• Clinical science
  • Physician

Acute abdomen

Summary

Acute abdomen refers to severe abdominal pain lasting for ≤ 5 days. The underlying pathology may be intra-abdominal, 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. Traumatic causes of abdominal pain, abdominal trauma, and chronic abdominal pain are not addressed here.

Approach

Approach to management [1]

Red flags for abdominal pain

  • Sudden onset of severe pain
  • Pain that interrupts sleep
  • Bilious vomiting
  • Hematemesis, hematochezia
  • Hypotension, tachycardia
  • Patient lying very still
  • Patient writhing in pain
  • Jaundice
  • Guarding and/or rigidity (focal or diffused)
  • Rebound tenderness (focal or diffused)
  • Absent or tinkling bowel sounds
  • Gross abdominal distention
  • Pain out of proportion to abdominal findings
  • High-risk patient characteristics

Immediately life-threatening diagnoses

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.

Laboratory studies

A urine pregnancy test should be performed in every woman of reproductive age, regardless of current contraception use.
Patients with obvious signs of diffuse peritonitis do not require further diagnostic imaging and should proceed straight to surgical management.

Imaging [2][3][4][5][6][7][8]

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 [5]

Suspected diagnosis Recommended imaging modality
Acute coronary syndrome

Hemorrhagic shock [6]

Bowel perforation [2]

  • CT abdomen and pelvis with IV contrast
  • X-ray abdomen (upright and supine) with x-ray chest (upright)
Small bowel obstruction [3]

Intra-abdominal abscess

  • CT abdomen and pelvis with IV contrast
Acute diverticulitis [7]
Acute appendicitis [4]

Acute mesenteric ischemia [9]

  • CTA of the abdomen
Acute pancreatitis [10]
  • Ultrasound abdomen
  • CT abdomen with IV contrast

Nephrolithiasis [11]

  • Ultrasound abdomen and pelvis
  • CT abdomen and pelvis without contrast
Acute complicated pyelonephritis [6]
  • CT abdomen and pelvis with IV contrast

Suspected symptomatic AAA in a hemodynamically stable patient [12]

  • Ultrasound abdomen
  • CT/MR angiography

By location of the pain

Site of pain
Initial test of choice

Alternatives

RUQ pain [13]

  • Ultrasound abdomen

RLQ pain [4]

or

LLQ pain [7]

  • CT abdomen and pelvis with IV contrast
  • CT abdomen and pelvis without IV contrast
  • MRI abdomen and pelvis with or without IV contrast
  • Abdominal and/or pelvic ultrasound
  • Duplex ultrasound of the pelvis ()/scrotum ()

LUQ pain [14]

  • CT abdomen with oral and IV contrast
  • Acute abdominal series

Suprapubic pain [14]

  • Ultrasound abdomen and pelvis

Pelvic pain [15]

  • Ultrasound pelvis (transabdominal and/or transvaginal)
  • CT abdomen and pelvis with IV contrast:
  • Duplex ultrasonography of pelvic adnexa
  • MRI pelvis (+/- abdomen) with IV contrast

Nonlocalized pain [2]

  • 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
  • Fluoroscopy (enema and/or upper abdominal series): Consider in postoperative patients with acute abdomen.

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. [16]

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

Cardiovascular causes

Clinical features Diagnostic findings Acute management
Acute coronary syndrome [17][18]

Acute mesenteric ischemia

[19][20][21][22]

Rupture or impending rupture of AAA [23]
  • Imaging is only recommended in hemodynamically-stable patients with a low pretest probability of ruptured AAA.
  • Abdominal ultrasound: aortic dilatation, periaortic fluid, intraperitoneal free fluid
  • CT/MR angiography: retro- and intraperitoneal hemorrhage; localization of the ruptured/leaking site

Aortic dissection

[24][25][26]

Gastrointestinal causes

Clinical features Diagnostic findings Acute management
GI tract perforation [27][28][2]

Mechanical bowel obstruction [2][3][29][30]

  • Colicky abdominal pain
  • Obstipation/bloating
  • Progressive nausea and vomiting (late finding)
  • Diffuse abdominal distention, tympanic abdomen, collapsed rectum on DRE
  • Tinkling bowel sounds
  • History of abdominal surgery
  • X-ray abdomen
    • Dilated bowel loops proximal to the obstruction
    • Rectal air shadow absent
    • Multiple air-fluid levels
  • CT abdomen with IV and oral contrast
    • Similar findings as on x-ray
    • Transition point at site of obstruction

Acute appendicitis

[31][32][33][34]

  • Neutrophilic leukocytosis
  • Abdominal CT scan with IV contrast : distended appendix with periappendiceal fat stranding
  • Abdominal ultrasonography : noncompressible, aperistaltic, distended appendix, probe tenderness in the RLQ, Target sign
Peptic ulcer disease [35][36][37]
  • Anemia, positive FOBT (in cases of bleeding ulcer)
  • Urea breath test for H. pylori: positive in most cases of PUD
  • EGD: Mucosal erosions and/or ulcers are required for a definitive diagnosis.
Diverticulitis [38][39][40][41][42][43][44]

Biliary and pancreatic causes

Clinical features Diagnostic findings Acute management

Acute pancreatitis

[45][46][47]

  • 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

[48][49][50]

  • Labs: normal
  • Abdominal ultrasound: gallstones with posterior acoustic shadow
Choledocholithiasis [51][48]
  • Labs: ALP, AST, ALT, total bilirubin
  • Abdominal ultrasound [52][53]
    • Dilated common bile duct (CBD)
    • Intrahepatic biliary dilatation
    • Echogenic structure within the CBD with shadowing
  • EUS: stone within the CBD
  • MRCP or ERCP: filling defect in the contrast-enhanced duct

Acute cholecystitis

[48][49][54][55][56]

Acute cholangitis

[48][49][58][59] [54][60][61]

Genitourinary causes

Clinical features Diagnostic findings Acute management
Ruptured ectopic pregnancy [62]
Ovarian torsion [63][64]
  • Sudden onset unilateral lower abdominal or pelvic pain
  • Nausea, vomiting
  • Unilateral iliac fossa tenderness
  • Pelvic (or transvaginal) ultrasound with Doppler velocimetry: enlarged, edematous ovaries with decreased blood flow
  • Pelvic CT scan with IV contrast
    • Unilateral thickened ovarian tube, enlarged ipsilateral ovary, and decreased enhancement of ipsilateral ovary
    • Twisted vascular pedicle (whirlpool sign)
Testicular torsion [65]
  • Clinical diagnosis
  • Doppler ultrasound: twisting of the spermatic cord; reduced perfusion of the affected testicle
Acute pyelonephritis [6][66][67][68][69]
  • Labs
  • Renal ultrasound: edema and focal hypoechogenic areas
  • CT pelvis with IV contrast: focal area(s) of hypoenhancement that extend to the cortical periphery

Empiric antibiotic therapy for intra-abdominal infections

Approach

Community-acquired infections [70][71][72]

  • Coverage of the following organisms should be considered:
  • Enterococcal coverage is not usually necessary for mild to moderate community-acquired infection but is recommended for severe infection.
  • Fluoroquinolones are only recommended as a single-agent regimen if the hospital antibiogram indicates > 90% susceptibility of E. coli. [70]
Severity of infection Suggested single-agent empiric regimen [70]

Suggested combination empiric regimen [70]

Mild or moderate infection

Severe infection
and/or
high-risk patient

Metronidazole is contraindicated in the first trimester of pregnancy.

Healthcare-associated infections [70][71][72][54]

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!

Patient and/or institutional risk factors
Suggested empiric regimens [70]
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.

Differential diagnoses

Gastrointestinal etiologies [14] Nongastrointestinal etiologies [14]
RUQ
LUQ
RLQ
LLQ
Epigastrium
Periumbilical
Suprapubic
Diffuse abdominal pain

The differential diagnoses listed here are not exhaustive.

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last updated 03/19/2020
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