What is the emergency department assessment and plan for a 34‑year‑old woman who developed sudden generalized abdominal pain (7/10) after eating breakfast with vinegar, did not obtain relief from Kremil S (sodium alginate/simethicone) and Buscopan (hyoscine butylbromide), experienced brief rotatory dizziness after riding an elevator, has stable vital signs, a normal neurologic exam, no bowel movement for two days with flatus only last night, and no significant past medical, surgical, medication, or family history?

Emergency Department Assessment and Plan

Assessment

Acute gastroenteritis with functional dyspepsia versus peptic ulcer disease in a 34-year-old woman with constipation and transient orthostatic dizziness.

This patient presents with generalized abdominal pain following vinegar ingestion, unresponsive to antacids and antispasmodics, accompanied by constipation (no bowel movement for 2 days) and brief rotatory dizziness after elevator use. The physical examination reveals diffuse abdominal tenderness without peritoneal signs, normal vital signs, and a completely normal neurological examination. The dizziness appears orthostatic/positional rather than neurological given the normal cranial nerve and cerebellar testing.

Key Clinical Features

• Diffuse abdominal tenderness on examination indicates organic pathology rather than purely functional disease and warrants further investigation regardless of age 1.
• The absence of rebound tenderness, involuntary guarding, fever, tachycardia, or absent bowel sounds argues against peritonitis, perforation, or acute mesenteric ischemia 2, 3.
• Constipation with last flatus only one night prior suggests fecal loading or ileus as a contributor to pain, which is an under-appreciated cause of chronic abdominal pain 2.
• The brief rotatory dizziness after elevator use, in the context of normal neurological examination and no orthostatic vital sign changes documented, likely represents benign positional vertigo or vasovagal response rather than central pathology 1.

Differential Diagnosis Priority

1. Peptic ulcer disease – epigastric tenderness, pain unrelieved by antacids, and vinegar (acidic trigger) make this the primary concern 1.
2. Acute gastritis – similar presentation but typically responds to antacids 1.
3. Functional dyspepsia with constipation – however, physical tenderness suggests organic disease 1.
4. Fecal impaction with overflow – 2 days without bowel movement warrants consideration 2.
5. Acute mesenteric ischemia – must be excluded despite low probability given age and lack of vascular risk factors 2.

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Plan

Immediate Actions (Within 1 Hour)

1. Laboratory Testing

• Complete blood count to detect anemia, which is an alarm feature mandating urgent endoscopy 1.
• Serum electrolytes and glucose to identify metabolic derangements contributing to symptoms 1.
• Serum lactate and C-reactive protein to exclude mesenteric ischemia and intra-abdominal inflammation 2.
• Liver function tests, renal function, and serum amylase/lipase to exclude hepatobiliary disease and pancreatitis 1.
• Beta-hCG testing (mandatory in all women of reproductive age before imaging) 2.

2. Electrocardiogram

• Obtain 12-lead ECG immediately to exclude atypical myocardial infarction, as epigastric pain can be the presenting symptom of acute coronary syndrome, particularly in women 1.

3. Imaging

• Plain abdominal radiograph (KUB) to assess for fecal loading, bowel gas pattern, and free air 2, 4.
• If clinical suspicion for perforation or mesenteric ischemia remains after initial assessment, proceed directly to CT abdomen/pelvis with IV contrast rather than relying on plain films alone 2.
• Given the patient's age (34), lack of alarm features beyond tenderness, and stable vital signs, ultrasound is not indicated as first-line imaging for generalized abdominal pain 2.

Therapeutic Interventions

1. Immediate Symptom Management

• Start high-dose proton pump inhibitor therapy: omeprazole 40 mg IV or oral once daily before meals while awaiting diagnostic workup 1.
• Administer antiemetic for nausea: ondansetron 8 mg sublingual or IV (obtain baseline ECG first due to QTc prolongation risk) 1.
• Continue hyoscine butylbromide (Buscopan) 20 mg IV or oral every 6-8 hours as needed for cramping pain, as it is effective for abdominal cramping and has an excellent safety profile 5, 6, 7.
• Provide adequate analgesia: avoid NSAIDs (worsen peptic ulcer disease); consider acetaminophen 1000 mg oral/IV every 6 hours 1.

2. Constipation Management

• Administer bisacodyl 10 mg suppository or sodium phosphate enema to address 2-day constipation and rule out fecal impaction as pain contributor 2.
• Nasogastric decompression is not indicated unless signs of bowel obstruction develop 2.

3. Fluid Resuscitation

• Initiate IV normal saline at 125 mL/hour to correct potential dehydration from poor oral intake and prepare for possible contrast imaging 2.

Diagnostic Testing Based on Initial Results

If Laboratory and Imaging Are Reassuring (No Alarm Features)

• Perform non-invasive H. pylori testing using stool antigen or 13C-urea breath test (serology not recommended) 1.
• If H. pylori positive: initiate standard eradication therapy (clarithromycin-based triple therapy or bismuth-based quadruple therapy) 1.
• If H. pylori negative: continue empirical PPI therapy for 4-8 weeks 1.

If Alarm Features Present (Anemia, Elevated Lactate, Peritoneal Signs Develop)

• Urgent surgical consultation for possible exploratory laparotomy 2.
• CT abdomen/pelvis with IV contrast immediately to identify perforation, ischemia, or other surgical emergencies 2.

Disposition and Follow-Up

Admission Criteria

• Admit if: peritoneal signs develop, lactate >2.0 mmol/L, hemodynamic instability, inability to tolerate oral intake, or imaging reveals acute pathology 2.
• Surgical consultation required if CT shows perforation (extraluminal gas in 97%), focal wall defect, or mesenteric ischemia 2, 1.

Discharge Criteria (If All of the Following Are Met)

• Normal vital signs maintained for 4-6 hours 3.
• Laboratory values within normal limits (no anemia, normal lactate, normal inflammatory markers) 1.
• Imaging excludes surgical pathology 2, 4.
• Pain controlled with oral medications 7.
• Tolerating oral fluids and able to pass flatus/stool 2.
• Reliable for follow-up 1.

Discharge Instructions

• Continue omeprazole 40 mg once daily before breakfast for 4-8 weeks 1.
• Avoid NSAIDs, coffee, citrus fruits, and lying down within 2-3 hours after meals 1.
• Follow up with primary care physician or gastroenterology within 1 week for H. pylori test results and symptom reassessment 1.
• Return immediately if: persistent vomiting, hematemesis, melena, worsening abdominal pain, fever, or inability to tolerate oral intake 1.

Outpatient Endoscopy Indications

• Schedule non-urgent upper endoscopy within 4-8 weeks if symptoms persist despite PPI therapy, as physical tenderness warrants endoscopic evaluation 1.
• Urgent endoscopy (within 2 weeks) is indicated if: age ≥40 years with new-onset symptoms, unintentional weight loss, anemia on CBC, dysphagia, persistent vomiting, or hematemesis develops 1.

Common Pitfalls to Avoid

• Do not attribute persistent vomiting to functional dyspepsia—it is a red-flag symptom requiring investigation for organic disease 1.
• Do not delay endoscopy in patients with epigastric tenderness and persistent symptoms beyond 8 weeks, regardless of age 1.
• Do not miss cardiac causes of epigastric pain—always obtain ECG in patients with risk factors 1.
• Do not overlook fecal impaction as a cause of abdominal pain—it is under-appreciated and easily treatable 2.
• Serial examinations every 4-6 hours increase diagnostic accuracy when initial findings are equivocal, as peritoneal signs may take hours to develop 3.