Acute Abdominal Pain

Aka: Acute Abdominal Pain, Acute Abdomen, Abdominal Pain

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II. Definitions

  1. Acute Abdominal Pain
    1. Abdiominal pain onset within 7 days

III. Epidemiology

  1. Abdominal Pain represents 5-10% of ER visits
  2. Only 10% of these evaluations require surgery
  3. Accounts for 10% of Malpractice claims

IV. Pearls

  1. Cohorts with atypical presentations of serious Abdominal Pain causes
    1. Elderly and Immunocompromised
      1. Use low threshold for admiting elderly (and Immunocompromised) for observation
      2. See Abdominal Pain in Older Adults
    2. Pregancy
      1. Appendix migrates upward into peri-renal and even RUQ in third trimester
  2. Most commonly missed surgical diagnoses
    1. Appendicitis
    2. Small Bowel Obstruction
  3. Specific Warning signs
    1. Low Back Pain in elderly
      1. Abdominal Aortic Aneurysm
    2. Atrial Fibrillation and Abdominal Pain
      1. Mesenteric Ischemia
  4. Common serious causes mimicking more benign causes
    1. Retrocecal appendix
      1. May present with back pain or upper quadrant Abdominal Pain
    2. Abdominal aoortic aneurysm
      1. May present with Renal Colic symptoms (Flank Pain, LLQ Pain and even Hematuria)
  5. Exercise caution when diagnosing Acute Gastroenteritis and non-specific Abdominal Pain
    1. Although combined these account for 20% of Acute Abdominal Pain, they are also common misdiagnoses
    2. Atypical Gastroenteritis (e.g. prominent pain, Vomiting without Diarrhea) may represent a more serious cause

V. Differential Diagnosis

  1. See Acute Abdominal Pain Causes
  2. See Generalized Abdominal Pain
  3. See Left Upper Quadrant Abdominal Pain
  4. See Right Upper Quadrant Abdominal Pain
  5. See Left Lower Quadrant Abdominal Pain
  6. See Right Lower Quadrant Abdominal Pain
  7. See Extraperitoneal Abdominal Pain Causes
  8. See Abdominal Wall Pain Causes
  9. See Epigastric Pain
  10. See Suprapubic Pain

VI. Findings

  1. See Abdominal Pain Evaluation for history and symptoms, exam and signs

VII. Evaluation

  1. See Acute Abdominal Pain Evaluation

VIII. Labs and Diagnostic Studies

  1. See Acute Abdominal Pain Evaluation

IX. Imaging

  1. See Acute Abdominal Pain Evaluation

X. Management: Surgery Consultation Indications

  1. Severe Abdominal Pain or progressive Abdominal Pain (regardless of non-diagnostic imaging)
  2. Vomit feculent or bile-stained
  3. Abdominal guarding or rigidity
  4. Abdominal Rebound Tenderness
  5. Abdominal Distention and hypertympanic to percussion
  6. Significant Traumatic Injury to Abdomen
  7. Abdominal Pain of unclear etiology
  8. Intra-abdominal fluid accumulation

XI. Management: General

  1. Antiemetics
    1. Ondansetron (Zofran)
    2. Prochlorperazine (Compazine)
      1. More effective Antiemetic in Abdominal Pain than Phenergan, Reglan
      2. Ernst (2000) Ann Emerg Med 36(2): 89-94 +PMID:10918098 [PubMed]
  2. Parenteral Analgesics
    1. Opioid Dosing
      1. Dilaudid 0.3 to 0.5 mg every 15 minutes prn
      2. Morphine Sulfate 2-4 mg every 15 minutes prn
    2. ParenteralNSAIDs
      1. Toradol 15-30 mg IV (or 30-60 mg IM) every 6 hours as needed
    3. Do not delay adequate analgesia
      1. Does not interfere with exam
      2. Pace (1996) Acad Emerg Med 3:1086-92 [PubMed]
      3. Thomas (2003) J Am Coll Surg 196:18-31 [PubMed]

XII. Management: Disposition

  1. Re-evaluate in 6-12 hours persistent Abdominal Pain with non-diagnostic evaluation and unclear cause
  2. Appendicitis rupture is unlikely in first 36 hours (<2%)
    1. Bickell (2006) J Am Coll Surg 202(3):401-6 [PubMed]

XIII. References

  1. Natesan (2015) Crit Dec Emerg Med 29(12): 2-11
  2. Graff (2001) Emerg Med Clin North Am 19:123-36 [PubMed]
  3. Yew (2023) Am Fam Physician 107(6): 585-96 [PubMed]

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