Acute Abdomen - StatPearls - NCBI Bookshelf
Acute Abdomen - StatPearls - NCBI Bookshelf
Acute Abdomen - StatPearls - NCBI Bookshelf
Acute Abdomen
John W. Patterson; Sarang Kashyap; Elvita Dominique.
Author Information and Affiliations
Last Update: July 11, 2022.
Objectives:
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]
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.
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
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
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Acute peritonitis
Acute pyelonephritis
Adrenal crisis
Biliary colic
Bowel obstruction
Bowel volvulus
Carcinoid
Hemoperitoneum
Kidney stone
Ovarian torsion
Ruptured spleen
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
Fistula
Death
Consultations
Infectious disease
Obstetrician
Gynecologist
Urologist
Vascular surgeon
General surgeon
Radiologist
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
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.
References
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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.