Last updated: October 26, 2022
Approach to management
Initial management 
Evaluate and stabilize critically ill patients concurrently.
- Perform ABCDE survey: e.g., large-bore IV access, fluid resuscitation, crossmatch and emergency transfusion for suspected hemorrhagic shock.
- Establish NPO status.
- Perform a focused clinical evaluation, including pelvic, testicular, and rectal examination, if indicated.
- Perform targeted diagnostic workup of acute abdomen.
- Obtain urgent specialty consult as needed, e.g., general surgery, vascular surgery, urology, OB/GYN (see “Disposition” for details).
- Administer supportive care for acute abdominal pain as needed.
- Identify and treat the underlying cause.
Remember to consider gynecological causes such as PID and pregnancy-related conditions. 
Red flags for abdominal pain
The following red flags highlight conditions that can put patients at high risk for life-threatening causes of abdominal pain or misdiagnosis.
Abdominal pain accompanied by hemodynamic instability may indicate internal bleeding, perforated viscus, necrotic bowel, or sepsis.
Maintain a high index of suspicion in immunocompromised and older patients, as they may present without fever, leukocytosis, or localized abdominal tenderness despite having an underlying life-threatening disease. 
Immediately life-threatening diagnoses
Delays in treatment of serious intraabdominal causes of acute abdominal pain can result in bowel necrosis, sepsis, fistula formation, and death.
- Hemodynamically unstable patients: Consider direct transfer to OR for patients needing emergency surgery or ICU admission.
- Underlying surgical pathology, intractable nausea and vomiting, and/or unremitting pain: inpatient admission
- Stable patients with inconclusive or negative diagnostic workup
- Extended observation in the ED with serial abdominal examination
- OR consider discharge with instructions and follow-up if the following criteria are met: :
- Resolution of pain and nausea
- Ability to tolerate oral intake
- Reassuring general appearance and physical examination
- Ability to adhere to discharge instructions.
- Examples of urgent consultations
The diagnostic workup should be guided by the pretest probability of the diagnoses under consideration. The following list includes some commonly used diagnostic tools that can help to diagnose or rule out possible etiologies in a patient with acute abdominal pain.
Strongly consider a urine pregnancy test in sexually active female patients of reproductive age, irrespective of current contraception use.
Patients with obvious signs of diffuse peritonitis or sepsis may require immediate surgical management without further diagnostic imaging.
- The initial imaging modality should be guided by the working diagnosis, as based on the patient history, vital signs, and examination.
- The following recommendations apply to nonpregnant adults.
- In pregnant women with acute abdominal pain, ultrasound and/or MRI of the abdomen and/or pelvis without contrast are the preferred initial imaging modalities.
By suspected diagnosis 
By location of the pain
Maintain a low threshold for obtaining diagnostic imaging in older patients, for whom abdominal pain is associated with higher morbidity and mortality as well as lower initial diagnostic accuracy. 
Consider diagnostic laparoscopy in hemodynamically stable patients in which the diagnosis is still unclear after complete physical examination and imaging. For patients with hemodynamic instability or severe abdominal distention, proceed to diagnostic laparotomy. 
In pregnant patients, regardless of the site of pain, ultrasound and MRI are the preferred initial imaging modalities.
Biliary and pancreatic causes
The differential diagnoses listed here are not exhaustive.
Special patient groups
Acute abdominal pain in adults ≥ 65 years
- Common etiologies of acute abdomen can manifest with atypical presentations.
- Always consider the following etiologies in adults ≥ 65 years:
- Older patients have an increased risk of morbidity and mortality, which can be related to:
- Higher incidence of serious causes of acute abdomen in this age group 
- Delayed presentation secondary to barriers to accessing healthcare 
- Increased risk of misdiagnosis and delayed diagnosis 
- Atypical clinical presentations are more common. 
- Absence of expected findings, for example:
- Presence of atypical findings, for example:
It is essential to maintain a broad differential diagnosis when evaluating older adults with acute abdominal pain.
Older adults with life-threatening conditions (e.g., mesenteric ischemia, appendicitis, ruptured abdominal aortic aneurysm) may present with a relatively unremarkable physical exam. 
- Obtain an ECG in all older adults with epigastric pain or PUD. 
- Interpret lab results with caution.
- Studies may be normal when pathology is present, e.g.:
- Abnormal studies may not be clinically significant, e.g.:
- Maintain a low threshold for imaging studies; CT abdomen and pelvis with IV contrast is preferred. 
- See also “Diagnostics for acute abdominal pain.”
Leukocytosis may be absent in older adults with acute cholecystitis, appendicitis, and diverticulitis. 
Asymptomatic bacteriuria is often found in older adults, but should not be considered a cause of acute abdominal pain. 
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