What is the best course of action for a geriatric patient presenting with nausea, vomiting, dull abdominal pain, and no fever?

Geriatric Patient with Nausea, Vomiting, Dull Pain, and No Fever

This geriatric patient requires urgent CT abdomen/pelvis with IV contrast to exclude life-threatening intra-abdominal pathology, as elderly patients frequently present with atypical symptoms and normal laboratory values despite serious infection or surgical emergencies. 1, 2

Critical Diagnostic Considerations

Why This Presentation is High-Risk in the Elderly

• Only 50% of elderly patients with acute cholecystitis have typical right upper quadrant pain, only 17% have fever, and 43% lack leukocytosis 1
• Atypical or absent pain occurs in 12-17% of elderly patients with acute cholecystitis, making clinical diagnosis unreliable 1
• Laboratory tests are frequently nonspecific and may be normal despite serious infection in elderly patients, increasing diagnostic difficulty 1, 2
• Absence of fever does NOT exclude serious pathology—only 6.4-10% of elderly patients with acute cholecystitis have temperature >38°C 1

Life-Threatening Diagnoses to Exclude

Intra-abdominal abscess presents with fever (which may be absent), diffuse or localized abdominal pain, and predisposing conditions including appendicitis, diverticulitis, inflammatory bowel disease, or pancreatitis 1, 2

Malignant conditions including lymphoma and necrotizing masses can present identically with abdominal pain, nausea, and vomiting 1, 2

Small bowel obstruction presents with generalized abdominal pain, nausea, and vomiting in elderly patients 3

Acute diverticulitis in elderly patients often lacks fever (only 50% have lower quadrant pain, 17% have fever, 43% lack leukocytosis) 1

Immediate Diagnostic Workup

Imaging (First Priority)

CT abdomen/pelvis with IV contrast is mandatory for all elderly patients with suspected intra-abdominal pathology 1, 2

• CT changes the leading diagnosis in 51% of cases and alters admission decisions in 25% of patients with abdominal pain 1
• CT increases detection of cholecystitis/cholangitis by 100% and detects abscesses, peritoneal thickening, lymphadenopathy, and bowel abnormalities 1, 2
• For elderly patients with suspected diverticulitis, CT with IV contrast should be used in all cases to distinguish complicated from uncomplicated disease 1

Alternative imaging if CT with IV contrast is contraindicated (severe renal disease or contrast allergy): ultrasound, MRI, or CT without contrast 1

Laboratory Testing

Obtain complete blood count, comprehensive metabolic panel, lipase, and C-reactive protein 1, 4

• CRP >175 mg/L suggests complicated diverticulitis, but 39% of complicated cases have CRP below this threshold 1
• Elevated WBC and CRP may be present but are unreliable—elderly patients with acute cholecystitis show only statistically (not clinically) significant elevations 1
• Urinalysis and urine culture to exclude urinary tract infection (which can present atypically in elderly) 1

Physical Examination Specifics

Assess for Murphy's sign (sensitivity 0.48, specificity 0.79 in elderly for acute cholecystitis) 1

Check for abdominal tenderness, guarding, or peritoneal signs (present in 64.7% of elderly patients with acute cholecystitis, but peritonitis signs only in 5.3-14.5%) 1

Evaluate hydration status and vital signs (dehydration, acidosis, or hemodynamic instability warrant immediate intervention) 4

Critical Pitfalls to Avoid

Do NOT rely on absence of fever to exclude serious pathology—fever is present in only 36-74% of elderly patients with acute cholecystitis 1

Do NOT delay CT imaging based on normal laboratory values—elderly patients frequently have normal labs despite serious infection 1, 2

Do NOT use plain abdominal radiographs as initial imaging—they have low sensitivity and should not delay CT 1, 2

Do NOT assume gastroenteritis without imaging—this presentation could represent bowel obstruction, abscess, or malignancy 1, 2, 3

Symptomatic Management While Awaiting Diagnosis

Antiemetic Therapy

Metoclopramide 10 mg PO/IV every 6-8 hours has the strongest evidence for nonspecific nausea and vomiting 1

Alternative agents include ondansetron 8 mg PO/IV (5-HT3 antagonist), prochlorperazine 10 mg PO/IV, or haloperidol 0.5-2 mg PO/IV 1, 5

• For elderly patients, no dosage adjustment of ondansetron is needed unless severe hepatic impairment (Child-Pugh ≥10), in which case limit to 8 mg total daily dose 5

Fluid and Electrolyte Management

Initiate IV fluid resuscitation if dehydration is present 4

Consider nasogastric tube placement if bowel obstruction is suspected on imaging 3

Disposition and Next Steps

Admit to hospital if imaging reveals:

• Complicated diverticulitis, abscess, or perforation 1, 2
• Small bowel obstruction 3
• Acute cholecystitis (especially if elderly, as they have higher complication rates) 1
• Any surgical emergency requiring intervention 1, 2

Percutaneous drainage under CT or ultrasound guidance combined with broad-spectrum antibiotics for identified abscesses 2

Surgery is reserved for complications including perforation, failed percutaneous drainage, or bowel ischemia 2