Acute abdomen
Last updated: April 20, 2022
Summary
Approach to management
Patient acuity and high-risk demographics for certain acute abdominal conditions determine the urgency of the approach. Critically ill patients need to be stabilized and evaluated concurrently.
Initial management [1]
To avoid misdiagnosis, remember to consider gynecological causes of abdominal pain such as PID and pregnancy-related conditions in sexually active female patients and those of childbearing age. [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.
Diagnostics
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.
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]
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
Gastrointestinal causes
Biliary and pancreatic causes
Genitourinary causes
Empiric antibiotic therapy for intraabdominal infections
Approach
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 and both institutional and individual patient antibiograms should be considered when choosing an empiric regimen!
- Coverage of the following organisms should be considered:
- Agents to avoid as empiric therapy:
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 |
- Single-agent or combination empiric regimen (see above) PLUS one of the following:
|
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.
Differential diagnoses



| Gastrointestinal etiologies [22] | Nongastrointestinal etiologies [22] |
RUQ |
|
|
LUQ |
|
RLQ |
|
|
LLQ |
|
Epigastrium |
|
|
Periumbilical |
|
|
Suprapubic |
|
|
Diffuse abdominal pain |
|
|
The differential diagnoses listed here are not exhaustive.
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