In a 26‑year‑old woman with recently diagnosed insulin‑dependent diabetes mellitus who presents with a 5‑hour history of epigastric pain, no fever, a soft abdomen with mild epigastric tenderness, leukocytosis of 26,000 with 86 % neutrophils, and normal platelet count, hemoglobin, liver function tests, and serum amylase, what is the appropriate diagnostic work‑up and initial management?

Diagnostic Work-Up and Initial Management

In this 26-year-old woman with insulin-dependent diabetes presenting with epigastric pain and marked leukocytosis (WBC 26,000 with 86% neutrophils), the priority is immediate CT abdomen/pelvis with IV contrast to exclude life-threatening surgical emergencies—specifically perforated peptic ulcer, acute pancreatitis, and diabetic ketoacidosis-related complications—followed by serum lipase, arterial blood gas, and ECG. 1, 2, 3

Immediate Life-Threatening Conditions to Exclude

The combination of epigastric pain, marked leukocytosis with neutrophilia, and recent-onset diabetes creates a high-risk scenario requiring urgent evaluation for:

Perforated Peptic Ulcer

• CT abdomen/pelvis with IV contrast is the diagnostic gold standard, demonstrating extraluminal gas in 97% of cases, fluid/fat stranding in 89%, ascites in 89%, and focal wall defects in 84% 1, 2
• Delayed treatment carries approximately 30% mortality 1, 2
• Normal amylase does not exclude perforation—the leukocytosis and neutrophilia are highly concerning 4

Acute Pancreatitis

• Serum lipase ≥2× upper limit of normal is the preferred diagnostic test with 80-90% specificity 2
• If lipase unavailable, serum amylase ≥4× normal can be used 2
• Pancreatitis characteristically presents with persistent vomiting that does not relieve pain, unlike peptic ulcer disease 5
• Overall mortality <10% but rises to 30-40% in necrotizing pancreatitis 2

Diabetic Ketoacidosis with Abdominal Pain

• Abdominal pain occurs in 46% of DKA patients and correlates strongly with metabolic acidosis severity, not hyperglycemia 6
• 86% of patients with bicarbonate <5 mmol/L report abdominal pain 6
• Obtain arterial blood gas, serum bicarbonate, and beta-hydroxybutyrate immediately 6
• The normal glucose reading ("GRBS normal") makes DKA less likely but does not exclude euglycemic DKA in insulin-treated patients 4

Cardiac Causes

• Obtain 12-lead ECG within 10 minutes to exclude acute coronary syndrome, especially critical in diabetic patients who may present atypically with isolated epigastric pain 1, 2
• Missed myocardial infarction carries 10-20% mortality 1

Critical Laboratory Work-Up

Beyond the normal tests already obtained, immediately order:

• Serum lipase (preferred) or amylase ≥4× normal 2
• Arterial blood gas with lactate to assess for metabolic acidosis and tissue hypoperfusion 4, 6
• Serum bicarbonate (if not included in metabolic panel) 6
• Beta-hydroxybutyrate or urine ketones to exclude DKA 4
• Procalcitonin as the most sensitive biomarker for pancreatic infection if pancreatitis confirmed 2

The marked leukocytosis (26,000) with 86% neutrophils suggests either:

• Severe metabolic acidosis from DKA 6
• Bacterial infection/perforation 4
• Necrotizing pancreatitis 2

Imaging Strategy

Contrast-enhanced CT abdomen/pelvis is mandatory and should be performed urgently to: 1, 2, 3

• Confirm or exclude pancreatitis and identify necrosis (which raises mortality from 0-11% to ≈40%) 2
• Detect perforation with high sensitivity 1, 2
• Rule out mesenteric ischemia, leaking aortic aneurysm, and other surgical emergencies 2

If CT is unavailable, obtain chest and abdominal X-rays as initial screening for free intraperitoneal air 1, 2

Initial Management Pending Diagnosis

Resuscitation

• Begin aggressive IV crystalloid resuscitation targeting urine output >0.5 mL/kg/h 2
• Maintain nil per os until surgical emergency excluded 2
• Insert Foley catheter to monitor urine output 4

Symptomatic Treatment

• Obtain baseline ECG before administering ondansetron (8 mg sublingual q4-6h) due to QTc prolongation risk 1, 2
• Alternative antiemetics: promethazine 12.5-25 mg q4-6h or prochlorperazine 5-10 mg q6-8h 1

Empiric Acid Suppression

• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) while awaiting definitive diagnosis, given ongoing possibility of peptic ulcer disease 1, 2
• This achieves 80-90% healing rates for duodenal ulcers and 70-80% for gastric ulcers 1

Critical Red Flags Present in This Case

• Marked leukocytosis (26,000) with neutrophilia (86%) suggests serious organic pathology requiring urgent intervention 4, 2
• Epigastric tenderness on examination indicates organic disease rather than functional disorder 1
• Recent-onset insulin-dependent diabetes increases risk for DKA, emphysematous gastritis, and severe infections 6, 7
• 5-hour symptom duration with these findings mandates immediate work-up rather than observation 1, 2

Common Pitfalls to Avoid

• Do not attribute abdominal pain to DKA without checking arterial blood gas and bicarbonate—investigation should be reserved for patients without severe metabolic acidosis or if pain persists after ketoacidosis resolution 6
• Do not delay CT imaging based on normal amylase alone—leukocytosis and neutrophilia suggest perforation or severe inflammation 4, 1
• Do not assume functional dyspepsia in a patient with epigastric tenderness, leukocytosis, and recent diabetes onset 1
• Do not miss cardiac causes in diabetic patients presenting with epigastric pain 1, 2

Disposition

• Tachycardia ≥110 bpm, fever ≥38°C, or hypotension are highly specific for sepsis, perforation, or anastomotic leak and mandate ICU-level care 4, 2
• If CT reveals perforation, immediate surgical consultation is required 1, 2
• If pancreatitis confirmed with necrosis, ICU admission for close monitoring 2