What is the line of treatment for a 37-year-old male with abdominal pain at the umbilical region, loose motions, and severe dysuria, who is not responding to diclofenac (diclofenac) and Fortwin (pentazocine) injections?

Immediate Hospital Admission Required

This patient requires immediate hospital admission for further evaluation and management, as he has failed first-line analgesic therapy with diclofenac and pentazocine (Fortwin), which indicates either inadequate pain control or a potentially serious underlying condition requiring urgent intervention. 1

Critical Assessment Points

The combination of umbilical abdominal pain, loose motions, vomiting, and severe dysuria with normal ultrasound findings presents several diagnostic possibilities that require urgent evaluation:

• Renal colic remains a strong possibility despite normal ultrasound, as ultrasound can miss ureteral stones; the severe dysuria and failure of diclofenac (first-line therapy for renal colic) after one hour mandates hospital admission per established protocols 1, 2

• Rule out surgical emergencies: The umbilical location with gastrointestinal symptoms requires exclusion of early appendicitis, bowel obstruction, or mesenteric ischemia, particularly given the three-day duration 1

• Assess for systemic infection: Check vital signs (pulse, blood pressure, temperature) to exclude sepsis, which would require urgent intervention 1

Immediate Management Steps

In the Emergency Department:

• Admit the patient immediately as per guidelines stating that failure of analgesia after 1 hour requires immediate hospital admission without further consultation 1

• Obtain complete vital signs to exclude shock and systemic infection 1

• Perform abdominal examination to exclude peritonitis, guarding, or signs of acute abdomen 1

• Order urgent CT urography (preferred over ultrasound) to definitively rule out or confirm urolithiasis, as ultrasound has limited sensitivity for ureteral stones 1, 2

• Consider alternative diagnoses including gastroenteritis with complications, early inflammatory bowel disease, or abdominal wall pain (though less likely given the gastrointestinal symptoms) 3

Pain Management in Hospital:

For suspected renal colic with failed NSAID therapy:

• Switch to opioid analgesia as second-line therapy since NSAIDs have failed 2
• Consider hydromorphone, tramadol, or fentanyl (avoid morphine in renal impairment) 2
• Fentanyl is preferred if renal function is compromised as it doesn't accumulate active metabolites 2
• Avoid standard opioid dosing in renal failure; start low and titrate carefully 2

If renal colic is ruled out:

• Consider acetaminophen (paracetamol) IV every 6 hours for ongoing pain control 1
• Reassess NSAID therapy with caution given gastrointestinal symptoms; if used, co-prescribe proton pump inhibitor 1
• Tramadol may be considered as it has reduced gastrointestinal effects compared to other opioids, though confusion can occur 1

Urgent Investigations Required

• CT urography or non-contrast CT abdomen/pelvis to identify stones, bowel pathology, or other structural abnormalities 1, 2
• Complete blood count to assess for infection or anemia 1
• Serum creatinine and electrolytes to evaluate renal function 1
• Urinalysis and urine culture if not already done 1
• Serum amylase/lipase to exclude pancreatitis (particularly relevant given diclofenac use, which has been associated with drug-induced pancreatitis) 4
• Stool studies if diarrhea persists, to exclude infectious gastroenteritis 1

Critical Decision Points

If imaging confirms urolithiasis:

• Continue opioid analgesia as needed 2
• Consider alpha-blocker therapy (medical expulsive therapy) for stones >5mm in distal ureter 2
• Urgent decompression via percutaneous nephrostomy or ureteral stenting is required if signs of sepsis or anuria develop 2
• Urology consultation within 7-14 days if stone requires intervention 1

If imaging is negative for stones:

• Reassess for gastrointestinal pathology requiring surgical consultation 1
• Consider gastroenterology consultation if inflammatory bowel disease suspected 1
• Evaluate for abdominal wall pain with trigger point examination (Carnett's test), though the gastrointestinal symptoms make this less likely 3

Common Pitfalls to Avoid

• Do not continue outpatient management when first-line therapy fails after one hour; this is an absolute indication for admission 1

• Do not rely solely on ultrasound to exclude urolithiasis; CT urography is the gold standard 1, 2

• Do not use morphine, codeine, or standard tramadol doses if renal impairment is present 2

• Do not overlook the possibility of diclofenac-induced complications such as pancreatitis or gastrointestinal bleeding, particularly with the vomiting and diarrhea 4

• Do not assume functional dyspepsia without excluding structural pathology in a patient with three days of progressive symptoms 1