What is the management for a 65-year-old female with sudden abdominal pain, vomiting, and hypertension, who missed her morning medication and has a history of similar episodes?

Management of Acute Abdominal Pain with Vomiting in a 65-Year-Old Hypertensive Patient

This patient requires immediate CT abdomen/pelvis with IV contrast to exclude life-threatening surgical emergencies, particularly given her age, missed antihypertensive medication, and recurrent episodes. 1, 2, 3

Immediate Assessment and Stabilization

Begin with rapid hemodynamic assessment looking specifically for tachycardia, hypotension, fever, or tachypnea—these combinations predict serious complications including bowel ischemia or perforation. 3 In elderly patients, even subtle vital sign abnormalities can indicate significant pathology. 4

• Start aggressive IV crystalloid resuscitation immediately to address dehydration from vomiting 3
• Place patient NPO and consider nasogastric tube decompression if vomiting continues or becomes bilious 3
• Obtain immediate laboratory tests: complete blood count, electrolytes, renal function, blood gas, lactate, lipase, and C-reactive protein 1, 3

Critical Red Flags to Assess

Perform focused physical examination specifically checking for:

• Peritoneal signs (rebound tenderness, guarding, rigidity)—these indicate possible perforation or bowel necrosis requiring immediate surgical consultation 1, 3
• Abdominal distension with diminished bowel sounds—classic for bowel obstruction 3
• Severe pain out of proportion to examination findings—suggests acute mesenteric ischemia until proven otherwise 2, 3

In elderly patients, clinical presentation is often atypical: only 43-48% have positive Murphy's sign, 36-74% have fever, and 12% present with atypical or no pain at all. 4 This makes imaging even more critical.

Diagnostic Imaging Strategy

Proceed directly to CT abdomen/pelvis with IV contrast as the definitive diagnostic test. 1, 2, 3 This is superior to plain radiography and must be obtained urgently to:

• Confirm or exclude acute cholecystitis (given epigastric/umbilical tenderness in elderly female) 4
• Identify bowel obstruction and transition points 3
• Detect bowel ischemia (mortality 30-70% if delayed) 2
• Rule out perforated peptic ulcer (sensitivity superior to plain films) 2
• Exclude other surgical emergencies simultaneously 2

Critical caveat: Plain abdominal radiograph has limited sensitivity—negative films do NOT exclude mesenteric ischemia or early obstruction. 3 Up to 12% of perforations may have normal CT, but it remains the most sensitive test available. 2

Consider ACE Inhibitor-Induced Angioedema

Given the missed antihypertensive medication this morning and recurrent episodes, specifically consider ACE inhibitor or ARB-induced intestinal angioedema. 5 This presents with:

• Sudden abdominal pain, nausea, and vomiting 5
• CT findings of markedly thickened stomach, duodenum, and jejunum with ascites 5
• Symptoms improve within 24 hours of discontinuing the medication 5

If CT shows bowel wall thickening without other surgical pathology and patient is on ACE inhibitor/ARB, discontinue the medication immediately. 5

Differential Diagnosis Requiring Urgent Action

If Acute Cholecystitis Suspected

• Elderly patients have higher rates of leucocytosis (41.2%) and elevated CRP (64.1%) compared to younger patients 4
• Start broad-spectrum antibiotics (third-generation cephalosporin plus metronidazole, or fluoroquinolone plus metronidazole) once suspected 1
• Obtain immediate surgical consultation for definitive management 1

If Bowel Obstruction Suspected

• Prior abdominal surgery has 85% sensitivity for adhesive small bowel obstruction 3
• Serial abdominal examinations every 4-6 hours to detect development of peritonitis 1, 3
• Any clinical deterioration mandates immediate surgical re-evaluation 1

If Mesenteric Ischemia Suspected

• Perform CT angiography immediately—delay accounts for mortality rates of 30-70% 2
• Elevated lactate and metabolic acidosis on blood gas are critical findings 3
• Absence of peritonitis does NOT exclude bowel ischemia 3

Symptomatic Management

Antiemetic therapy with ondansetron 8 mg sublingual every 4-6 hours (requires baseline ECG due to QTc prolongation risk), promethazine 12.5-25 mg every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours. 4 Use caution with promethazine and prochlorperazine in elderly patients due to anticholinergic effects and CNS depression. 4

Surgical Consultation Timing

Immediate surgical consultation is mandatory if:

• Signs of shock (tachycardia alone is a critical warning sign) 3
• Diffuse peritonitis 1
• Clinical deterioration 1
• Imaging confirms surgical pathology 1

Do not delay imaging or surgical consultation by attempting empiric medical management—this is dangerous in the setting of possible perforation or ischemia. 2

Special Consideration: Cyclic Vomiting Syndrome

Only after excluding all surgical emergencies, consider cyclic vomiting syndrome if patient has documented history of similar self-limited episodes with complete recovery between episodes. 4, 6 However, this is a diagnosis of exclusion requiring extensive workup including esophagogastroduodenoscopy, blood work (CBC, electrolytes, glucose, liver function, lipase), and urinalysis. 4 The association with hypertension has been reported. 6