What is the management for a patient with 2 days of intermittent fever, epigastric pain, and vomiting?

Management of Intermittent Fever with Epigastric Pain and Vomiting

Immediately exclude life-threatening cardiac and surgical emergencies before attributing symptoms to gastroenteritis or peptic disease, as myocardial infarction can present with isolated epigastric pain and has 10-20% mortality if missed. 1, 2

Immediate Assessment and Risk Stratification

Obtain an ECG within 10 minutes of presentation and measure serial cardiac troponins at 0 and 6 hours to rule out acute coronary syndrome, as cardiac causes present atypically with epigastric pain in women, diabetics, and elderly patients. 1, 2 Do not rely on a single troponin measurement. 1

Check vital signs immediately for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict perforation or sepsis with high specificity. 1 Perform abdominal examination specifically looking for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) that indicate perforated peptic ulcer with 30% mortality if treatment is delayed. 1, 2

Order the following laboratory tests immediately:

• Complete blood count, C-reactive protein, serum lactate 1
• Liver and renal function tests 1
• Serum amylase or lipase (≥4x normal for amylase or ≥2x normal for lipase diagnoses pancreatitis with 80-90% sensitivity) 1, 2
• Serum electrolytes and glucose 1

Imaging Strategy

If peritoneal signs are present or diagnosis remains unclear after initial assessment, obtain CT abdomen and pelvis with IV contrast immediately. 1, 2 This is the gold standard for identifying pancreatitis, perforated peptic ulcer (shows extraluminal gas in 97% of cases), and vascular emergencies. 1, 2

Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis. 2

Empiric Management While Awaiting Results

Start high-dose PPI therapy immediately with omeprazole 20-40 mg once daily for suspected acid-related pathology, which achieves healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 1, 2

Maintain NPO status until surgical emergency is excluded. 1

Establish IV access and provide fluid resuscitation if hemodynamically unstable. 1

For symptomatic relief of nausea and vomiting, use:

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk) 1
• Alternatively, promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Or prochlorperazine 5-10 mg every 6-8 hours 1

Ondansetron reduces vomiting rate, improves oral intake tolerance, and decreases need for IV rehydration. 3, 4

Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk. 1

Differential Diagnosis Priority

The most likely diagnoses given 2 days of intermittent fever with epigastric pain and vomiting are:

1. Peptic ulcer disease (incidence 0.1-0.3%, complications in 2-10% of cases) 1, 2
2. Acute gastroenteritis (most common cause of this symptom triad in otherwise healthy patients) 3, 4
3. Acute pancreatitis (look for pain radiating to back) 1, 2
4. Gastroesophageal reflux disease/gastritis (affects 42% of Americans monthly) 1, 2

Disposition Decision

If cardiac causes excluded, vital signs stable, no peritoneal signs, and patient tolerates oral intake: Discharge with PPI therapy, antiemetics, and 24-48 hour follow-up. 1

If any of the following present, admit for observation:

• Persistent vomiting despite antiemetics 1
• Inability to tolerate oral fluids 4
• Hemodynamic instability 1
• Elevated pancreatic enzymes 1, 2
• Concerning imaging findings 1, 2

Critical pitfall: Never dismiss cardiac causes in patients with "atypical" epigastric pain regardless of age or presentation, as this is the most dangerous missed diagnosis. 1, 2