How to manage abdominal pain in patients with dengue fever?

Management of Abdominal Pain in Dengue Fever

Abdominal pain in dengue fever requires careful clinical assessment with conservative management focused on judicious intravenous fluid resuscitation, close monitoring for warning signs of severe disease, and avoidance of NSAIDs, while recognizing that abdominal symptoms can herald life-threatening complications requiring urgent imaging. 1

Initial Diagnostic Evaluation

Laboratory Assessment

• Obtain complete blood count with particular attention to platelet count and hematocrit trends, as thrombocytopenia and hemoconcentration are hallmarks of plasma leakage 1
• Perform liver function tests and comprehensive metabolic panel to assess hepatic involvement and organ dysfunction 1
• Monitor daily complete blood count to detect early signs of progression to dengue hemorrhagic fever 1
• Elevated alanine aminotransferase (ALT) levels occur in 77.2% of dengue patients, with higher elevations more common in dengue hemorrhagic fever compared to classic dengue fever 2

Clinical Warning Signs Requiring Intensive Monitoring

The presence of specific gastrointestinal manifestations predicts need for intensive care and should trigger heightened surveillance 2:

• Abdominal pain with tenderness on examination (strong predictor of severe disease) 2
• Gastrointestinal bleeding 2
• Jaundice 2
• Hepatomegaly 2
• Ascites 2

Imaging Considerations

• Abdominal ultrasonography is the preferred initial imaging modality when serious pathology is suspected, particularly to evaluate for acalculous cholecystitis, pleural effusion, ascites, and gallbladder wall thickening 1, 3
• CT scan with IV contrast should be reserved for cases where ultrasound is inconclusive or when surgical pathology cannot be excluded 1
• Gallbladder wall thickening and pericholecystic fluid on ultrasound may indicate acalculous cholecystitis, a recognized complication of dengue that can mimic surgical abdomen 3, 4

Critical pitfall: Dengue hemorrhagic fever can present as acute abdomen, making diagnosis challenging and potentially leading to unnecessary surgical intervention 5. Surgery is contraindicated in patients with dengue-related abdominal findings unless true surgical pathology is confirmed 4.

Fluid Management Strategy

Intravenous Fluid Resuscitation

• Careful IV fluid resuscitation is essential, especially in patients with warning signs or evidence of plasma leakage 1
• The goal is to maintain adequate perfusion while avoiding fluid overload, as dengue involves capillary leak syndrome 1
• Monitor for signs of both inadequate resuscitation (rising hematocrit, decreased urine output) and fluid overload (respiratory distress, pulmonary edema) 1

Monitoring Parameters

• Track vital signs, urine output, and hematocrit regularly to detect early signs of shock 1
• Serial hematocrit measurements help assess plasma leakage severity—rising hematocrit indicates worsening capillary leak 1
• Maintain strict fluid balance charting 1

Pain Management

Analgesic Selection

• Avoid NSAIDs completely due to increased bleeding risk in dengue patients with thrombocytopenia 1
• Acetaminophen (paracetamol) is the analgesic of choice for pain and fever control 1
• Aspirin is also contraindicated due to antiplatelet effects and bleeding risk 1

Specific Complications Requiring Recognition

Acalculous Cholecystitis

• Can occur in dengue due to direct viral invasion of gallbladder epithelial cells, vasculitis, biliary stasis, or ischemia 3
• Presents with sharp right upper quadrant pain, and ultrasound shows gallbladder wall thickening, pericholecystic fluid, and cholestasis 3
• Management is conservative—surgery is not indicated unless true surgical pathology is confirmed 3, 4

Rectus Sheath Hematoma

• Rare complication that can occur from severe vomiting and retching in thrombocytopenic patients 6
• Presents as severe abdominal pain with palpable induration 6
• Diagnosed by non-contrast CT showing bleeding into rectus sheath 6
• Managed conservatively with supportive care 6

Hepatic Involvement

• Hepatomegaly with elevated transaminases is common, with 5.9% developing acute fulminant hepatitis 2
• Jaundice indicates severe disease and need for intensive monitoring 2

Disposition and Follow-up

Criteria for Intensive Care

Patients with the following require high-dependency unit admission 2:

• Abdominal pain with tenderness
• Gastrointestinal bleeding
• Jaundice
• Hepatomegaly
• Ascites
• Signs of shock or severe plasma leakage

Outpatient vs. Inpatient Management

• Patients without warning signs and with stable vital signs, adequate oral intake, and reliable follow-up may be managed as outpatients with daily monitoring 1
• Any patient with abdominal pain and warning signs requires hospital admission for close observation during the critical phase (typically days 3-7 of illness) 1

Key principle: The pathophysiology of abdominal pain in dengue is multifactorial—including hepatic involvement, plasma leakage causing ascites, acalculous cholecystitis, and potential hemorrhagic complications—making conservative management with close surveillance the cornerstone of care rather than surgical intervention 3, 5, 4.