What are the next steps for a patient with persistent stomach pain lasting more than 48 hours?

Evaluation and Management of Stomach Pain >48 Hours

For a patient with persistent stomach pain lasting more than 48 hours, immediately check vital signs and obtain CT abdomen/pelvis with IV contrast along with laboratory testing (CBC, CRP, lactate) to identify life-threatening conditions requiring urgent intervention. 1

Immediate Assessment

Check vital signs immediately for fever, tachycardia, tachypnea, hypotension, or altered mental status—these indicate potential organ failure or sepsis requiring immediate resuscitation. 1

• Establish IV access and initiate fluid resuscitation if signs of sepsis or shock are present. 1
• Administer low-molecular-weight heparin for VTE prophylaxis, as acute abdominal pain carries high thrombotic risk. 1
• Severe abdominal pain out of proportion to physical examination findings should be assumed to be acute mesenteric ischemia until disproven. 2

Laboratory Testing

Obtain the following tests to assess for surgical disease and infection:

• Complete blood count with differential to assess for signs of infection or inflammation. 1
• C-reactive protein (CRP) levels, as it is more sensitive than WBC alone for identifying surgical abdominal disease. 1
• Serum lactate levels, as elevated levels suggest bowel ischemia or sepsis. 1
• Hepatobiliary markers, electrolytes, creatinine, glucose, urinalysis, lipase, and pregnancy testing (if applicable). 3

Imaging

Obtain CT abdomen/pelvis with IV contrast as the primary imaging modality, as it changes diagnosis in 51-54% of cases and alters management in 25-42% of patients. 1

• Do not delay CT for oral contrast, as this delays diagnosis without improving accuracy. 1
• For right upper quadrant pain specifically, ultrasonography is the study of choice. 3
• In pregnant patients with inconclusive ultrasonography, magnetic resonance imaging is preferred over CT when available. 3

High-Risk Conditions to Prioritize

Life-threatening conditions that must be identified urgently include:

• Acute mesenteric ischemia: Suspect in patients with severe pain out of proportion to exam, especially with acidosis and organ failure. 2
• Perforated viscus: Look for free air on imaging. 1
• Small bowel obstruction: Common cause requiring surgical evaluation. 1, 3
• Appendicitis: Most common surgical cause (15.9-28.1% of acute abdominal pain). 3, 4
• Acute cholecystitis: Particularly in right upper quadrant pain. 3
• Diverticulitis: More common in elderly patients. 3
• Intra-abdominal abscess: Requires antibiotics and possible drainage. 1

Antibiotic Management

Do not routinely administer antibiotics for undifferentiated abdominal pain unless there is evidence of intra-abdominal infection or sepsis. 2, 1

Antibiotics are indicated when:

• Intra-abdominal abscess is identified on imaging. 1
• Clinical signs of sepsis are present. 1
• Specific infection is confirmed. 1
• In inflammatory bowel disease patients, reserve antibiotics only for superinfection, intra-abdominal abscesses, and sepsis. 2

Surgical Consultation

Obtain immediate surgical consultation for any of the following:

• Signs of peritonitis. 1
• Hemodynamic instability. 1
• Free air on imaging. 1
• Complete bowel obstruction. 1
• Mesenteric ischemia. 1
• Failed conservative management of identified surgical pathology. 1

For inflammatory bowel disease patients, if condition does not improve or deteriorates within 48-72 hours from initiation of medical therapy, surgery should be considered in discussion with gastroenterology. 2

Special Considerations for Non-Surgical Causes

If imaging and laboratory testing do not reveal surgical pathology:

• Consider irritable bowel syndrome in patients <45 years without alarm features (rectal bleeding, weight loss, anemia) with symptom duration >2 years. 2, 5
• For patients >45 years with new-onset symptoms, colonoscopy is required to exclude colorectal malignancy. 5
• Gastroenteritis and nonspecific abdominal pain are the most common causes overall (24-44.3% of cases). 3, 4

Common Pitfalls

• Do not withhold analgesia while awaiting diagnosis—early administration reduces patient discomfort without impairing diagnostic accuracy. 4
• Do not rely on plain abdominal radiography alone—it has significant diagnostic limitations compared to CT. 6
• Do not delay imaging in patients with persistent pain >48 hours, as this represents a critical threshold for identifying serious pathology. 2
• In critically ill patients requiring vasopressor support with abdominal pain or distension, suspect non-occlusive mesenteric ischemia (NOMI). 2