Acute abdomen

Last updated: August 15, 2022

Summarytoggle arrow icon

Acute abdomen refers to severe abdominal pain lasting for hours to a few days. The underlying pathology may be intraabdominal, thoracic, or systemic and may require urgent surgical intervention. The initial approach to acute abdomen should be to assess for immediately life-threatening causes (e.g., ruptured abdominal aortic aneurysm, bowel perforation) by checking vital signs, performing a quick physical examination, and immediately conducting the appropriate focused diagnostic tests (e.g., abdominal ultrasound, abdominal x-ray). Once emergency causes have been ruled out, a thorough history and physical examination should be performed to narrow the differential diagnoses and guide further diagnostic workup and therapy. Causes of chronic abdominal pain are not addressed in this article.

See “Blunt abdominal trauma” and “Penetrating abdominal trauma” for details on traumatic causes of abdominal pain.

Initial management [1]

Evaluate and stabilize critically ill patients concurrently.

Remember to consider gynecological causes such as PID and pregnancy-related conditions. [2]

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. [3][5]

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.

Disposition [6][7]

  • 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.

Laboratory studies

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.

Imaging [8][9][10][11][12][13][14]

Approach

  • 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 [11]

Suspected diagnosis Recommended imaging modality
Acute coronary syndrome

Hemorrhagic shock [12]

Bowel perforation [8]

Small bowel obstruction [9]

Intraabdominal abscess

  • CT abdomen and pelvis with IV contrast
Acute diverticulitis [13]
Acute appendicitis [10]

Acute mesenteric ischemia [15]

  • CTA of the abdomen
Acute pancreatitis [16]

Nephrolithiasis [17]

Acute complicated pyelonephritis [12]
  • CT abdomen and pelvis with IV contrast

Suspected symptomatic AAA in a hemodynamically stable patient [20]

By location of the pain

Site of pain
Initial test of choice

Alternatives

RUQ pain [21]

RLQ pain [10]

or

LLQ pain [13]

  • CT abdomen and pelvis with IV contrast

LUQ pain [22]

  • CT abdomen with oral and IV contrast

Suprapubic pain [22]

Pelvic pain [23]

  • Gynecological etiology suspected: ultrasound pelvis (transabdominal and/or transvaginal)
  • Nongynecological etiology suspected and β-HCG is negative: CT abdomen and pelvis with IV contrast

Nonlocalized pain [8]

  • CT abdomen and pelvis with IV contrast
  • CT abdomen and pelvis without IV contrast
  • MRI abdomen and pelvis with/without IV contrast
  • Ultrasound abdomen and/or pelvis
  • Postoperative patients with acute abdomen: Consider fluoroscopy (enema and/or upper abdominal series).

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. [24]

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. [25]

In pregnant patients, regardless of the site of pain, ultrasound and MRI are the preferred initial imaging modalities.

Cardiovascular causes of acute abdominal pain
Clinical features Diagnostic findings Acute management
Acute coronary syndrome [26][27]

Acute mesenteric ischemia
[28][29][30][31]

Ruptured AAA (or impending rupture) [32]

Aortic dissection [33][34][35]

Gastrointestinal causes of acute abdomen
Clinical features Diagnostic findings Acute management
GI tract perforation [8][36][37]

Mechanical bowel obstruction [8][9][38][39]

  • X-ray abdomen
    • Dilated bowel loops proximal to the obstruction
    • Rectal air shadow absent
    • Multiple air-fluid levels
  • CT abdomen with IV contrast
    • Similar findings as on x-ray
    • Transition point at site of obstruction

Acute appendicitis (including perforated appendicitis) [40][41][42][43]

Peptic ulcer disease [44][45][46]
Diverticulitis [47][48][49][50][51][52][53]
Gastroenteritis [54]

Neutropenic enterocolitis (typhlitis)
[55][56][57]


Epiploic appendagitis [60][61]

  • Lower abdominal pain
Biliary and pancreatic causes of acute abdomen
Clinical features Diagnostic findings Acute management

Acute pancreatitis [62][63][64]

  • Severe epigastric pain that radiates to the back (circumferential pain)
  • Nausea, vomiting
  • Epigastric tenderness, guarding, rigidity
  • Hypoactive bowel sounds
  • Possibly fever
  • History of gallstones or alcohol use

Symptomatic cholelithiasis [65][66][67]

Choledocholithiasis [65][68]

Acute cholecystitis [65][66][71][72][73]

Acute cholangitis [65][66][75][76] [71][77][78]

Genitourinary causes of acute abdominal pain
Clinical features Diagnostic findings Acute management
Ruptured ectopic pregnancy [79]
Ovarian torsion [80][81]
  • Sudden onset unilateral lower abdominal or pelvic pain
  • Nausea, vomiting
  • Unilateral iliac fossa tenderness
Testicular torsion [82]
Acute pyelonephritis [12][83][84][85][86]
Nephrolithiasis
  • Urine dipstick and urinalysis: gross or microscopic hematuria
  • Urine microscopy: to detect crystals
  • Abdominopelvic CT: Nonenhanced CT scan is the gold standard.
  • Ultrasound: method of choice for patients in whom radiation exposure should be minimized (e.g., pregnant patients, children, recurrent stone formers)

Pelvic inflammatory disease

Acute urinary retention [7][87][88]

  • Commonly seen in older men
  • Painful inability to void
  • Suprapubic pain
  • Palpable distended bladder
  • Restlessness and/or acute distress

Definitive treatment of abdominal pain is cause-specific (e.g., see “Gastrointestinal causes of acute abdominal pain”). Consider the following general therapies on an individual basis:

Supportive care for acute abdominal pain

Empiric antibiotics for intraabdominal infections

Community-acquired infections [89][90][91]

Severity of infection Suggested single-agent empiric regimen [89]

Suggested combination empiric regimen [89]

Mild or moderate infection

Severe infection
and/or
high-risk patient

Metronidazole is contraindicated in the first trimester of pregnancy.

Healthcare-associated infections [71][89][90][91]

Healthcare-associated infections are more likely to be antibiotic-resistant. Consider institutional and individual patient antibiograms when choosing an empiric regimen.

Patient and/or institutional risk factors
Suggested empiric regimens [89]
Low risk (< 20%) of infection with resistant organism
High risk (> 20%) of infection with resistant organism
High risk of MRSA

  • Combination empiric regimen (see above)
  • PLUS vancomycin

Obtain cultures, if necessary, before the administration of empirical IV antibiotics.

For patients with a beta-lactam or carbapenem allergy, consider vancomycin with aztreonam and metronidazole.

The differential diagnoses listed here are not exhaustive.

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