What is the appropriate initial management for a patient presenting with stomach ache?

Initial Management of Stomach Ache

Begin with immediate vital sign assessment and focused clinical evaluation to determine pain location, then proceed directly to appropriate imaging based on anatomic location—CT with contrast for nonlocalized pain, ultrasound for right upper quadrant pain, and CT for lower quadrant pain—while simultaneously obtaining mandatory pregnancy testing in all women of reproductive age. 1, 2, 3

Immediate Assessment Priorities

Vital Signs and Red Flags

• Check for hemodynamic instability immediately: tachycardia, hypotension, fever >38.5°C, tachypnea, or decreased urine output indicate potential sepsis, bleeding, or perforation requiring urgent intervention 1, 3
• Tachycardia is the single most sensitive early warning sign of surgical complications and should trigger urgent investigation even before other symptoms develop 3
• Pain out of proportion to physical findings strongly suggests mesenteric ischemia and requires immediate vascular imaging 2, 3
• Peritoneal signs (rigid abdomen, rebound tenderness, guarding) indicate perforation or ischemia requiring emergency surgical consultation 1, 2

Focused History Elements

• Pain location is the primary determinant of your diagnostic and imaging approach 1, 3, 4
• Document onset (sudden onset suggests vascular catastrophe), duration, quality, radiation, and aggravating/alleviating factors 1, 3
• Associated symptoms: nausea, vomiting (early vomiting suggests small bowel obstruction), diarrhea, constipation, fever, or hematemesis 5, 1
• Last bowel movement and passage of gas (85% sensitivity for adhesive small bowel obstruction in patients with prior surgery) 3

Physical Examination Specifics

• Inspect for distension, auscultate for bowel sounds, percuss for tympany, palpate systematically by quadrant 1
• Check all hernia orifices and surgical scars—missing an incarcerated hernia is a common pitfall 2
• Murphy's sign for right upper quadrant pathology 3
• Digital rectal examination (empty rectum classic for sigmoid volvulus) 3

Mandatory Laboratory Testing

Essential Initial Labs

• Complete blood count for leukocytosis (infection/inflammation) 1, 3
• β-hCG in ALL women of reproductive age before any imaging—failure to obtain this test can delay diagnosis of ectopic pregnancy, a critical pitfall 1, 2, 3
• Metabolic panel, liver function tests, amylase, lipase for suspected hepatobiliary or pancreatic disease 1, 3
• Lactate level to assess for bowel ischemia or severe sepsis 1, 3
• C-reactive protein (superior sensitivity/specificity compared to WBC for surgical disease, though normal CRP doesn't exclude complications) 3

Additional Labs Based on Suspicion

• Procalcitonin for suspected sepsis 3
• D-dimer if mesenteric ischemia suspected 3

Imaging Strategy by Pain Location

Right Upper Quadrant Pain

• Ultrasound is the initial imaging test of choice (81% sensitivity, 83% specificity for cholecystitis) 1, 2, 3, 4
• Evaluates for acute cholecystitis, choledocholithiasis, cholangitis 5, 2

Right Lower Quadrant Pain

• CT abdomen/pelvis with IV contrast for suspected appendicitis (>95% sensitivity) 1, 2, 3
• Consider ultrasound first in young patients to minimize radiation exposure, then proceed to CT if nondiagnostic 3
• Must exclude ectopic pregnancy in women of reproductive age 2

Left Lower Quadrant Pain

• CT abdomen/pelvis with IV contrast for suspected diverticulitis 1, 2, 3
• Consider sigmoid volvulus in elderly with chronic constipation 2, 3

Epigastric Pain

• If clinical suspicion for GERD, esophagitis, gastritis, or peptic ulcer disease: CT is not first-line but may be performed if symptoms are nonspecific 5
• CT has relatively low negative predictive value (64%) for upper abdominal pathology and commonly misses pancreaticobiliary inflammatory processes, gastritis, and duodenitis 2
• Upper endoscopy is the standard test of choice for these entities 5

Nonlocalized or Diffuse Abdominal Pain

• CT abdomen/pelvis with IV contrast is the imaging modality of choice (changes primary diagnosis in 51% of cases, alters admission decision in 25%) 5, 1, 2, 3
• Plain radiographs have limited diagnostic value and should not be routinely ordered except for suspected bowel obstruction 1, 3

Suspected Kidney Stones

• Non-contrast CT abdomen/pelvis 1, 3

Initial Management Approach

Hemodynamically Unstable Patients

• Immediate IV fluid resuscitation with crystalloid solutions 1
• Emergency surgical consultation for signs of peritonitis, perforation, or septic shock 1
• These patients require emergency surgical exploration 1

Stable Patients with Suspected Infection

• Antibiotics are NOT routinely administered but are indicated for suspected infection or intra-abdominal abscess 1
• Abscesses >3cm: consider percutaneous drainage with antimicrobial therapy 1
• Small abscesses (<3cm): may be treated with IV antibiotics alone 1

Empiric Acid Suppression (When Appropriate)

For suspected peptic ulcer disease or GERD after excluding surgical emergencies:

• Proton pump inhibitors are preferred over H2-receptor antagonists for acid suppression 6
• H2-receptor antagonists (e.g., cimetidine 800 mg at bedtime) can be used for duodenal ulcer, though PPIs are more effective 7

Special Population Considerations

Elderly Patients

• Atypical presentations are the rule, not the exception—may have normal laboratory tests despite serious pathology 5, 2, 3
• Higher likelihood of malignancy, diverticulitis, and vascular causes 2, 3
• Require more thorough evaluation even with normal initial workup 2, 3

Women of Reproductive Age

• Always consider gynecologic causes: ectopic pregnancy, ovarian torsion, pelvic inflammatory disease 1, 3
• Ultrasound should be first-line imaging in pregnancy, with MRI preferred over CT if additional imaging needed 1

Immunocompromised Patients

• May have masked signs of abdominal sepsis with delayed diagnosis and high mortality 3
• Lower threshold for advanced imaging 5

Post-Bariatric Surgery Patients

• Tachycardia is the most critical warning sign—classic peritoneal signs often absent 3
• Consider internal herniation even with normal lactate 3

Disposition Decisions

Admit to Hospital

• Severe pain with hemodynamic instability 1
• Peritoneal signs or suspected surgical conditions 1
• Fever with tachycardia and tachypnea (predicts serious complications including anastomotic leak, perforation, or sepsis) 3

Consider Discharge with Close Follow-up

• Stable vital signs, no peritoneal signs, diagnostic workup negative or shows non-surgical pathology 1
• Ensure patient can tolerate oral intake and has reliable follow-up 1

Critical Pitfalls to Avoid

• Relying solely on laboratory tests without appropriate imaging—many conditions require imaging for definitive diagnosis 1
• Delaying surgical consultation in patients with peritonitis or signs of septic shock 1
• Overlooking gynecological causes in women of reproductive age 1, 2
• Over-relying on normal laboratory values early in disease—elderly patients especially may have normal labs despite serious infection 2, 3
• Failing to check all hernia orifices and surgical scars during examination 2
• Overusing CT scans in young patients without considering ultrasound first 3
• Assuming absence of peritonitis excludes bowel ischemia—patients with sigmoid volvulus often lack peritoneal signs despite established ischemia 3
• Ordering plain radiographs routinely—they have limited diagnostic value except for suspected bowel obstruction 1, 3