II. Definition

  1. Acute Abdominal Pain
    1. Abdiominal pain onset under 6 hours

III. Epidemiology

  1. Abdominal Pain represents 5% 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)

V. Signs and symptoms: Findings suggestive of surgical Abdomen

  1. See Acute Abdominal Pain Evaluation
  2. Duration of pain at presentation
    1. Severe, sudden onset pain under 1 hour
      1. High risk for intra-abdominal catastrophe
      2. Causes (especially in elderly)
        1. Ruptured Abdominal Aortic Aneurysm
        2. Mesenteric Ischemia
        3. Myocardial Infarction
        4. Perforated viscus
        5. Nephrolithiasis
    2. Pain duration under 48 hours: 18% need surgery
    3. Pain duration over 48 hours: 11% need surgery
    4. Delayed presentation in young and old
  3. Pain precedes Vomiting
    1. Appendicitis
    2. Cholecystitis
    3. Small Bowel Obstruction
  4. Fever >38 C (only when accompanied by another sign)
    1. Fever lags symptoms in elderly
  5. Tachycardia (Heart Rate exceeds 110 bpm)
  6. Leukocytosis with Neutrophils >75%
  7. Peritoneal signs
  8. Age over 65 years

VI. Signs and symptoms: Findings suggestive of non-surgical Abdomen

  1. Anorexia not present

VIII. Evaluation

IX. Labs and Diagnostic Studies

X. Imaging

XI. 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

XII. 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. Parenteral NSAIDs
      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]

XIII. 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]

XIV. References

  1. Natesan (2015) Crit Dec Emerg Med 29(12): 2-11
  2. Graff (2001) Emerg Med Clin North Am 19:123-36 [PubMed]

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Related Studies

Ontology: Abdomen, Acute (C0000727)

Definition (MSHCZE) Klinickým syndromem náhlé příhody břišní je kritický stav a rychlý nástup. Příčinou jsou různé poruchy, zranění nebo nemoci.
Definition (MSH) A clinical syndrome with acute abdominal pain that is severe, localized, and rapid onset. Acute abdomen may be caused by a variety of disorders, injuries, or diseases.
Concepts Sign or Symptom (T184)
MSH D000006
ICD10 R10.0
SnomedCT 207221008, 207255006, 140460009, 269021002, 158499006, 9209005
English Abdomen, Acute, Abdomens, Acute, Acute Abdomen, Acute Abdomens, [D]Acute abdomen, [D]Acute abdomen (context-dependent category), ACUTE ABDOMEN, acute abdomen (diagnosis), acute abdomen, Abdominal syndrome acute, Syndrome abdominal acute, Abdomen, Acute [Disease/Finding], abdomen acute, acute abdominal syndrome, surgical abdomen, [D]Acute abdomen (situation), Abdomen - acute, Acute abdomen, Acute abdomen (disorder), Acute abdominal pain syndrome, Surgical abdomen, abdomen; acute abdomen, abdomen; acute, abdomen; pain, general, acute abdomen, abdominal; syndrome, acute, acute; abdomen, acute; abdominal syndrome, pain; abdomen, general, acute abdomen, syndrome; abdominal, acute, syndrome; acute abdominal, Acute abdomen, NOS, Acute abdominal pain syndrome, NOS
French ABDOMEN AIGU, Syndrome abdominal aigu, Abdomen aigu, Urgence abdominale, Syndrome douloureux abdominal, Ventre aigu
Dutch abdominaal syndroom, acuut, syndroom abdominaal acuut, abdomen; acute buik, abdominaal; syndroom, acuut, acuut; abdominaal syndroom, acuut; buik, buik; acuut, buik; pijn, algemeen, acute buik, pijn; buik, algemeen, acute buik, syndroom; abdominaal, acuut, syndroom; acuut abdominaal, acuut abdomen, Acute buik, Buik, acute
German Abdominalsyndrom akut, akutes Abdominalsyndrom, akutes Abdomen, Abdomen, akutes, Akutes Abdomen
Italian Sindrome addominale acuta, Addome acuto
Portuguese Síndrome abdominal agudo, Síndrome abdominal aguda, ABDOMEN AGUDO, Abdómen agudo, Abdome Agudo
Spanish Síndrome de abdomen agudo, Síndrome abdominal agudo, [D]abdomen agudo (categoría dependiente del contexto), [D]abdomen agudo, [D]abdomen agudo (situación), Abdomen en Tabla, abdomen agudo (trastorno), abdomen agudo, síndrome de dolor abdominal agudo, Abdomen agudo, Abdomen Agudo
Japanese 急性腹症, 急性腹部症候群, キュウセイフクショウ, キュウセイフクブショウコウグン
Swedish Akut buk
Finnish Akuutti vatsa
Czech Syndrom akutního břicha, Akutní břicho, náhlá příhoda břišní, náhlé příhody břišní, břicho - náhlé příhody, akutní břišní bolest, akutní bolest břicha
Korean 급성 복통
Polish Zespół ostrego brzucha, Ostry brzuch, Brzuch ostry
Hungarian Acut has syndroma, Acut has, Acut abdominalis syndroma
Norwegian Akutt abdomen

Ontology: Abdominal Pain (C0000737)

Definition (MSHCZE) Pocit nevolnosti, obtíží nebo bolesti v břišní oblasti; obvykle při funkčních poruchách, tkáňových poraněních nebo nemocech.
Definition (MEDLINEPLUS)

Your abdomen extends from below your chest to your groin. Some people call it the stomach, but your abdomen contains many other important organs. Pain in the abdomen can come from any one of them. The pain may start somewhere else, such as your chest. Severe pain doesn't always mean a serious problem. Nor does mild pain mean a problem is not serious.

Call your healthcare provider if mild pain lasts a week or more or if you have pain with other symptoms. Get medical help immediately if

  • You have abdominal pain that is sudden and sharp
  • You also have pain in your chest, neck or shoulder
  • You're vomiting blood or have blood in your stool
  • Your abdomen is stiff, hard and tender to touch
  • You can't move your bowels, especially if you're also vomiting
Definition (NCI_CTCAE) A disorder characterized by a sensation of marked discomfort in the abdominal region.
Definition (NCI) Painful sensation in the abdominal region.
Definition (MSH) Sensation of discomfort, distress, or agony in the abdominal region; generally associated with functional disorders, tissue injuries, or diseases.
Concepts Sign or Symptom (T184)
MSH D015746 , D003085
ICD9 789.00, 789.0
ICD10 R10.9
SnomedCT 207205003, 207230000, 158498003, 158512003, 139313005, 21522001
LNC MTHU013636, LA15468-4
English Abdominal Pains, Pains, Abdominal, Abdominal pain NOS, Abdominal Pain, [D]Abdominal pain (context-dependent category), [D]Abdominal pain NOS (context-dependent category), Abdo pain, Pain abdo, Abd. pain, [D]Abdominal pain, [D]Abdominal pain NOS, abdominal pain (symptom), abdominal pain, Pain abdominal, Gut pain, Abdmnal pain unspcf site, Unspecified abdominal pain, Abdominal Pain [Disease/Finding], Pain;abdominal, gut pain, abdomen pain, abdominal pains, Bellyache, Pain, Abdominal, Abdomen pain, [D]Abdominal pain (situation), [D]Abdominal pain NOS (situation), ABDOMINAL PAIN, PAIN, ABDOMINAL, Abdominal pain, AP - Abdominal pain, Abdominal pain (finding), abdominal; pain, abdominalgia, pain; abdominal, Abdominal pain, unspecified site
French DOULEUR ABDOMINALE, Douleur abdominale SAI, Douleur intestinale, Douleur abdo, Douleur abdo., Douleur abd., Colique, Douleur abdominale, Douleur de l'abdomen
Portuguese DOR ABDOMINAL, Dor abdominal NE, Dor intestinal, Câimbras Abdominais, Cólicas, Câimbra Abdominal, Cãibra Abdominal, Dor abdominal, Cólica, Dor Abdominal
Dutch darmpijn, buikpijn NAO, pijn abdominaal, abdominaal; pijn, pijn; abdominaal, abdominale pijn, Buikpijn, Pijn, buik-
German Schmerz abdominal, Bauchschmerz, abd. Schmerz, Abdominalschmerzen NNB, Schmerz abdo, abdo. Schmerz, ABDOMEN SCHMERZHAFT, Abdominalschmerz, Abdominalschmerzen, Bauchschmerzen, Kolik
Italian Dolore intestinale, Dolore addominale NAS, Dolore colico, Colica, Dolore addominale
Spanish Dolor de barriga, Dolor abdominal NEOM, [D]dolor abdominal, SAI (categoría dependiente del contexto), [D]dolor abdominal (categoría dependiente del contexto), ABDOMEN, DOLOR, [D]dolor abdominal (situación), [D]dolor abdominal, SAI (situación), [D]dolor abdominal, [D]dolor abdominal, SAI, dolor abdominal (hallazgo), dolor abdominal, Dolor abdominal, Dolor Abdominal
Japanese 腸管痛, 腹痛NOS, 腹痛, フクツウ, チョウカンツウ, フクツウNOS, 疝痛, 腹部痙攣, 仙痛, 腹部けいれん
Swedish Buksmärta
Czech kolika, Břišní bolest NOS, Střevní bolest, Bolest břicha, bolesti břicha, břicho - bolest
Finnish Koliikki, Vatsakipu
Polish Ból brzucha
Hungarian Hasi fájdalom, Abdominalis fájdalom k.m.n., Bél fájdalom, Abdominalis fájdalom, Hasfájdalom
Norwegian Kolikksmerter, Magesmerter, Kolikk, Abdominalsmerter, Magesmerte

Ontology: Acute abdominal pain (C0740577)

Concepts Sign or Symptom (T184)
SnomedCT 116290004, 9991008
English Acute abdominal pain, acute abdominal pain, abdominal acute pain, abdominal pain acute, Acute abdominal pain (finding), pain; abdomen, acute abdomen
Dutch pijn; buik, acute buik
Spanish dolor abdominal agudo (hallazgo), dolor abdominal agudo