What is the next step in managing a patient with sudden onset severe epigastric pain, nausea, vomiting, tachycardia, and moderate epigastric tenderness?

Next Step: CT Scan of Abdomen and Pelvis

In a previously healthy patient presenting with sudden severe epigastric pain, normal amylase/lipase, and tachycardia with leukocytosis, the next step is computerized tomography of the abdomen and pelvis with IV contrast (Option C). 1

Clinical Reasoning for CT Imaging

CT scan is the recommended first-line imaging for suspected perforated peptic ulcer, which classically presents with sudden severe epigastric pain. 1 The World Society of Emergency Surgery strongly recommends CT imaging in patients with acute abdomen from suspected perforated peptic ulcer, as it has superior sensitivity for detecting free air, characterizing perforation site and size, and excluding other causes. 1

Key Clinical Features Supporting CT

• Leukocytosis with severe pain suggests significant intra-abdominal pathology, and this combination warrants urgent CT evaluation 1
• The sudden onset and severity of pain, combined with tachycardia and leukocytosis (16% segmented neutrophils), indicates a potentially surgical emergency 2
• Normal amylase and lipase do not exclude surgical emergencies - the World Society of Emergency Surgery advises against relying on these values to exclude perforated ulcer and early mesenteric ischemia 1

Critical Differential Diagnoses Requiring CT

Perforated Peptic Ulcer

• CT detects pneumoperitoneum, unexplained intraperitoneal fluid, bowel wall thickening, and mesenteric fat streaking with high sensitivity 1
• Typical CT findings include extraluminal gas (97%), fluid or fat stranding along gastroduodenal region (89%), ascites (89%), focal wall defect/ulcer (84%), and wall thickening (72%) 3
• Up to 12% of perforations may have normal CT, but it remains the most sensitive test available 1

Acute Mesenteric Ischemia

• Patients with acute mesenteric ischemia present with "abdominal pain out of proportion to physical examination", and CT angiography should be performed as soon as possible 1
• The American College of Radiology recommends CT angiography for any patient with suspicion for acute mesenteric ischemia, as delay in diagnosis accounts for mortality rates of 30-70% 1
• Early laboratory findings, including normal amylase/lipase, are insufficient for diagnosis 1

Why Other Options Are Inappropriate

Option A (IV Ranitidine) - Incorrect

• Administering empiric acid suppression without establishing a diagnosis delays potentially life-saving intervention 2
• In the setting of possible perforation or ischemia, medical management alone is dangerous 2

Option B (Urgent Endoscopy) - Incorrect

• Endoscopy is contraindicated if perforation is suspected, as insufflation can worsen pneumoperitoneum 2
• Diagnostic imaging must precede endoscopy to exclude surgical emergencies 2

Option D (Abdominal Ultrasonography) - Incorrect

• While ultrasound is mentioned in guidelines for intra-abdominal infections, CT with IV contrast is superior for evaluating acute abdomen 2
• The American College of Radiology recommends proceeding directly to CT in facilities with CT access, given superior diagnostic accuracy and the need to exclude multiple life-threatening conditions simultaneously 1

Common Pitfalls to Avoid

• Do not delay CT imaging for additional laboratory tests - in patients not undergoing immediate laparotomy, CT scan is the imaging modality of choice to determine the presence of an intra-abdominal infection and its source 2
• Do not assume normal pancreatic enzymes exclude serious pathology - this patient's presentation is more consistent with perforation or ischemia than pancreatitis 1
• Do not miss cardiac causes - while obtaining CT, ensure an EKG has been performed to exclude myocardial ischemia, particularly given the tachycardia 3

Immediate Management Priorities

While arranging CT imaging, the patient should undergo:

• Rapid restoration of intravascular volume to address tachycardia 2
• NPO status pending diagnosis 4
• Surgical consultation notification given the high likelihood of surgical pathology 2