# Three days of abdominal pain and vomiting in a 70-year-old: a case to work up

> A gastroenterology case for medical students: a 70-year-old with three days of waves of upper abdominal pain, vomiting and yellow eyes. What to ask, red flags, first tests and the differential.

- Gastroenterology · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/70-year-old-woman-with-abdominal-pain-and-vomiting
- Work up this patient: https://www.medikarya.in/case-studies/70-year-old-woman-with-abdominal-pain-and-vomiting

## How the patient presents

A 70-year-old woman has had upper abdominal pain for three days, with waves of worse pain and vomiting. Her eyes are yellow and her urine has been darker, which she thinks is a urine infection. She has had a few bad bouts of pain over the past five years.

## Why abdominal pain and vomiting in an older woman matters

In older people, abdominal pain with vomiting can hide serious disease behind mild signs. Yellow eyes point to the bile ducts, and waves of pain with vomiting also raise the question of a blockage further down the gut.

## What to ask in the history

- How it started; waves of pain or constant
- What she vomits; is she passing wind or opening her bowels
- Swelling of the abdomen
- Fever, shivering
- Yellow eyes, urine and stool colour
- Previous bouts and any known gallstones
- Past operations
- Medicines, weight loss

## Red flags

- Fever with jaundice and pain
- Confusion or low blood pressure
- No wind or stools with a swollen abdomen
- Rigidity or guarding
- Foul-smelling vomit

## What to examine

- Observations, hydration
- Jaundice
- Abdomen: swelling, tenderness, scars, hernias, bowel sounds
- Rectal examination

## First investigations

- Full blood count, CRP, liver function, amylase or lipase
- Kidney function, electrolytes, lactate
- Blood cultures
- Ultrasound of the abdomen
- Abdominal X-ray or CT
- MRCP or endoscopic tests as needed

## Differential diagnosis of abdominal pain and vomiting in an older woman

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Bowel

- Obstruction from adhesions, a hernia, a gallstone or a tumour

### Bile ducts and gallbladder

- Biliary colic
- Cholecystitis
- A stone in the common bile duct
- Cholangitis

### Pancreas

- Gallstone pancreatitis

### Other

- Mesenteric ischaemia
- A heart attack presenting as abdominal pain

## Common mistakes

- Putting dark urine down to a urine infection.
- Missing sepsis in an older patient who has no high fever.
- Not looking for hernias.

---

A study guide for medical students, not medical advice. Follow your institution's protocols in practice.