What is the appropriate evaluation and management for a 51‑year‑old woman presenting with abdominal pain and nausea?

Evaluation and Management of a 51-Year-Old Woman with Abdominal Pain and Nausea

This patient requires a systematic evaluation starting with vital signs assessment and targeted physical examination to identify red flags, followed by laboratory testing (CBC, comprehensive metabolic panel including liver enzymes) and CT imaging with IV contrast if concerning features are present. 1, 2

Immediate Assessment Priorities

Vital Signs and Hemodynamic Status

• Check for tachycardia immediately – this is the most sensitive early warning sign of serious intra-abdominal pathology and should trigger urgent investigation 3
• Assess orthostatic vital signs to evaluate volume status and hemodynamic stability, particularly if vomiting is present 1
• Measure temperature, though absence of fever does not exclude serious pathology – only 6-17% of elderly patients with acute cholecystitis have fever >38°C, and this principle applies across age groups 2

Physical Examination Red Flags

• Examine for peritoneal signs (guarding, rebound tenderness, rigidity) – their presence mandates urgent surgical evaluation 1, 4
• Assess for abdominal distension and bowel sounds 1
• Localize tenderness carefully – epigastric pain with nausea suggests upper GI or hepatobiliary pathology 3
• Note that classic peritoneal signs may be absent even with serious pathology, particularly in patients with obesity or atypical presentations 3

Essential History Elements

Critical Questions to Ask

• Previous abdominal surgery – this has 85% sensitivity and 78% specificity for adhesive small bowel obstruction 1
• Onset and character of pain (acute vs. gradual, cramping vs. constant, location and radiation) 3
• Associated symptoms: vomiting (frequency, presence of blood or bile), diarrhea, constipation, dysphagia 3
• Gynecologic history in this 51-year-old woman – last menstrual period, possibility of pregnancy, history of gynecologic conditions 5
• Recent medication changes, particularly opioids which can cause abdominal pain and nausea 3

Laboratory Workup

Order the following tests immediately: 1, 2

• Complete blood count (CBC) – to evaluate for infection, anemia, or hematologic abnormalities 1
• Comprehensive metabolic panel – including electrolytes, renal function, glucose, and liver enzymes (AST, ALT, alkaline phosphatase, bilirubin) 1, 2
• Lipase – to evaluate for pancreatitis 2
• Lactate level if severe pain, peritoneal signs, or hemodynamic instability present – suggests bowel ischemia or high-grade obstruction 1
• Urinalysis and urine pregnancy test (if premenopausal or perimenopausal status unclear) 6

Important Caveat

Normal laboratory values do not exclude serious pathology – elderly patients frequently have normal labs despite serious infection, and this applies to middle-aged patients as well 2. Do not delay imaging based on reassuring labs if clinical suspicion remains high.

Imaging Strategy

When to Order CT Immediately

CT abdomen/pelvis with IV contrast is indicated if any of the following are present: 1, 2

• Peritoneal signs on examination
• Severe or worsening pain
• Hemodynamic instability or tachycardia
• Abnormal laboratory values (elevated WBC, elevated lactate, significantly elevated liver enzymes)
• History of previous abdominal surgery with concern for obstruction
• Age >50 with new-onset symptoms (to exclude malignancy)

CT changes the leading diagnosis in 51% of cases and alters admission decisions in 25% of patients with abdominal pain 2. It has high diagnostic accuracy for small bowel obstruction, abscess, perforation, and can identify complications like bowel ischemia 1.

Alternative Imaging

• Ultrasound may be considered first in young women without alarm features, particularly to evaluate for gynecologic or hepatobiliary pathology 5
• However, do not delay CT if ultrasound is nondiagnostic and clinical suspicion remains high 5

Life-Threatening Diagnoses to Exclude

The following conditions can present with abdominal pain and nausea and require urgent identification: 2, 7

• Bowel obstruction (particularly if history of prior surgery)
• Bowel ischemia or perforation
• Acute cholecystitis or cholangitis
• Intra-abdominal abscess
• Acute pancreatitis
• Ruptured viscus
• Malignancy (lymphoma, necrotizing masses can present identically)

Symptomatic Management

While awaiting diagnostic workup, provide symptomatic relief: 3, 2

• For nausea/vomiting: Metoclopramide 10 mg PO/IV every 6-8 hours, or ondansetron 4-8 mg IV/PO every 8 hours 3, 2
• Alternative antiemetics: prochlorperazine, haloperidol, or promethazine 3
• Avoid opioid analgesics until surgical abdomen is excluded, as they can mask peritoneal signs and worsen nausea 3
• IV fluid resuscitation if signs of dehydration or hemodynamic compromise 3

Disposition Criteria

Indications for Hospital Admission

Admit if any of the following are present: 1, 2, 8

• Significantly elevated liver enzymes (AST >200-300 or AST:ALT ratio >3:1) with GI symptoms – requires serial monitoring 8
• Signs of bowel ischemia, complete obstruction, or peritonitis 1
• Hemodynamic instability or persistent tachycardia 3
• Inability to tolerate oral intake with dehydration 6
• CT findings requiring surgical consultation (abscess, perforation, complicated diverticulitis, acute cholecystitis) 2

Outpatient Management Appropriate If:

• Benign examination without peritoneal signs
• Normal or mildly abnormal laboratory values
• Able to tolerate oral intake
• Reliable for follow-up
• No concerning imaging findings

Critical Pitfalls to Avoid

• Do not rely on absence of fever to exclude serious pathology – fever is frequently absent in serious intra-abdominal infections 2
• Do not dismiss tachycardia as anxiety – it is the most sensitive early warning sign of surgical complications 3
• Do not delay imaging in patients >50 years old – atypical presentations are common and serious pathology may be missed 2
• Do not assume normal labs exclude serious disease – clinical examination and imaging are more reliable 2
• Consider extra-abdominal causes: myocardial infarction, pneumonia, diabetic ketoacidosis can present with abdominal pain 7, 6