3/8/24, 1:57 PM Acute Abdomen - StatPearls - NCBI Bookshelf

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

Acute Abdomen
Authors

John W. Patterson1; Sarang Kashyap2; Elvita Dominique3.

Affiliations
1 St. Luke's Univ. Hosp. Bethlehem
2 Beckley Appalachian Regional Healthcare Hospital
3 Wyckoff Heights Medical Center

Last Update: July 10, 2023.

Continuing Education Activity

An acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by
an infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of
abdominal pain with associated nausea or vomiting. This activity reviews the evaluation and treatment of patients
presenting with an acute abdomen, and highlights the role of the interprofessional team in caring for these patients.

Objectives:

Explain how a patient with an acute abdomen might present.

Describe the evaluation of a patient with an acute abdomen.

Generate a differential diagnosis for a patient presenting with an acute abdomen.

Explain how a well-coordinated, interprofessional team approach can improve outcomes for patients presenting
with an acute abdomen.

Access free multiple choice questions on this topic.

Introduction
Acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by an
infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of
abdominal pain with associated nausea or vomiting. Most patients with an acute abdomen appear ill.

The approach to a patient with an acute abdomen should include a thorough history and physical exam. The location
of pain is critical as it may signal a localized process. However, in patients with free air, it may present with diffuse
abdominal pain. Auscultation may reveal absent bowel sounds and palpation may reveal rebound tenderness and
guarding, suggestive of peritonitis. The causes of an acute abdomen include appendicitis, perforated peptic ulcer,
acute pancreatitis, ruptured sigmoid diverticulum, ovarian torsion, volvulus, ruptured aortic aneurysm, lacerated
spleen or liver, and ischemic bowel.[1][2][3]

Etiology
Common causes of an acute abdomen include acute appendicitis, cholecystitis, pancreatitis, and diverticulitis. Acute
peritonitis is a cause of acute abdomen and can result from rupture of a hollow viscus or as a complication of
inflammatory bowel disease or malignancy. Vascular events causing an acute abdomen include mesenteric ischemia
and ruptured abdominal aortic aneurysm. Obstetric and gynecologic causes include ruptured ectopic pregnancy and
ovarian torsion. Urologic conditions including ureteral colic and pyelonephritis can also present as acute abdominal
pain. Many authors include small bowel obstruction as a cause of acute abdomen. Newborns can present with
necrotizing enterocolitis. Midgut volvulus present 40% of the time in the first week of life, 50% in the first month and
75% in the first year. Intussusception usually occurs at ages nine to 24 months. The most common cause of an acute
pediatric abdomen is appendicitis.[4]
https://www.ncbi.nlm.nih.gov/books/NBK459328/?report=printable 1/6
3/8/24, 1:57 PM Acute Abdomen - StatPearls - NCBI Bookshelf

Epidemiology
No exact numbers are available, but between 7% and 10% of emergency department visits are for abdominal pain.
The Centers for Disease Control and Prevention (CDC), using data from the 1999 through 2008 National Hospital
Ambulatory Medical Care Survey, reported that eleven percent of emergency room department visits in 2008 were for
abdominal pain and that abdominal pain accounted for 12.5% of emergent or urgent patients. About one-third of
abdominal pain patients are diagnosed with non-specific abdominal pain. Another 30% have acute renal colic.[5]

Pathophysiology
The pathophysiology of each disease entity is beyond the scope of this review. Causes include infection (appendicitis,
diverticulitis) and obstruction (appendicitis, cholecystitis). Anatomic abnormalities include malrotation of the gut.
Age is associated with some diseases: older patients are more likely to present with diverticulitis, cholecystitis, and
vascular emergencies.

The classic presentations of appendicitis, cholecystitis, pancreatitis, and diverticulitis, are in large part the result of the
dual innervation of the abdomen, both visceral and somatic. Visceral nerves are part of the autonomic nervous system
and innervate the viscera. These nerves are sensitive to mechanical distention, inflammation, ischemia, and the
intense, smooth muscle contraction seen in colic. The pain is often midline, poorly localized, deep, and dull. Pain
from embryonic foregut structures such as the stomach, liver, pancreas, and gallbladder radiate to the epigastrium.
Midgut structures, small bowel, and appendix, to the periumbilical area and hindgut, large bowel and rectum, to the
lower abdomen. Somatic sensory nerves provide sensation to the parietal peritoneum. Somatic pain is sharper and
better localized. Somatic pain suggests peritoneal irritation. An example is a pain over McBurney’s point when the
inflamed or ruptured appendix is irritating the parietal peritoneum. Because visceral and somatic afferent nerve fibers
share spinal cord segments, visceral pain can be felt as referred pain from a somatic distribution. This explains
cholecystitis radiating to the right scapula.

History and Physical

The history and physical exam serve to eliminate some diagnoses and suggest others. Acute care physicians are well
aware of the modes of presentation of these disease entities. The immediate onset of pain suggests a vascular event
such as mesenteric ischemia. Syncope hints at blood loss as from a ruptured ectopic or leaking abdominal aortic
aneurysm (AAA). Various causes of an acute abdomen have classic presentations. Appendicitis is supposed to start
with dull periumbilical pain that migrates with time to the right lower quadrant. Ovarian torsion is supposed to start
with sudden, unilateral, lower abdominal pain that waxes and wanes and is associated with vomiting. Unfortunately,
most diseases fail to present classically. A leaking abdominal aortic aneurysm can present exactly like renal colic or as
apparently a benign low back pain. The clinician simply has to consider serious diagnoses in patients at risk.

Pain in various quadrants suggests varying diagnoses. Acute diverticulitis usually lives in the left lower quadrant
while cholecystitis is usually felt in the epigastrium or right upper quadrant. Diagnosing a patient with a full-blown
acute abdomen is easy. It is amazingly difficult to diagnose an incipient abdominal catastrophe in a patient presenting
with early, non-specific symptoms.

The past medical history can be important. Hypertension is a risk factor for abdominal aortic aneurysm. The social
history regarding alcohol use and possible pancreatitis, helps as well.

The physical exam should be focused and completed in a timely fashion. Abnormal vital signs or the general
appearance of the patient including facial expression, skin color and temperature, and altered mentation should alert
the clinician that a patient may be in extremis. A complete abdominal exam is essential. Bowel sounds must be
assessed. Palpation for masses, pain, guarding and rebound is important. Classic teaching demands a rectal on every
patient with abdominal pain. Literature suggests that rectal exam, at least in appendicitis, does not add any useful
information. Certainly, a rectal exam is important when gastrointestinal (GI) bleeding or prostate issues are suspected.
A pelvic exam should be performed when a gynecologic source of pain is suspected. A young male with abdominal
pain needs a testicular exam to exclude testicular torsion. Examination for hernias should be routine.

Evaluation

https://www.ncbi.nlm.nih.gov/books/NBK459328/?report=printable 2/6
3/8/24, 1:57 PM Acute Abdomen - StatPearls - NCBI Bookshelf

Again, rapid initial diagnosis and treatment of the acute abdomen are crucial. Evaluation and treatment should be
simultaneous. Diagnostic interventions include blood work and imaging. In adults older than 40, a 12 lead ECG can
help exclude myocardial infarction as the cause of apparent severe abdominal pain. It is important to know if a patient
with mesenteric ischemia is in atrial fibrillation. Usually, a complete blood count (CBC), comprehensive metabolic
profile and lipase are obtained. For sepsis or mesenteric ischemia, a lactate should be ordered. A urine or serum
pregnancy test is needed in the workup of ectopic pregnancy. Diagnostic imaging has advanced rapidly in the past
three decades. A bedside ultrasound in the Emergency Department can diagnose cholecystitis, hydronephrosis,
hemoperitoneum, and the presence of an abdominal aortic aneurysm in a less than 5 minutes. Diagnostic ultrasound is
the preferred modality for cholecystitis, pediatric appendicitis, ruptured ectopic, and ovarian torsion. Multislice helical
CT scanning has made the diagnosis of an acute abdomen much more straightforward. In the majority of cases,
intravenous (IV) contrast is sufficient. Oral contrast is time-consuming and not usually necessary. MRI is not usually
utilized simply because of the time required in a potentially unstable patient.[6][4][7]

Treatment / Management
Hypotension and tachycardia suggest blood loss, hypovolemia, or sepsis and require prompt aggressive fluid
resuscitation with adequate large bore IV access. Broad-spectrum antibiotics covering gram-negative enteric
organisms should be administered in a timely fashion when infection, peritoneal soilage, or sepsis is in the
differential. Sick patients should be monitored with ongoing vital sign resuscitation. Adequate pain relief with opioids
is a standard of care. The use of anti-emetics is likewise important. If a surgical emergency is suspected based on
presentation or physical findings, a surgeon should be consulted in an emergent fashion. The surgeon must be
contacted before potentially time-consuming testing is performed.

In summary, the acute abdomen consists of several intrabdominal processes that require rapid intervention in both
diagnosis and treatment. An acute abdomen may present in an obvious or subtle manner, but must always be
recognized. Rapid, appropriate testing and concomitant resuscitative therapy are mandatory. If the condition is even
possibly surgical, early consultation with a surgeon is mandatory as well.

Differential Diagnosis

Abdominal aortic aneurysm

Acute appendicitis

Acute cholecystitis

Acute diverticulitis

Acute Intestinal ischemia

Acute peptic ulce

Acute pancreatitis

Acute peptic ulcer

Acute peritonitis

Acute pyelonephritis

Acute ureteric colic

Adrenal crisis

Biliary colic

Bowel obstruction

https://www.ncbi.nlm.nih.gov/books/NBK459328/?report=printable 3/6
3/8/24, 1:57 PM Acute Abdomen - StatPearls - NCBI Bookshelf

Bowel volvulus

Carcinoid

Ectopic pregnancy with tubal rupture

Familial mediterranean fever

Hemoperitoneum

Kidney stone

Ovarian torsion

Ruptured spleen

Sicle cell anemia

Prognosis
In general, the finding of an acute abdomen is indicative of a surgical problem, and in the past, the patient was taken
directly to the operating room. Unfortunately, there are also some medical disorders that can present with acute
abdominal pain that requires medical therapy. These conditions include acute pancreatitis, sickle cell anemia, diabetic
ketoacidosis, adrenal crisis, and pyelonephritis. Today, ultrasound and/or CT scans are widely used to determine the
cause of acute abdomen, so that the surgeon knows beforehand what to expect during surgery. It also avoids
unnecessary surgery in patients with medical causes of an acute abdomen. All patients with an acute abdomen need to
be seen by a surgeon. If the patient is stable, imaging studies can be obtained. If the patient is unstable, immediate
surgical intervention may be necessary. The prognosis of patients depends on the cause.[8][9]

Complications
If left untreated, an acute abdomen may result in the following:

Sepsis

Necrosis and/or gangrene of bowel

Fistula

Death

Postoperative and Rehabilitation Care

Since most patients with an acute abdomen are seniors, they are best managed in an ICU setting. Intravenous
hydration, Nasogastric decompression and pain control are often required. The role of antibiotics depends on the
cause. Close monitoring is required as patients may develop complications like atelectasis, ileus, wound infections,
DVT and pneumonia.

Consultations

Infectious disease

Obstetrician

Gynecologist

Urologist

Vascular surgeon

General surgeon

https://www.ncbi.nlm.nih.gov/books/NBK459328/?report=printable 4/6
3/8/24, 1:57 PM Acute Abdomen - StatPearls - NCBI Bookshelf

Radiologist

Pearls and Other Issues

Acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by an
infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of
abdominal pain with associated nausea or vomiting. Most patients with an acute abdomen appear ill.

The history and physical exam serve to eliminate some diagnoses and suggest others. Acute care physicians are well
aware of the modes of presentation of these disease entities.

An acute abdomen may present in an obvious or subtle manner, but must always be recognized. Rapid, appropriate
testing and concomitant resuscitative therapy are mandatory. If the condition is even possibly surgical, early
consultation with a surgeon is mandatory

Enhancing Healthcare Team Outcomes

Acute abdominal pain frequently poses a diagnostic dilemma. These patients may exhibit non-specific signs and
symptoms such as vomiting, nausea, and leukocytosis. The cause of acute abdominal pain may be due to a myriad of
diagnosis including gynecological, obstetrical, gastrointestinal, urological, metabolic and vascular etiologies. While
the physical exam may reveal that the patient has a surgical abdomen, the cause is difficult to know without proper
imaging studies.

An Interprofessional Approach and Outcomes

While the general surgeon is almost always involved in the care of patients with an acute abdomen, it is important to
consult with an interprofessional team of specialists that include an obstetrician, gynecologist, and a vascular surgeon.
The nurses are also a vital member of the interprofessional group as they will monitor the patient's vital signs. In the
postoperative period for pain, wound infection and ileus; the pharmacist will ensure that the patient is on the right
analgesics, antiemetics, and appropriate antibiotics. The radiologist also plays a vital role in determining the cause.
Without providing a proper history, the radiologist may not be sure what to look for or what additional radiologic
exams may be needed. This problem gets even more complex when women of childbearing age present with an acute
abdomen. The American College of Radiology Appropriateness Criteria® are evidence-based guidelines for specific
clinical disorders that are reviewed by an interprofessional expert committee every three years. The current guidelines
have been developed after an exhaustive review of current medical literature from peer-reviewed journals to
determine the appropriateness of radiological imaging and treatment procedures by the committee. In cases where
evidence is not definitive or minimal, expert opinion from the specialist may be utilized to recommend the type
of imaging or treatment. [10] [Level A]

The outcomes of an acute abdomen depend on the cause. However, to improve outcomes, prompt consultation with an
interprofessional group of specialists is recommended.

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

References
1. Elhardello OA, MacFie J. Digital rectal examination in patients with acute abdominal pain. Emerg Med J. 2018
Sep;35(9):579-580. [PubMed: 30030218]
2. Maleki Verki M, Motamed H. Rectus Muscle Hematoma as a Rare Differential Diagnosis of Acute Abdomen; a
Case Report. Emerg (Tehran). 2018;6(1):e28. [PMC free article: PMC6036518] [PubMed: 30009230]
3. Kaushal-Deep SM, Anees A, Khan S, Khan MA, Lodhi M. Primary cecal pathologies presenting as acute
abdomen and critical appraisal of their current management strategies in emergency settings with review of
literature. Int J Crit Illn Inj Sci. 2018 Apr-Jun;8(2):90-99. [PMC free article: PMC6018260] [PubMed: 29963412]
4.

https://www.ncbi.nlm.nih.gov/books/NBK459328/?report=printable 5/6
3/8/24, 1:57 PM Acute Abdomen - StatPearls - NCBI Bookshelf

Li PH, Tee YS, Fu CY, Liao CH, Wang SY, Hsu YP, Yeh CN, Wu EH. The Role of Noncontrast CT in the Evaluation
of Surgical Abdomen Patients. Am Surg. 2018 Jun 01;84(6):1015-1021. [PubMed: 29981641]
5. de Burlet K, Lam A, Larsen P, Dennett E. Acute abdominal pain-changes in the way we assess it over a decade. N
Z Med J. 2017 Oct 06;130(1463):39-44. [PubMed: 28981493]
6. Geng WZM, Fuller M, Osborne B, Thoirs K. The value of the erect abdominal radiograph for the diagnosis of
mechanical bowel obstruction and paralytic ileus in adults presenting with acute abdominal pain. J Med Radiat
Sci. 2018 Dec;65(4):259-266. [PMC free article: PMC6275248] [PubMed: 30039624]
7. Mohammed MF, Elbanna KY, Mohammed AME, Murray N, Azzumea F, Almazied G, Nicolaou S. Practical
Applications of Dual-Energy Computed Tomography in the Acute Abdomen. Radiol Clin North Am. 2018
Jul;56(4):549-563. [PubMed: 29936947]
8. Nakashima T, Miyamoto K, Shimokawa T, Kato S, Hayakawa M. The Association Between Sequential Organ
Failure Assessment Scores and Mortality in Patients With Sepsis During the First Week: The JSEPTIC DIC Study.
J Intensive Care Med. 2020 Jul;35(7):656-662. [PubMed: 29764273]
9. Pucher PH, Carter NC, Knight BC, Toh S, Tucker V, Mercer SJ. Impact of laparoscopic approach in emergency
major abdominal surgery: single-centre analysis of 748 consecutive cases. Ann R Coll Surg Engl. 2018
Apr;100(4):279-284. [PMC free article: PMC5958847] [PubMed: 29364016]
10. Bhosale PR, Javitt MC, Atri M, Harris RD, Kang SK, Meyer BJ, Pandharipande PV, Reinhold C, Salazar GM,
Shipp TD, Simpson L, Sussman BL, Uyeda J, Wall DJ, Zelop CM, Glanc P. ACR Appropriateness Criteria®
Acute Pelvic Pain in the Reproductive Age Group. Ultrasound Q. 2016 Jun;32(2):108-15. [PubMed: 26588104]
Disclosure: John Patterson declares no relevant financial relationships with ineligible companies.

Disclosure: Sarang Kashyap declares no relevant financial relationships with ineligible companies.

Disclosure: Elvita Dominique declares no relevant financial relationships with ineligible companies.

Copyright © 2024, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) (
http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used
commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Bookshelf ID: NBK459328 PMID: 29083722

https://www.ncbi.nlm.nih.gov/books/NBK459328/?report=printable 6/6