What is the best course of action for a female patient (Pt) complaining of abdominal pain and itching all over her body for the last 10 days, with no recent changes to medication or hygiene?

Immediate Evaluation for Life-Threatening Causes

This patient requires urgent evaluation for cholestasis/biliary obstruction and parasitic infection, as generalized pruritus with abdominal pain in the absence of medication changes strongly suggests hepatobiliary disease or systemic helminthic infection. 1

Critical First Steps

Rule Out Cholestatic Disease (Most Likely)

• Obtain liver function tests immediately (ALT, AST, alkaline phosphatase, bilirubin, GGT) as generalized pruritus with abdominal pain is pathognomonic for cholestasis until proven otherwise 1
• Check complete blood count looking specifically for eosinophilia, which would suggest parasitic infection 2
• Measure C-reactive protein or ESR to assess for inflammatory processes 1

Physical Examination Priorities

• Examine for jaundice (scleral icterus, skin discoloration) indicating biliary obstruction 1
• Palpate right upper quadrant for hepatomegaly or Murphy's sign suggesting biliary disease 3
• Assess for excoriations from scratching, which confirms true pruritus rather than paresthesia 4
• Check for fever, which combined with right upper quadrant pain suggests cholangitis requiring emergency intervention 1

Diagnostic Imaging

If liver enzymes show cholestatic pattern (elevated alkaline phosphatase, GGT, bilirubin), obtain right upper quadrant ultrasonography immediately to evaluate for biliary obstruction, choledocholithiasis, or hepatic pathology 3

Parasitic Infection Consideration

When to Suspect Helminthic Disease

• If eosinophilia is present (>500 cells/μL), strongly consider parasitic causes 2
• Obtain concentrated stool microscopy or fecal PCR for ova and parasites 2, 1
• Ask specifically about:
  • Recent travel to endemic areas 2
  • Consumption of raw/undercooked meat or fish 2
  • Walking barefoot on soil 2
  • Contact with contaminated water 2

Specific Parasites Causing Abdominal Pain + Pruritus

• Ascariasis can cause biliary obstruction in adults with generalized symptoms 2
• Strongyloidiasis causes abdominal pain, diarrhea, and urticarial rash with pruritus 2
• Hookworm presents with ground itch followed weeks later by abdominal pain 2

Functional Causes (Diagnosis of Exclusion Only)

Do not diagnose functional abdominal pain until organic causes are excluded - symptoms must be present for at least 6 months with active symptoms for 3 months before considering IBS or functional disorders 1

This patient's 10-day duration is far too acute for functional diagnosis 1

Immediate Management Algorithm

1. Stat laboratory tests: LFTs, CBC with differential, CRP/ESR 1
2. If cholestatic pattern: RUQ ultrasound within hours 3
3. If eosinophilia present: Stool studies for parasites, consider empiric treatment if severe 2
4. If fever + RUQ pain + jaundice (Charcot's triad): Emergency surgical consultation for possible cholangitis 1
5. If all initial workup negative: Consider celiac serology, fecal calprotectin to exclude inflammatory bowel disease 1

Common Pitfalls to Avoid

• Do not attribute generalized pruritus to "dry skin" or dermatologic causes when accompanied by abdominal pain - this combination mandates systemic workup 4
• Do not delay imaging if cholestatic labs are present - biliary obstruction can rapidly progress to cholangitis with high mortality 1
• Do not miss parasitic infection in patients without obvious travel history - many helminths have worldwide distribution 2
• Do not diagnose functional pain in a patient with only 10 days of symptoms - the 6-month criterion exists specifically to prevent missing organic disease 1