careful evaluation to avoid unnecessary surgical interventions 2, 3
• Warning signs that require close monitoring include persistent vomiting and abdominal pain, as these may precede clinical deterioration in severe dengue 4
• Specific examination findings to look for include:
  • Hepatomegaly (present in about 2% of cases) 1
  • Signs of plasma leakage such as ascites (0.1%) 1
  • Evidence of gastrointestinal bleeding (0.3%) 1

Diagnostic Approach

• Laboratory evaluation should include:

  • Complete blood count with particular attention to platelet count (thrombocytopenia is common in dengue) 2, 5
  • Liver function tests, as 70% of hospitalized dengue patients show alterations 1
  • Comprehensive metabolic panel to assess organ function 5
  • Serum lipase if pancreatitis is suspected (a rare but reported complication of dengue) 4, 5

• Imaging considerations:

  • Ultrasonography may show findings suggestive of acalculous cholecystitis, which has been reported in dengue and should not be managed surgically 6
  • CT scan with IV contrast may be necessary if serious pathology is suspected, but should be used judiciously 7, 5

Management Recommendations

• Fluid management:

  • Careful intravenous fluid resuscitation is essential, especially in patients with warning signs or evidence of plasma leakage 8
  • Monitor for signs of fluid overload or inadequate resuscitation 8

• Pain management:

  • Acetaminophen (paracetamol) is the recommended analgesic for pain control in dengue fever 9
  • Maximum adult dose should not exceed 4000 mg in 24 hours (no more than 6 doses) to avoid liver damage 9
  • NSAIDs should be avoided due to increased bleeding risk in dengue patients with thrombocytopenia 8

• Specific complications management:

  • For suspected acute pancreatitis: supportive care with IV fluids, pain management, and bowel rest 4
  • For acalculous cholecystitis: conservative management is recommended as surgery is contraindicated in these patients 6
  • For rectus sheath hematoma (rare complication): conservative management with pain control and monitoring 3

Monitoring and Follow-up

• Patients with abdominal pain and dengue should be monitored closely as these symptoms are significantly more common in patients requiring hospitalization (74% of hospitalized patients had gastrointestinal symptoms, p=0.0001) 1
• Monitor vital signs, urine output, and hematocrit regularly to detect early signs of shock 8
• Daily complete blood count to monitor platelet trends and hematocrit 8
• Liver function tests should be followed in patients with abdominal pain 1

Important Considerations and Pitfalls

• Avoid unnecessary surgical interventions in dengue patients with abdominal pain mimicking surgical conditions without clear evidence of a surgical emergency 2, 6
• Be cautious with fluid administration in patients with evidence of plasma leakage to prevent fluid overload 8
• Consider dengue in the differential diagnosis of acute febrile syndrome with abdominal pain in patients from endemic areas or with recent travel history 1
• Bladder wall involvement on imaging has been reported as a predictive sign of severe disease and impending shock 6