Abdominal Pain and Vomiting Management

Initial Assessment and Intervention

The World Journal of Emergency Surgery recommends beginning with immediate assessment of hemodynamic stability, followed by focused history for surgical red flags, physical examination for distension and peritonitis, and laboratory tests including lactate and blood gas analysis to detect bowel ischemia 1, 2
Checking vital signs for tachycardia, hypotension, fever, and tachypnea is crucial as these combinations predict serious complications including anastomotic leak, bowel ischemia, or sepsis 3, 4
Tachycardia alone is a critical warning sign in post-surgical patients and should trigger aggressive investigation 3
Signs of shock mandate immediate surgical exploration without delay 3

Prior abdominal surgery has 85% sensitivity and 78% specificity for adhesive small bowel obstruction, which causes 55-75% of small bowel obstructions 2, 5
Bilious or feculent vomiting indicates mechanical obstruction and requires immediate nasogastric decompression and NPO status 2
Severe abdominal pain out of proportion to physical findings suggests acute mesenteric ischemia until proven otherwise 4
The triad of abdominal pain, constipation, and vomiting suggests sigmoid volvulus, particularly in elderly institutionalized patients on psychotropic medications 1

Peritoneal signs, such as rebound tenderness, guarding, or rigidity, indicate possible perforation or bowel necrosis 1, 2
Abdominal distension with diminished bowel sounds is classic for bowel obstruction 1, 5
Empty rectum on digital examination supports diagnosis of complete obstruction 1
Critical caveat: Absence of peritonitis does NOT exclude bowel ischemia—lactate and blood gas are essential 1

Complete blood count, electrolytes, renal function, blood gas, and lactate levels are essential for detecting bowel ischemia and guiding management 1, 3
Elevated C-reactive protein predicts postoperative complications 3
Liver function tests and serum albumin are important in appropriate contexts 3

Plain abdominal radiograph is the initial test but has limited sensitivity—negative films do NOT exclude mesenteric ischemia or early obstruction 2, 4
CT abdomen/pelvis with IV contrast is the definitive test for identifying obstruction, transition points, bowel ischemia, and surgical causes 2, 5
CT helps distinguish mechanical obstruction from functional bloating and prevents unnecessary laparotomy 6

IV fluid resuscitation with aggressive crystalloid administration is crucial for dehydration from vomiting 1, 2
NPO status and nasogastric tube decompression are mandatory for bilious vomiting or suspected obstruction 2
Antiemetic therapy may be considered for persistent vomiting, but its use should be guided by clinical judgment 1, 2

For suspected bowel obstruction, obtain CT to identify transition point and assess for ischemia, and perform serial abdominal exams every 4-6 hours to detect peritonitis 2, 5
For suspected mesenteric ischemia, immediate CT angiography and surgical consultation without delay are recommended 4
For sigmoid volvulus, plain radiograph may show characteristic findings, and CT confirms diagnosis; endoscopic decompression is first-line if no peritonitis 1

The American College of Radiology recommends that mesenteric duplex ultrasound be used for celiac artery compression diagnosis 7
The American College of Gastroenterology suggests that gastroparesis diagnosis should be based on symptoms, laboratory tests, and imaging studies showing delayed gastric emptying or gastric outlet obstruction 8, 9
The American College of Emergency Physicians states that signs of shock, such as tachycardia, hypotension, and altered mental status, mandate immediate surgical exploration 10

The American Gastroenterological Association recommends that patients with gastroparesis be treated with dietary adjustments, antiemetics, and prokinetics, with consideration of gastric electrical stimulation for severe cases 8, 11
The Society of Interventional Radiology suggests that transcatheter thrombolysis or embolectomy be used for arterial occlusion in mesenteric ischemia 7, 12
The American College of Surgeons recommends that surgical consultation be obtained immediately for suspected bowel obstruction or mesenteric ischemia 10

The American College of Radiology recommends that CT abdomen/pelvis with IV contrast be used as the definitive test for bowel obstruction diagnosis 10
The American Gastroenterological Association suggests that liver function tests be included in the initial laboratory testing for abdominal pain and vomiting 11
The American College of Emergency Physicians states that lactate and blood gas analysis are essential for detecting ischemia in patients with abdominal pain 10

In elderly patients, clinical presentation of acute abdominal pain is often atypical, with only 43-48% having positive Murphy's sign, 36-74% having fever, and 12% presenting with atypical or no pain at all, making imaging critical for diagnosis 13
Elderly patients have higher rates of leucocytosis (41.2%) and elevated CRP (64.1%) compared to younger patients when suspected of having acute cholecystitis 13

Antiemetic therapy with ondansetron, promethazine, or prochlorperazine can be used, but caution is advised with promethazine and prochlorperazine in elderly patients due to anticholinergic effects and CNS depression 14

CT abdomen/pelvis with IV contrast is the definitive diagnostic test and should be obtained urgently to confirm or exclude acute cholecystitis, identify bowel obstruction, detect bowel ischemia, and rule out other surgical emergencies 13