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CLINICAL SCIENCE PHYSICIAN

Acute abdomen Clinical knowledge

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]

ABCDE survey
IV access with two large-bore peripheral IVs
IV fluid resuscitation (see fluid therapy)
Hemodynamic and respiratory support
NPO status
Perform a focused history and physical examination.
Perform targeted diagnostics (see “Diagnostics” below) and further tests as required.
Early surgical consult
Administer supportive care as needed.
Parenteral analgesics
Empiric antibiotics for intra-abdominal infections
Antiemetics
NG tube placement
Identify and treat the underlying cause.

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
Age > 50 years
Previous abdominal surgery
History of CAD and/or atrial fibrillation

Immediately life-threatening diagnoses

Ruptured or expanding aortic aneurysm
 Aortic dissection
Myocardial infarction
Bowel perforation
Mechanical bowel obstruction
Acute mesenteric ischemia
Acute pancreatitis
Acute cholangitis
Ruptured ectopic pregnancy

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
Blood gas analysis
Lactate
Troponin
Serum glucose
CBC
Coagulation studies (e.g., INR, PT)
BMP
LFTs
Lipase, amylase
Blood type and screen
ESR/CRP
Urinalysis
β-hCG urine test
Cultures

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 ECG

TTE
Hemorrhagic shock [6] FAST

Bowel perforation [2] CT abdomen and pelvis with IV contrast

[3] X-ray abdomen (upright and supine) with x-ray chest (upright)
Small bowel obstruction

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 CT abdomen with IV contrast

MRCP
HIDA scan

RLQ pain [4] CT abdomen and pelvis with IV contrast CT abdomen and pelvis without IV contrast
or MRI abdomen and pelvis with or without IV contrast
Abdominal and/or pelvic ultrasound
LLQ pain [7]
Duplex ultrasound of the pelvis (♀)/scrotum (♂)

LUQ pain [14] CT abdomen with oral and IV contrast Acute abdominal series

Suprapubic pain Ultrasound abdomen and pelvis CT abdomen and pelvis with/without IV contrast
[14] MRI with/without IV contrast
Transvaginal ultrasound

Pelvic pain [15] Ultrasound pelvis (transabdominal and/or Duplex ultrasonography of pelvic adnexa
transvaginal) MRI pelvis (+/- abdomen) with IV contrast
CT abdomen and pelvis with IV contrast:

Nonlocalized pain CT abdomen and pelvis with IV contrast CT abdomen and pelvis without IV contrast
[2] 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 coronary Heavy, dull, pressure/squeezing sensation ECG: nonspecific changes, ST-segment elevation/depression, T-wave inversions,
syndrome [17][18] Substernal or epigastric pain with radiation to Q waves
left shoulder Increased or normal troponin
Nausea, vomiting TTE: hypokinesis, regional wall motion abnormalities
Diaphoresis, anxiety
Dizziness, lightheadedness, syncope
Pain may improve with nitroglycerin.

Acute mesenteric Age > 60 years, embolic risk factors (e.g., atrial Labs: lactic acidosis, hyperkalemia, leukocytosis
ischemia fibrillation, thrombophilia), cardiovascular X-ray abdomen: normal (early stages), pneumatosis intestinalis (late stages)
disease CT angiography: mesenteric arterial narrowing or occlusion, thickening of bowel
[19][20][21][22] Pain out of proportion to findings wall, nonenhancing segments of solid organs or of the bowel wall, pneumatosis
Severe, diffuse abdominal pain and distention intestinalis

Vomiting, diarrhea
Melena, hematochezia

Rupture or Age > 50 years Imaging is only recommended in hemodynamically-stable patients with a low
impending rupture Sudden, severe central abdominal, chest, pretest probability of ruptured AAA.
of AAA [23] and/or back pain Abdominal ultrasound: aortic dilatation, periaortic fluid, intraperitoneal free fluid
Hypotension, shock CT/MR angiography: retro- and intraperitoneal hemorrhage; localization of the
Pulsatile mass in the midline of the abdomen ruptured/leaking site
Grey Turner sign and/or Cullen sign
History of atherosclerosis, hypertension, and/or
smoking
Aortic dissection Sudden onset of severe, sharp tearing chest or Elevated D-dimer
abdominal pain that radiates to the back ECG: nonspecific ST-segment changes
[24][25][26] Hypotension, syncope, neurological symptoms CXR: widening of the aorta
CT angiography of chest/abdomen/pelvis : intimal flap with false lumen
Asymmetrical blood pressure, pulse deficit Transesophageal echocardiography (TEE): proximal aortic dissection,
New diastolic murmur (due to aortic tamponade, aortic regurgitation
regurgitation)
Symptoms of myocardial ischemia

Gastrointestinal causes
 Clinical features Diagnostic findings
GI tract perforation Sudden onset of diffuse abdominal pain Abdominal x-ray: pneumoperitoneum
[27][28][2] Nausea, vomiting
Constipation/obstipation
Diffuse abdominal guarding, rigidity, and
rebound tenderness
Absent bowel sounds
Loss of liver dullness on RUQ percussion
Mechanical bowel Colicky abdominal pain X-ray abdomen
obstruction [2][3][29][30] Obstipation/bloating Dilated bowel loops proximal to the obstruction
Progressive nausea and vomiting (late Rectal air shadow absent
finding) Multiple air-fluid levels
Diffuse abdominal distention, tympanic CT abdomen with IV and oral contrast
abdomen, collapsed rectum on DRE Similar findings as on x-ray
Tinkling bowel sounds Transition point at site of obstruction
History of abdominal surgery
Acute appendicitis RLQ, epigastric, and/or periumbilical pain Neutrophilic leukocytosis
[31][32][33][34] (migrating abdominal pain) Abdominal CT scan with IV contrast : distended appendix with
Fever periappendiceal fat stranding
Nausea, anorexia Abdominal ultrasonography : noncompressible, aperistaltic, distended
Guarding, tenderness, and rebound appendix, probe tenderness in the RLQ, Target sign
tenderness in the RLQ

Peptic ulcer disease Epigastric pain Anemia, positive FOBT (in cases of bleeding ulcer)
[35][36][37] Duodenal ulcer: pain relieved with food; Urea breath test for H. pylori: positive in most cases of PUD
weight gain EGD: Mucosal erosions and/or ulcers are required for a definitive diagnosis.
Gastric ulcer: pain exacerbated by food;
weight loss
Signs of GI bleed
History of NSAID intake

Diverticulitis Fever Labs: ↑ WBC

[38][39][40][41][42][43][44] LLQ pain CT with IV and oral contrast: colonic diverticula with pericolic mesenteric fat
Constipation stranding
Tender mass in LLQ

Biliary and pancreatic causes

Clinical features Diagnostic findings

Acute pancreatitis Severe epigastric pain that radiates to ↑ Lipase, amylase
[45][46][47] the back (circumferential pain) Hypocalcemia (poor prognostic indicator)
Nausea, vomiting Abdominal ultrasound: pancreatic edema, peripancreatic fluid, gallstones
Epigastric tenderness, guarding, rigidity Abdominal CT with IV contrast : pancreatic edema, peripancreatic fat stranding,
Hypoactive bowel sounds gallstones
Possibly fever
History of gallstones or alcohol use
Symptomatic Biliary colic: RUQ pain with radiation to Labs: normal
cholelithiasis the right shoulder Abdominal ultrasound: gallstones with posterior acoustic shadow
[48][49][50] Postprandial onset
Nausea, vomiting
Normal abdominal examination
Choledocholithiasis RUQ pain Labs: ↑ ALP, AST, ALT, total bilirubin
[51][48] Abdominal ultrasound [52][53]
Features of obstructive jaundice
Nausea, vomiting Dilated common bile duct (CBD)
Normal abdominal examination 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 Severe RUQ pain Labs: ↑ WBC
[48][49][54][55][56] Fever, chills Abdominal ultrasound: sonographic Murphy sign , pericholecystic fluid collection,
Nausea, vomiting gallbladder wall thickening, and/or edema (double-wall sign) [57]

Right shoulder referred pain HIDA scan : nonvisualization of the gallbladder wait
Murphy sign
Acute cholangitis Charcot triad: RUQ pain, fever, and Labs
[48][49][58][59] jaundice ↑ WBC and CRP
[54][60][61] Reynold pentad ↑ ALP, ↑ AST, ↑ ALT, ↑ GGT
↑ Total bilirubin
Positive blood cultures
 Clinical features RUQ ultrasound: biliary dilation and/or evidence
Diagnostic of obstruction (e.g., choledocholithiasis),
findings
thickening of bile duct walls
MRCP/ERCP : findings similar to those on ultrasound

Genitourinary causes

Clinical features Diagnostic findings

Ruptured ectopic
pregnancy [62]
Sudden severe lower abdominal pain ↑ β-hCG
Vaginal bleeding or amenorrhea Transabdominal/transvaginal ultrasound
Lower abdominal guarding and tenderness Free fluid within Morison pouch and/or pouch of Douglas
Cervical motion tenderness, closed cervix Empty uterine cavity, thickened endometrial lining
Enlarged uterus Adnexal mass
Tachycardia, hypotension Tubal ring sign

Ovarian torsion [63][64] Sudden onset unilateral lower abdominal or pelvic Pelvic (or transvaginal) ultrasound with Doppler velocimetry: enlarged,
pain edematous ovaries with decreased blood flow
Nausea, vomiting Pelvic CT scan with IV contrast
Unilateral iliac fossa tenderness Unilateral thickened ovarian tube, enlarged ipsilateral ovary, and
decreased enhancement of ipsilateral ovary
Twisted vascular pedicle (whirlpool sign)
Testicular torsion [65] Severe lower quadrant and testicular pain Clinical diagnosis
Nausea and vomiting Doppler ultrasound: twisting of the spermatic cord; reduced perfusion of
Abnormally elevated position of the testis within the the affected testicle
scrotum

Acute pyelonephritis High fever, chills Labs

[6][66][67][68][69] Flank pain with costovertebral angle tenderness ↑ WBC, CRP, ESR
(usually unilateral, may be bilateral) Positive urinalysis
Dysuria, urinary frequency, urgency Positive urine culture
Renal ultrasound: edema and focal hypoechogenic areas
CT pelvis with IV contrast: focal area(s) of hypoenhancement that
extend to the cortical periphery

Differential diagnoses

Gastrointestinal etiologies [14] Nongastrointestinal etiologies [14]

RUQ Biliary colic Lower lobe pneumonia

Acute cholecystitis Lower lobe pulmonary infarction
Ascending cholangitis Empyema
Emphysematous cholecystitis Ureteric colic
Acute hepatitis Pyelonephritis
Pyogenic liver abscess

LUQ Gastric ulcer

Splenic abscess
Splenic laceration
Splenic infarction
RLQ Acute appendicitis Ectopic pregnancy
Colitis Ovarian torsion
IBD Testicular torsion
PID
LLQ Diverticulitis
Ureteric colic
Colitis
IBD
Epigastrium Acute gastritis Myocardial infarction
PUD Pericarditis
GERD AAA
Acute pancreatitis Aortic dissection
Acute mesenteric ischemia
Periumbilical Acute appendicitis AAA
Mesenteric ischemia Aortic dissection
Suprapubic Diverticulitis Ectopic pregnancy
PID
Cystitis
Diffuse abdominal pain Bowel perforation Diabetic ketoacidosis
Bowel obstruction Sickle cell crisis
Mesenteric ischemia Porphyria
Retroperitoneal hematoma Cocaine use
Constipation Opioid withdrawal
Heavy metal poisoning
 Gastrointestinal etiologies Nongastrointestinal etiologies
The differential diagnoses listed here are not exhaustive.

last updated 01/29/2020

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