What is the most appropriate initial step in managing a patient with severe upper abdominal pain, nausea, abdominal rigidity, and elevated serum amylase (Amylase) and lipase (Lipase) levels, leukocytosis (White Blood Cell count of 15,000), and exquisite tenderness to palpation of the epigastric region?

Surgical Consultation is the Most Appropriate Initial Step

This patient requires immediate surgical consultation given the clinical presentation of acute abdomen with peritoneal signs (abdominal rigidity and exquisite epigastric tenderness), which suggests a surgical emergency such as perforated peptic ulcer or acute pancreatitis with potential complications. 1

Clinical Reasoning for Surgical Consultation

The combination of sudden severe epigastric pain, abdominal rigidity, exquisite tenderness, and leukocytosis (WBC 15,000) indicates a potentially surgical emergency requiring urgent evaluation. 1 While the elevated amylase (204 U/L) and lipase (135 U/L) suggest pancreatic involvement, these values are only modestly elevated (less than 3 times the upper limit of normal), which does not exclude severe acute pancreatitis or other surgical pathologies. 2, 3

The presence of abdominal rigidity is a critical finding that indicates peritoneal irritation and mandates surgical evaluation regardless of enzyme levels. 1 The World Society of Emergency Surgery emphasizes that patients with peritoneal signs, hemodynamic instability, or clinical deterioration require urgent surgical consultation and should not be delayed while awaiting laboratory or imaging results. 4

Why Other Options Are Inappropriate

GI Cocktail

• Administering empiric acid suppression or symptomatic treatment without establishing a diagnosis delays potentially life-saving intervention in the setting of possible perforation or ischemia. 1
• Medical management alone is dangerous when peritoneal signs are present. 1

Blood Transfusion

• There is no indication for blood transfusion in this presentation—no evidence of anemia, bleeding, or hemodynamic instability requiring transfusion is described.

H2 Blocker Therapy

• Initiating acid suppression therapy without diagnostic evaluation is inappropriate and potentially harmful, as it delays recognition of surgical emergencies. 1
• This approach assumes peptic ulcer disease without excluding perforation or other surgical pathologies.

Gastric Referral

• Non-urgent gastroenterology referral is inappropriate when surgical pathology is suspected.
• Diagnostic imaging must precede endoscopy to exclude surgical emergencies. 1

Diagnostic Considerations

Acute Pancreatitis vs. Perforated Viscus

The modest elevation in pancreatic enzymes (amylase 204 U/L, lipase 135 U/L) does not exclude severe acute pancreatitis. Research demonstrates that patients with enzyme elevations less than 3 times the upper limit of normal can still develop severe acute pancreatitis with the same incidence of complications, need for surgery, and mortality as those with higher enzyme levels. 2 This is particularly true in alcohol-induced pancreatitis, where enzyme levels tend to be lower. 2

However, the presence of abdominal rigidity is atypical for uncomplicated acute pancreatitis and raises concern for:

• Perforated peptic ulcer 1
• Acute mesenteric ischemia 1
• Complicated pancreatitis with peritonitis 5

Imaging Requirements

CT scan with IV contrast is the recommended first-line imaging for this presentation, as it can:

• Detect pneumoperitoneum with high sensitivity in perforated peptic ulcer 1
• Evaluate for acute mesenteric ischemia (which can present with "pain out of proportion to exam" and normal initial enzyme levels) 1
• Assess pancreatic inflammation and complications 5
• Identify other surgical pathologies 1

The World Society of Emergency Surgery strongly recommends CT imaging in patients with acute abdomen and peritoneal signs, as it has superior sensitivity for detecting surgical emergencies. 1

Immediate Management Algorithm

1. Obtain immediate surgical consultation (do not delay for imaging if patient is unstable) 4, 1
2. Initiate aggressive IV fluid resuscitation with isotonic crystalloids while awaiting surgical evaluation 5
3. Order urgent CT abdomen/pelvis with IV contrast (if hemodynamically stable) 1
4. Keep patient NPO 5
5. Provide IV analgesia (avoid oral medications given potential surgical intervention) 5
6. Monitor vital signs continuously 5

Critical Pitfalls to Avoid

• Do not delay surgical consultation while waiting for imaging results if peritoneal signs are present. 4
• Do not rely on normal or mildly elevated amylase/lipase to exclude surgical emergencies—these values are non-specific and frequently normal in perforated ulcer and early mesenteric ischemia. 1
• Do not assume mild enzyme elevation indicates mild disease—severity of acute pancreatitis is independent of enzyme elevation magnitude. 2
• Do not initiate empiric medical therapy without establishing a diagnosis when surgical pathology is suspected. 1

The inability to control a septic source is associated with intolerably high mortality rates, making early surgical evaluation paramount in patients with peritoneal signs. 5