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Diseases

Evaluation of acute abdomen

OVERVIEW

  • Summary
  • Urgent Considerations
  • Etiology

DIAGNOSIS

  • Differential Diagnosis
  • Diagnostic Approach

IMAGES

  • Library

REFERENCES

  • Citations
  • Credits

Summary

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Acute abdomen refers to the rapid onset of severe symptoms of abdominal pathology. It may indicate a potentially life-threatening condition that requires urgent surgical intervention. Acute abdominal pain is a common reason for emergency department attendance.[1]

Clinical features

Immediate assessment should focus on distinguishing patients with true acute abdomen that requires urgent surgical intervention from patients who can initially be managed conservatively.[2] Data from the UK suggest that access to an experienced surgeon reduces unnecessary admissions.[3]
A patient with acute surgical pathology may deteriorate rapidly; patients with severe, unremitting symptoms warrant thorough investigation and close monitoring.
Pain may:

  • Be located in any quadrant of the abdomen

  • Be intermittent, sharp or dull, achy, or piercing

  • Radiate from a focal site

  • Be accompanied by nausea and vomiting

Acute abdomen can occur without pain in older people, children, patients who are immunocompromised, and women in the last trimester of pregnancy.

Diagnostic workup

An acute abdomen is diagnosed by a combination of history, physical exam, laboratory results and imaging.
Diagnostic laparoscopy can be considered in selected patients.[4] [5] [6]

Analgesia

Give patients adequate analgesia.[3] One meta-analysis of randomized controlled trials that included adult patients with acute abdominal pain found that opioid analgesia does not increase the risk of diagnosis error or treatment decision error, and improves patient comfort.[7]

Special groups

Abdominal pain in older people, patients who are immunocompromised, and pregnant women often presents atypically, which can lead to delayed diagnosis of life-threatening abdominal pathology.[8]
Older people

  • Comorbid conditions or medications used to treat them may affect an older patient's ability to mount a characteristic physiologic response.

  • Older patients are at higher risk for more severe disease due to decreased immune function.[9]

  • Central and peripheral nervous systems are affected by aging. Conditions such as dementia can restrict an older person's ability to communicate problems, and decreased peripheral nervous system function can alter perception of pain and temperature, making diagnosis and management more difficult.

  • One study of patients with perforated ulcers found that only 21% of older patients presented with peritonitis.[9]

Pregnant women

  • The physical and physiologic changes associated with pregnancy may present a challenge to diagnosis and treatment.

  • The enlargement of the uterus, which displaces and compresses intra-abdominal organs, and the laxity of the abdominal wall make it difficult to localize pain and can blunt peritoneal signs.[10]

  • Pregnant women may have mild physiologic leukocytosis, so this finding is nonspecific in pregnant women presenting with an acute abdomen.

  • If there is a high index of suspicion for intra-abdominal pathology, further studies are warranted and may include additional laboratory testing, radiographic testing, or in some cases serial physical exams.

  • See also Assessment of abdominal pain in pregnancy (urgent considerations) .

Immunocompromised patients

  • Immunocompromised patients mount an altered inflammatory response, and may display atypical symptoms and signs of acute abdominal pathology. Abdominal pain is usually nonspecific, and physical exam is often inconclusive.[11]

  • Immunocompromised patients are susceptible to opportunistic infections, e.g., cytomegalovirus colitis in patients with AIDS.

  • An acute abdomen may occur as a result of immunosuppressive therapy. Typhlitis (neutropenic enterocolitis) is a complication of chemotherapy that typically presents with fever, neutropenia, and right iliac fossa pain 10 to 14 days after initiation of chemotherapy.[12]

  • A lower threshold for admission to hospital and cross-sectional imaging is required in immunocompromised patients.[11]

content by BMJ Group
Last updated

Library

  • Common locations of visceral pain

    Common locations of visceral pain

  • Areas of pain that present suddenly and severe in onset

    Areas of pain that present suddenly and severe in onset

  • Areas of pain that present more colicky, crampy, and intermittent in nature

    Areas of pain that present more colicky, crampy, and intermittent in nature

  • Areas of pain that present gradually or more progressively

    Areas of pain that present gradually or more progressively

  • Solid circles represent the primary sites of pain and dotted circles represent the areas of referred

    Solid circles represent the primary sites of pain and dotted circles represent the areas of referred pain

  • Solid circles represent the primary sites of pain and the dotted circles represent the areas of refe

    Solid circles represent the primary sites of pain and the dotted circles represent the areas of referred pain

  • Cullen sign (periumbilical discoloration) in a 36-year-old man who presented with a 4-day history of

    Cullen sign (periumbilical discoloration) in a 36-year-old man who presented with a 4-day history of severe epigastric pain following an alcoholic binge

  • Grey-Turner sign (bruising of the flanks) in a 40-year-old woman with worsening epigastric pain of 5

    Grey-Turner sign (bruising of the flanks) in a 40-year-old woman with worsening epigastric pain of 5 days' duration

  • Abdominal free gas pockets, x-ray

    Abdominal free gas pockets, x-ray

  • Intussusception: Ultrasound image showing invagination of a segment of bowel into the adjacent segme

    Intussusception: Ultrasound image showing invagination of a segment of bowel into the adjacent segment

  • Intussusception: Transverse sonogram of the abdomen showing the donut sign (concentric rings within

    Intussusception: Transverse sonogram of the abdomen showing the donut sign (concentric rings within the lumen of a distended loop of bowel)

  • Intussusception: Abdominal x-ray showing impaired passage of barium at site of obstruction due to in

    Intussusception: Abdominal x-ray showing impaired passage of barium at site of obstruction due to intussusception

  • Intussusception: Site of intussusception as revealed by abdominal x-ray, showing the meniscus

    Intussusception: Site of intussusception as revealed by abdominal x-ray, showing the meniscus

  • Intussusception: Site of intussusception as revealed by abdominal x-ray, showing the meniscus

    Intussusception: Site of intussusception as revealed by abdominal x-ray, showing the meniscus

  • Cholecystitis: Operative photo showing acute cholecystitis

    Cholecystitis: Operative photo showing acute cholecystitis

  • Cholecystitis: Ultrasound of acute cholecystitis and presence of gallstones

    Cholecystitis: Ultrasound of acute cholecystitis and presence of gallstones

  • Appendicitis: CT abdomen showing thickened appendix

    Appendicitis: CT abdomen showing thickened appendix

  • Ectopic pregnancy: Ultrasound image of ectopic pregnancy showing the donut sign

    Ectopic pregnancy: Ultrasound image of ectopic pregnancy showing the donut sign

  • Ectopic pregnancy: Ultrasound image of ectopic pregnancy

    Ectopic pregnancy: Ultrasound image of ectopic pregnancy

  • Ectopic pregnancy: Ultrasound image of ectopic pregnancy

    Ectopic pregnancy: Ultrasound image of ectopic pregnancy

  • Ectopic pregnancy: Surgical extraction of ectopic pregnancy

    Ectopic pregnancy: Surgical extraction of ectopic pregnancy

  • Ectopic pregnancy: Surgical extraction of ectopic pregnancy

    Ectopic pregnancy: Surgical extraction of ectopic pregnancy

  • Ectopic pregnancy: Blood in the abdomen

    Ectopic pregnancy: Blood in the abdomen

  • Ectopic pregnancy: Blood in cul de sac

    Ectopic pregnancy: Blood in cul de sac

  • Abdominal aortic aneurysm: CT scan of a ruptured abdominal aortic aneurysm

    Abdominal aortic aneurysm: CT scan of a ruptured abdominal aortic aneurysm

  • Ischemic bowel disease: CT scan showing colonic thickening with pneumatosis intestinalis

    Ischemic bowel disease: CT scan showing colonic thickening with pneumatosis intestinalis

  • Ischemic bowel disease: CT angiogram: acute superior mesenteric artery thrombus

    Ischemic bowel disease: CT angiogram: acute superior mesenteric artery thrombus

  • Ischemic bowel disease: 84-year-old man presenting with symptoms suggestive of ischemic bowel diseas

    Ischemic bowel disease: 84-year-old man presenting with symptoms suggestive of ischemic bowel disease: (A) Abdominal CT revealing a massive circumferential and band-like air formation as intestinal pneumatosis (arrows) and pronounced edema of mesenteric fat (arrowhead) around necrotic bowel loops; (B) Another slice of abdominal CT showing long segmental pneumatosis of the small bowel

  • Crohn disease: CT scan demonstrating thickening of the terminal ileum in a patient with Crohn diseas

    Crohn disease: CT scan demonstrating thickening of the terminal ileum in a patient with Crohn disease exacerbation

  • Crohn disease: CT scan demonstrating thickening of the terminal ileum in a patient with Crohn diseas

    Crohn disease: CT scan demonstrating thickening of the terminal ileum in a patient with Crohn disease exacerbation

  • Crohn disease: Endoscopic view of Crohn ileitis

    Crohn disease: Endoscopic view of Crohn ileitis

  • Crohn disease: Endoscopic view of normal terminal ileum

    Crohn disease: Endoscopic view of normal terminal ileum

  • Ultrasound of acute cholecystitis and presence of gallstones: the arrow points to a gallstone in the

    Ultrasound of acute cholecystitis and presence of gallstones: the arrow points to a gallstone in the fundus of the gallbladder with its echogenic shadow below

  • Gallbladder ultrasound demonstrating cholelithiasis with characteristic shadowing

    Gallbladder ultrasound demonstrating cholelithiasis with characteristic shadowing

  • Liver abscess: CT scan showing 8 cm by 8 cm superinfected and ruptured echinococcal cyst, and a 4 cm

    Liver abscess: CT scan showing 8 cm by 8 cm superinfected and ruptured echinococcal cyst, and a 4 cm by 4 cm echinococcal cyst in a 69-year-old man who presented with hypotension and chest pain radiating to the epigastric region

  • Liver abscess: CT scan showing a liver abscess (7 cm x 5 cm) in a 46-year-old man who presented with

    Liver abscess: CT scan showing a liver abscess (7 cm x 5 cm) in a 46-year-old man who presented with fever, fatigue, and cough

  • Liver abscess: CT scan (coronal view) showing liver abscess in a 46-year-old man who presented with

    Liver abscess: CT scan (coronal view) showing liver abscess in a 46-year-old man who presented with fever, fatigue, and cough

  • Liver abscess: A noncontrast abdominal CT scan showing a huge gas-containing liver abscess (arrow)

    Liver abscess: A noncontrast abdominal CT scan showing a huge gas-containing liver abscess (arrow)

  • Liver Abscess: Gross pathology of amebic abscess of liver; tube of "chocolate" pus from abscess

    Liver Abscess: Gross pathology of amebic abscess of liver; tube of "chocolate" pus from abscess

  • Mallory-Weiss tear: Nonbleeding adherent clot

    Mallory-Weiss tear: Nonbleeding adherent clot

  • Mallory-Weiss tear: Actively bleeding tear appears as a red longitudinal defect with normal surround

    Mallory-Weiss tear: Actively bleeding tear appears as a red longitudinal defect with normal surrounding mucosa

  • Budd-Chiari syndrome: Hepatic venogram demonstrating "spider web" and thrombus in the inferior vena

    Budd-Chiari syndrome: Hepatic venogram demonstrating "spider web" and thrombus in the inferior vena cava

  • Clostridium difficile-associated disease: CT scan of the abdomen showing gross thickening of the lar

    Clostridium difficile-associated disease: CT scan of the abdomen showing gross thickening of the large bowel wall and obliteration of the lumen

  • Endometriosis: Laparoscopic image of endometriotic nodule

    Endometriosis: Laparoscopic image of endometriotic nodule

  • Endometriosis: Laparoscopic image of ovarian endometrioma

    Endometriosis: Laparoscopic image of ovarian endometrioma

  • Testicular torsion: Bilateral transverse color Doppler images in a 12-year-old boy with right-sided

    Testicular torsion: Bilateral transverse color Doppler images in a 12-year-old boy with right-sided scrotal pain of sudden onset, showing no color flow signals in the right testis, which is enlarged and has heterogeneous echogenicity; reactive hydrocele (h) and thickening of the scrotal wall (*) are also seen; testicular torsion and bell clapper deformity were confirmed at surgery

Citations

    Key Articles

    • American College of Radiology. ACR Appropriateness Criteria: acute nonlocalized abdominal pain. 2018 [internet publication].[Abstract][Full Text]

    • American College of Radiology. ACR Appropriateness Criteria: right lower quadrant pain. 2022 [internet publication].[Abstract][Full Text]

    • American College of Radiology. ACR Appropriateness Criteria: left lower quadrant pain. 2023 [internet publication].[Full Text]

    • American College of Radiology. ACR Appropriateness Criteria: right upper quadrant pain. 2022 [internet publication].[Full Text]

    Referenced Articles

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