I have epigastric pain with three episodes of vomiting yesterday, no stool for three days but passed flatus twice yesterday and have increased bowel sounds; what is the likely diagnosis and recommended emergency management?

Likely Diagnosis: Small Bowel Obstruction vs. Perforated Peptic Ulcer

Based on your presentation of epigastric pain, three episodes of vomiting, no bowel movement for three days, minimal flatus passage, and increased bowel sounds, you most likely have either a small bowel obstruction or a perforated peptic ulcer requiring immediate emergency evaluation and imaging. 1, 2

Immediate Emergency Assessment

Critical Physical Examination Findings to Check NOW

• Check for peritoneal signs immediately: abdominal rigidity, rebound tenderness, or absent bowel sounds indicate perforated peptic ulcer with mortality reaching 30% if treatment is delayed 1, 2
• Assess vital signs: tachycardia ≥110 bpm, fever ≥38°C, or hypotension predict perforation or sepsis with high specificity 2
• Palpate for epigastric tenderness: this suggests organic pathology rather than functional disease and warrants urgent investigation 2

The combination of increased bowel sounds with inability to pass stool suggests early mechanical obstruction rather than paralytic ileus, while the epigastric location raises concern for perforated peptic ulcer 1, 3

Mandatory Imaging - Do Not Delay

CT abdomen and pelvis with IV contrast is the gold standard and must be obtained immediately to differentiate between these life-threatening conditions 1, 2:

• For perforation: CT will show extraluminal gas (97% sensitivity), fluid or fat stranding along gastroduodenal region (89%), ascites (89%), focal wall defect/ulcer (84%), and wall thickening (72%) 1, 2
• For small bowel obstruction: CT demonstrates dilated small bowel loops, transition point, and can identify the cause 1, 4

Plain abdominal X-rays are insufficient - they miss critical findings and delay definitive diagnosis 1

Essential Laboratory Tests

Order immediately while arranging imaging 1, 2, 5:

• Complete blood count (assess for leukocytosis, anemia)
• Serum electrolytes and glucose (vomiting causes hypokalemia, hypochloremia, metabolic alkalosis)
• Serum lactate (elevated suggests bowel ischemia or perforation)
• Liver and renal function tests
• Serum lipase (≥2x normal excludes acute pancreatitis)
• C-reactive protein

Emergency Management While Awaiting Imaging

Resuscitation

• Start isotonic IV fluids immediately (lactated Ringer's or normal saline) for severe dehydration from three days of vomiting and no oral intake 5
• Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia from prolonged vomiting 5
• Insert nasogastric tube for decompression if small bowel obstruction is suspected - this relieves distension and prevents aspiration 3
• Make patient NPO (nothing by mouth) until surgical evaluation is complete 3

Critical Medication Warning

DO NOT give antiemetics if mechanical bowel obstruction is suspected - this can mask progressive ileus and gastric distension, leading to catastrophic outcomes 5

Definitive Treatment Based on Diagnosis

If Perforated Peptic Ulcer is Confirmed

Immediate surgical consultation is mandatory 1:

• Laparoscopic or open repair with simple/double-layer suture with omental patch for small perforations 1
• Distal gastrectomy for large perforations near pylorus or if malignancy is suspected 1
• Start broad-spectrum antibiotics immediately after diagnosis 1:
  • For non-critically ill: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 1
  • For critically ill: Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g every 6 hours 1
  • Continue antibiotics for 4 days if source control is adequate 1

If Small Bowel Obstruction is Confirmed

Management depends on presence of ischemia or perforation 1, 3:

• Conservative management initially if no signs of strangulation: NPO, IV fluids, nasogastric decompression, serial abdominal exams 3
• Immediate surgical exploration if CT shows bowel ischemia, perforation, or closed-loop obstruction 1
• Laparoscopic or open small bowel resection with primary anastomosis if viable bowel 1
• Resection with delayed anastomosis at second-look operation if bowel ischemia is present 1

Common Pitfalls to Avoid

• Delaying CT imaging in favor of plain X-rays - this misses 30-40% of perforations and delays life-saving surgery 1
• Assuming functional dyspepsia - persistent vomiting with inability to pass stool for 3 days is a red flag for mechanical obstruction, not functional disease 2, 5
• Missing cardiac causes - obtain ECG to exclude myocardial infarction, especially if you have cardiac risk factors, as MI can present with epigastric pain 2, 6
• Giving antiemetics before ruling out obstruction - this masks critical symptoms and can lead to aspiration 5
• Waiting for "alarm features" like weight loss or anemia - your current presentation already constitutes an emergency requiring immediate imaging 1, 2

Bottom line: You need emergency department evaluation NOW with CT imaging and surgical consultation standing by. The combination of epigastric pain, vomiting, and inability to pass stool for three days represents a surgical emergency until proven otherwise 1, 3