Adult female with no significant past medical history presents with a one‑month history of severe (9‑10/10) generalized abdominal pain that began in the epigastrium and now radiates to both lower quadrants, not relieved by antispasmodic (buscopan [hyoscine butylbromide]) or antacids and only briefly improved with omeprazole after a normal CT abdomen/pelvis; she has an ibuprofen allergy, is a non‑smoker, drinks alcohol only occasionally, and on examination has epigastric and bilateral lower‑quadrant tenderness while awake and not in distress. What is the appropriate assessment and management plan?

Assessment and Plan for Severe Recurrent Abdominal Pain with Normal CT

This patient requires urgent comprehensive workup for organic pathology before attributing symptoms to functional disorders, given the severity (9-10/10 pain), bilateral lower quadrant tenderness, and failure of initial therapy. 1

Assessment

Primary Differential Diagnoses to Exclude

Acute organic pathology remains the priority despite normal CT one month ago:

• Gynecologic emergencies (ovarian torsion, ruptured ovarian cyst, pelvic inflammatory disease, ectopic pregnancy) – epigastric pain radiating to bilateral lower quadrants in a female patient mandates urgent pelvic evaluation 1
• Early appendicitis or atypical presentation – right lower quadrant tenderness with severe pain warrants repeat imaging if CT was performed >4 weeks ago 1
• Small bowel pathology (early obstruction, mesenteric ischemia, inflammatory bowel disease) – may not be evident on initial CT, especially if performed without optimal contrast 1
• Biliary pathology (cholecystitis, choledocholithiasis) – epigastric pain can present with lower abdominal radiation; case reports document this presentation leading to cholecystectomy 2
• Peptic ulcer disease or gastritis – partial response to omeprazole suggests acid-related pathology may be contributing 3

Red Flags Present

• Severe pain intensity (9-10/10) unresponsive to multiple agents 1
• Bilateral lower quadrant tenderness on examination – suggests peritoneal involvement or pelvic pathology 1
• Progressive symptoms – worsening from initial presentation despite treatment 4
• Failure of antispasmodic therapy – buscopan ineffective suggests non-spasmodic etiology 5, 6

Immediate Management Plan

1. Urgent Diagnostic Workup

Laboratory investigations:

• Complete blood count (assess for leukocytosis, anemia suggesting bleeding or inflammation) 1
• Comprehensive metabolic panel (liver enzymes, lipase, renal function) 1
• Pregnancy test (mandatory in reproductive-age female with lower abdominal pain) 1
• Urinalysis and urine culture (exclude urinary tract pathology) 1
• C-reactive protein and ESR (inflammatory markers) 1

Imaging:

• Repeat CT abdomen/pelvis with IV contrast (oral contrast optional per institutional preference) is the most appropriate next step given the time interval from initial CT and persistent severe symptoms 1
• Pelvic ultrasound should be performed urgently to evaluate for ovarian pathology, free fluid, or other gynecologic emergencies 1
• Consider right upper quadrant ultrasound if biliary pathology suspected based on pain pattern 2

2. Acute Pain Management

Avoid opioids given the risks in undifferentiated abdominal pain and potential for chronic pain development: 1

• Intravenous paracetamol (acetaminophen) 1g IV is the first-line agent for acute undifferentiated abdominal pain, as effective as hyoscine butylbromide with better tolerability 7
• Discontinue buscopan – ineffective in this patient and may mask evolving pathology; hyoscine butylbromide is indicated for cramping/spasmodic pain, not severe constant pain 5, 6, 8
• Continue omeprazole 20mg twice daily (given partial prior response) until organic pathology excluded, taken 30-60 minutes before meals 3

3. Specialist Consultation

• Gynecology consultation for evaluation of bilateral lower quadrant tenderness in female patient 1
• General surgery consultation if imaging reveals any surgical pathology or if peritoneal signs develop 1
• Consider gastroenterology referral if initial workup negative but symptoms persist 1

If Initial Workup is Negative

Secondary Considerations (Only After Excluding Organic Disease)

If comprehensive workup including repeat imaging is unrevealing:

• Trial of higher-dose PPI therapy: Omeprazole 20mg twice daily for 4-8 weeks (if not already optimized) for possible acid-related pathology 3
• Assess for functional disorders: Consider irritable bowel syndrome, functional dyspepsia, or visceral hypersensitivity, but only after thorough exclusion of organic disease 1
• Screen for psychological comorbidities: Anxiety and depression are associated with chronic abdominal pain and should be assessed early 1
• Consider neuromodulator therapy: Low-dose tricyclic antidepressants (amitriptyline 10-25mg at bedtime, avoiding ibuprofen due to allergy) for visceral hypersensitivity if functional disorder confirmed 1

Critical Pitfalls to Avoid

• Do not attribute severe pain to functional disorders without exhaustive exclusion of organic pathology – one-third of symptoms initially attributed to functional causes are found to have organic etiology upon investigation 1
• Do not continue ineffective antispasmodics – buscopan failure suggests non-spasmodic mechanism 5, 6, 7
• Do not initiate opioid therapy – associated with poor outcomes, increased healthcare utilization, and risk of chronic pain syndrome 1
• Do not delay gynecologic evaluation in reproductive-age females with lower abdominal pain 1
• Do not assume prior normal CT excludes all pathology – interval development of disease is possible, and some conditions (early appendicitis, small bowel pathology) may not be evident on initial imaging 1

Disposition

Admit for observation and expedited workup given severity of pain (9-10/10), examination findings (bilateral lower quadrant tenderness), and failure of outpatient management 1. Discharge is inappropriate until organic pathology is excluded and pain adequately controlled.