What is the appropriate evaluation and management for a 35‑year‑old woman who experiences weekly abdominal pain accompanied by nausea, vomiting, back pain, and fever?

Evaluation and Management of Weekly Recurrent Abdominal Pain with Systemic Symptoms in a 35-Year-Old Woman

This presentation of weekly recurrent abdominal pain with nausea, vomiting, back pain, and fever requires urgent evaluation with laboratory studies, imaging, and consideration of serious conditions including mesenteric ischemia, bowel obstruction, and gastroparesis mimics, with hospital admission indicated if elevated liver enzymes or signs of peritonitis are present. 1, 2

Immediate Clinical Assessment Priorities

Critical History Elements to Elicit

• Previous abdominal surgeries (85% sensitivity and 78% specificity for adhesive small bowel obstruction) 2
• Oral contraceptive use or estrogen therapy (risk factor for mesenteric venous thrombosis in young women) 3
• Cardiac history including atrial fibrillation (nearly 50% of embolic mesenteric ischemia patients have atrial fibrillation) 3
• Pattern of pain relative to meals (postprandial pain with weight loss suggests chronic mesenteric ischemia progressing to acute thrombosis) 3
• Cyclic nature of symptoms (consider cyclic vomiting syndrome or cannabinoid hyperemesis syndrome as gastroparesis mimics) 3

Physical Examination Red Flags

• Severe pain out of proportion to examination findings (classic for early acute mesenteric ischemia until proven otherwise) 3
• Peritoneal signs (suggest irreversible intestinal ischemia with bowel necrosis requiring emergency surgery) 3
• Succussion splash (suggests delayed gastric emptying or gastric outlet obstruction) 3
• Right upper quadrant bruit on auscultation (celiac artery compression syndrome) 3
• Orthostatic vital signs (assess volume status and hemodynamic stability) 2

Essential Laboratory Workup

Mandatory Initial Tests

• Complete blood count to evaluate for infection, anemia, or hematologic abnormalities 2
• Comprehensive metabolic panel including electrolytes, renal function, glucose, and liver enzymes 2
• Liver function tests with AST and ALT (AST:ALT ratio of 3:1 suggests severe liver injury requiring hospitalization) 1
• Lactate level if concerning features for bowel ischemia (severe pain, peritoneal signs, hemodynamic instability) 2
• Lipase to evaluate for pancreatitis 4
• Pregnancy test (mandatory in all women of reproductive age to rule out ectopic pregnancy) 4
• Urinalysis to exclude urinary tract infection or urolithiasis 4

Hypercoagulability Workup if Mesenteric Venous Thrombosis Suspected

• Consider testing for Factor V Leiden, prothrombin mutation, protein S/C deficiency, antithrombin deficiency, and antiphospholipid syndrome 3

Imaging Strategy

Primary Imaging Modality

CT abdomen and pelvis with IV contrast is the primary imaging modality for acute abdominal pain with concerning features such as peritoneal signs, severe pain, fever, or abnormal labs 2, 4. This has high diagnostic accuracy for:

• Small bowel obstruction with identification of cause, location, and complications like ischemia 2
• Mesenteric ischemia (though plain radiographs have limited value and only become positive when bowel infarction occurs) 3
• Diverticulitis, appendicitis, and other inflammatory conditions 4

Alternative Imaging Considerations

• Ultrasonography is recommended for right upper quadrant pain to assess for cholecystitis or cholelithiasis 4
• Point-of-care ultrasound can aid in prompt diagnosis of cholelithiasis, urolithiasis, and appendicitis 4
• MRI is preferred over CT in pregnant patients when ultrasound is inconclusive 4

Differential Diagnosis Framework

Life-Threatening Conditions Requiring Immediate Recognition

1. Acute mesenteric ischemia (95% present with abdominal pain, 44% with nausea, 35% with vomiting; one-third have triad of abdominal pain, fever, and hemocult-positive stools) 3
2. Bowel obstruction with ischemia (distension, peritoneal signs, abnormal bowel sounds) 2
3. Perforated viscus (peritonitis, free air on imaging) 3

Gastroparesis Mimics to Consider

• Cyclic vomiting syndrome (episodic severe nausea and vomiting) 3
• Cannabinoid hyperemesis syndrome (must be differentiated from nausea/vomiting predominant gastroparesis) 3
• Celiac artery compression syndrome (can be initially evaluated with mesenteric duplex ultrasound) 3
• Superior mesenteric artery syndrome (evaluated with small bowel follow-through or CT enterography) 3
• Intestinal pseudo-obstruction (diagnosed by symptoms, laboratory tests, and imaging) 3

Common Non-Emergent Causes

• Gastroenteritis and nonspecific abdominal pain (most common causes) 4
• Functional dyspepsia 3
• Urolithiasis 4

Hospital Admission Criteria

Mandatory Admission Indicators

• Significantly elevated liver enzymes (AST >273, ALT >108) with gastrointestinal symptoms warrant inpatient monitoring with serial liver function tests 1
• AST:ALT ratio approximately 3:1 is concerning for severe liver injury requiring close monitoring 1
• Signs of bowel ischemia, complete obstruction, or peritonitis require immediate surgical consultation 2
• Hemodynamic instability or septic shock 3

Inpatient Management Priorities

• Serial liver function tests to monitor for worsening liver injury 1
• Close monitoring of vital signs and serial laboratory testing to track enzyme trends 1
• Surgical consultation for any peritoneal signs or imaging findings suggesting ischemia or obstruction 2

Common Pitfalls to Avoid

• Do not dismiss severe pain with minimal physical findings as this is the hallmark of early mesenteric ischemia 3
• Do not rely on plain radiographs to exclude mesenteric ischemia, as they only become positive with bowel infarction 3
• Do not overlook oral contraceptive use as a risk factor for mesenteric venous thrombosis in young women 3
• Do not assume gastroparesis without ruling out anatomic/organic causes with upper endoscopy and selective imaging 3
• Do not delay imaging in patients with fever, elevated WBC, and peritoneal signs, as this raises suspicion for complications requiring urgent intervention 2