What is the best course of management for a 22-year-old non-pregnant female presenting to the emergency department (ED) with lower abdominal pain, lymphocytosis (elevated lymphocytes), hypokalemia (low potassium), mildly elevated liver enzymes (aspartate aminotransferase (AST) and alanine aminotransferase (ALT)), and imaging findings of gastroenteritis and a right ovarian cyst?

Management of 22-Year-Old Female with Lower Abdominal Pain, Gastroenteritis, and Ovarian Cyst

This patient requires conservative management with supportive care, correction of hypokalemia and electrolyte abnormalities, and close clinical monitoring for complications of the ovarian cyst, with no immediate surgical intervention indicated unless signs of ovarian torsion, rupture with hemodynamic instability, or peritonitis develop. 1, 2

Immediate Management Priorities

Electrolyte Correction

• Potassium replacement is essential given the hypokalemia (3.2 mEq/L, normal 3.5-5.0) which likely results from gastroenteritis-related losses through vomiting or diarrhea 3
• Administer oral potassium chloride supplementation for mild-to-moderate hypokalemia in patients who can tolerate oral intake 3
• If the patient cannot tolerate oral intake due to ongoing vomiting, IV potassium replacement should be initiated with close monitoring 3
• Correct hyponatremia (135 mEq/L) with appropriate fluid management, typically isotonic saline given the context of gastroenteritis 1

Supportive Care for Gastroenteritis

• Provide IV hydration to address fluid losses and correct the low BUN (7 mg/dL), which suggests volume depletion 1
• Antiemetics as needed for symptom control 1
• Monitor for worsening abdominal pain, fever, or signs of peritonitis that would suggest complications 4, 1

Ovarian Cyst Management

Conservative Approach Indicated

• 84.7% of ruptured ovarian cysts are managed conservatively with excellent outcomes 2
• The CT has already been performed and shows the cyst; no additional imaging is immediately necessary unless clinical deterioration occurs 1
• Most functional ovarian cysts (corpus luteum, follicular) resolve spontaneously without intervention 2

Indications for Surgical Intervention

Surgery is reserved for specific complications, which should be monitored for but are not currently present 2:

• Hemodynamic instability (hypotension, tachycardia, signs of significant hemorrhage) 2
• Large volume of free fluid on imaging suggesting significant hemorrhage (>500 mL) 2
• Signs of ovarian torsion: sudden severe pain, enlarged ovary with decreased blood flow on Doppler ultrasound 4
• Peritonitis with rigid abdomen and rebound tenderness 4, 1
• Cyst size >5-6 cm with persistent symptoms after conservative management 2

Laboratory Abnormalities Assessment

Lymphocytosis (17.2 × 10³/μL)

• Likely reactive lymphocytosis secondary to viral gastroenteritis 1
• Eosinopenia (0.6) is consistent with acute stress response or infection 1
• These findings support the gastroenteritis diagnosis rather than suggesting alternative pathology 1

Mild Transaminitis and Hyperbilirubinemia

• AST 55 and ALT 55 (mild elevation) with total bilirubin 2.4 and alkaline phosphatase 127 suggest mild hepatic involvement 1
• This pattern is consistent with dehydration, systemic inflammation from gastroenteritis, or transient hepatic congestion 1
• These abnormalities typically resolve with hydration and treatment of the underlying condition 1
• No specific hepatobiliary intervention is needed unless values worsen or right upper quadrant symptoms develop 4

Monitoring Plan

Clinical Reassessment

• Serial abdominal examinations every 4-6 hours to detect peritoneal signs, increasing pain, or guarding 4, 1
• Monitor vital signs closely, particularly for tachycardia (most sensitive early warning sign of complications) 1
• Assess for severe pain out of proportion to examination findings, which would suggest vascular compromise 1

Laboratory Monitoring

• Repeat complete blood count to monitor for worsening leukocytosis or development of anemia (suggesting hemorrhage) 1
• Repeat comprehensive metabolic panel after electrolyte replacement to confirm correction 1
• If liver enzymes worsen or bilirubin continues to rise, consider hepatobiliary ultrasound 4

Repeat Imaging Considerations

• Repeat imaging has low yield (5.9%) if initial CT was comprehensive and clinical status is stable 1
• Consider repeat ultrasound or CT only if: clinical deterioration occurs, new peritoneal signs develop, or hemodynamic instability emerges 1
• Pelvic ultrasound with Doppler is preferred over repeat CT if ovarian torsion becomes a concern, to assess ovarian blood flow and avoid additional radiation 4

Common Pitfalls to Avoid

• Do not dismiss worsening abdominal pain as "just gastroenteritis" – ovarian cyst complications can develop acutely and require surgical intervention 2, 5
• Do not delay potassium replacement – hypokalemia can cause cardiac arrhythmias, particularly if the patient has any underlying cardiac conditions 3
• Do not routinely operate on ovarian cysts in young women – the vast majority resolve spontaneously, and unnecessary surgery carries risks 2
• Do not assume all lower abdominal pain in young women is gynecologic – gastroenteritis is confirmed on CT and is the primary driver of symptoms here 4
• Avoid repeat CT scanning without clear clinical indication – diagnostic yield drops significantly with repeated imaging in stable patients 1

Disposition and Follow-Up

• Admit for observation if unable to tolerate oral intake, persistent vomiting, or significant pain requiring IV analgesia 1
• Discharge with close outpatient follow-up (24-48 hours) if tolerating oral intake, pain controlled with oral analgesia, and electrolytes corrected 1
• Arrange gynecology follow-up in 4-6 weeks with repeat pelvic ultrasound to confirm cyst resolution 2
• Provide clear return precautions: severe abdominal pain, fever >38.5°C, persistent vomiting, dizziness, or syncope 1, 2