What is the appropriate immediate management for a 66‑year‑old woman with hypertension, hyperlipidemia, occasional cigar smoking who presents with epigastric pain worse on the left, abdominal distension, inability to burp or pass flatus, soft stools, chills without fever, hyperactive bowel sounds, no guarding or palpable masses, and is holding her lower abdomen?

Immediate Management of Suspected Gastric Outlet Obstruction with Possible Volvulus

This patient requires urgent CT abdomen and pelvis with IV contrast to rule out gastric outlet obstruction, volvulus, or closed-loop bowel obstruction, followed by immediate surgical consultation if imaging confirms mechanical obstruction. 1, 2

Critical Red Flags in This Presentation

The combination of inability to burp or pass flatus with abdominal distension and epigastric pain strongly suggests mechanical gastric outlet or proximal bowel obstruction rather than simple gastritis or peptic ulcer disease. 2, 3

• Hyperactive bowel sounds indicate early mechanical obstruction with bowel attempting to overcome the blockage 3
• Soft stools do not exclude proximal obstruction, as distal colon may still evacuate residual contents 4
• Chills without fever may represent early systemic inflammatory response before frank sepsis develops 2

Immediate Diagnostic Workup

First-Line Imaging

Obtain CT abdomen and pelvis with IV contrast immediately as the gold standard for evaluating unclear abdominal presentations, which can identify gastric outlet obstruction, volvulus, perforation, and vascular emergencies. 1, 2, 5

• Use neutral oral contrast (water or dilute barium) if gastric pathology suspected to delineate intraluminal space 1
• CT will show the transition point, degree of distension, bowel wall thickening, and presence of ischemia 1

Exclude Cardiac Causes First

Despite the primarily gastrointestinal presentation, obtain ECG within 10 minutes and serial troponins at 0 and 6 hours to exclude atypical myocardial infarction, particularly given her age, hypertension, and smoking history. 2, 5, 6

• Myocardial infarction presents atypically with epigastric pain in 10-20% of cases, especially in women and those with cardiovascular risk factors 2, 5
• Never rely on single troponin measurement; serial measurements at least 6 hours apart are mandatory 2, 6

Essential Laboratory Tests

• Complete blood count to assess for leukocytosis suggesting ischemia or perforation 2
• Serum lactate and D-dimer may assist in detecting mesenteric ischemia, though not sufficiently accurate alone 1
• Amylase or lipase to exclude acute pancreatitis 2, 5
• C-reactive protein, liver and renal function, electrolytes 2

Immediate Resuscitative Management

While Awaiting Imaging

Keep patient NPO (nil per os) until surgical emergency excluded and establish IV access for fluid resuscitation. 2

• Nasogastric decompression should be initiated immediately for symptomatic relief and to decompress distended stomach 1
• IV fluid resuscitation to enhance visceral perfusion, especially if any concern for ischemia 1
• Correct electrolyte abnormalities that commonly occur with vomiting and obstruction 1

Empiric Medical Therapy

Broad-spectrum antibiotics should be administered if any concern for bowel ischemia or impending perforation. 1

• Consider anticoagulation with unfractionated heparin if mesenteric ischemia suspected, unless contraindicated 1

Differential Diagnosis Priority

Most Likely: Gastric Outlet Obstruction

Malignancy is now the most common cause of gastric outlet obstruction in adults, surpassing peptic ulcer disease. 1, 5

• CT findings concerning for malignancy include nodular or irregular wall thickening, soft tissue attenuation, lymphadenopathy 1
• Her age (66), smoking history, and lack of prior diverticulosis make gastric cancer a significant concern 1

Consider: Gastric Volvulus

The inability to burp or pass flatus with distension is pathognomonic for gastric volvulus (Borchardt's triad: severe epigastric pain, retching without vomiting, inability to pass nasogastric tube). 4

• CT will definitively diagnose volvulus showing abnormal gastric position and rotation 4
• Requires urgent surgical intervention to prevent ischemia and perforation 4

Must Exclude: Mesenteric Ischemia

Severe abdominal pain out of proportion to physical examination findings should be assumed to be acute mesenteric ischemia (AMI) until disproven. 1

• Her cardiovascular risk factors (hypertension, hyperlipidemia, smoking) increase AMI risk 1
• CTA should be performed as soon as possible for any patient with suspicion for AMI 1
• Prompt laparotomy required if overt peritonitis develops 1

Surgical Consultation Timing

Obtain immediate surgical consultation if CT demonstrates:

• Closed-loop obstruction with risk of ischemia 1
• Gastric volvulus requiring detorsion 4
• Free air indicating perforation 1, 2
• Signs of bowel ischemia (pneumatosis, portal venous gas, lack of wall enhancement) 1

Early surgery within 24 hours is critical if mechanical obstruction confirmed, as delays significantly worsen prognosis. 1

Critical Pitfalls to Avoid

• Do not assume simple gastritis or GERD without imaging given the inability to pass flatus and distension 2, 5
• Do not delay imaging in patients with distension and obstructive symptoms, as mortality increases with delayed diagnosis 2, 5
• Do not dismiss cardiac causes based on "typical GI presentation" without objective ECG and troponin testing 2, 5, 6
• Do not wait for fever to develop before considering ischemia; chills alone warrant aggressive workup 1
• Hyperactive bowel sounds do not exclude serious pathology; they indicate early obstruction before ileus develops 3