Acute abdomen
Last updated: March 12, 2021Summary
Acute abdomen refers to severe abdominal pain lasting for ≤ 5 days. The underlying pathology may be intra-abdominal, thoracic, or systemic and may require urgent surgical intervention. The initial approach to acute abdomen should be to assess for immediately life-threatening causes (e.g., ruptured abdominal aortic aneurysm, bowel perforation) by checking vital signs, performing a quick physical examination, and immediately conducting the appropriate focused diagnostic tests (e.g., abdominal ultrasound, abdominal x-ray). Once emergency causes have been ruled out, a thorough history and physical examination should be performed to narrow the differential diagnoses and guide further diagnostic workup and therapy. Traumatic causes of abdominal pain, abdominal trauma, and chronic abdominal pain are not addressed here.
Approach
Approach to management [1]
- ABCDE survey
- IV access with two large-bore peripheral IVs
-
IV fluid resuscitation (see fluid therapy)
- Hemodynamic and respiratory support
-
NPO status
- Perform a focused history and physical examination.
- Perform targeted diagnostics (see “Diagnostics” below) and further tests as required.
- Early surgical consult
- Administer supportive care as needed.
- Identify and treat the underlying cause.
Red flags for abdominal pain
Immediately life-threatening diagnoses
Diagnostics
The diagnostic workup should be guided by the pretest probability of the diagnoses under consideration. The following list includes some commonly used diagnostic tools that can help to diagnose or rule out possible etiologies in a patient with acute abdominal pain.
A urine pregnancy test should be performed in every woman of reproductive age, regardless of current contraception use.
Patients with obvious signs of diffuse peritonitis do not require further diagnostic imaging and should proceed straight to surgical management.
Imaging [2][3][4][5][6][7][8]
Approach
- The initial imaging modality should be guided by the working diagnosis, as based on the patient history, vital signs, and examination.
- The following recommendations apply to nonpregnant adults.
- In pregnant women with acute abdominal pain, ultrasound and/or MRI of the abdomen and/or pelvis without contrast are the preferred initial imaging modalities.
By suspected diagnosis [5]
By location of the pain
Site of pain |
Initial test of choice | Alternatives |
RUQ pain [13] |
|
|
RLQ pain [4] or LLQ pain [7] |
- CT abdomen and pelvis with IV contrast
|
|
LUQ pain [14] |
- CT abdomen with oral and IV contrast
|
|
Suprapubic pain [14] |
|
|
Pelvic pain [15] |
- Gynecological etiology suspected: Ultrasound pelvis (transabdominal and/or transvaginal)
- Nongynecological etiology suspected and β-HCG is negative: CT abdomen and pelvis with IV contrast
|
|
Nonlocalized pain [2] |
- CT abdomen and pelvis with IV contrast
|
- CT abdomen and pelvis without IV contrast
-
MRI abdomen and pelvis with/without IV contrast
-
Ultrasound abdomen and/or pelvis
- Postoperative patients with acute abdomen: consider fluoroscopy (enema and/or upper abdominal series)
|


Consider diagnostic laparoscopy in hemodynamically stable patients in which the diagnosis is still unclear after complete physical examination and imaging. For patients with hemodynamic instability or severe abdominal distention, proceed to diagnostic laparotomy. [16]
In pregnant patients, regardless of the site of pain, ultrasound and MRI are the preferred initial imaging modalities.
Cardiovascular causes
Gastrointestinal causes
Biliary and pancreatic causes
Genitourinary causes
Empiric antibiotic therapy for intra-abdominal infections
Approach
Severity of infection | Suggested single-agent empiric regimen [70]
| Suggested combination empiric regimen [70] |
Mild or moderate infection
|
|
|
Severe infection and/or high-risk patient
|
|
|
Metronidazole is contraindicated in the first trimester of pregnancy.
Healthcare-associated infections [54][70][71][72]
Healthcare-associated infections are more likely to be antibiotic-resistant and both institutional and individual patient antibiograms should be considered when choosing an empiric regimen!
- Coverage of the following organisms should be considered:
- Agents to avoid as empiric therapy:
Patient and/or institutional risk factors
| Suggested empiric regimens [70]
|
Low risk (< 20%) of infection with resistant organism
|
|
|
High risk (> 20%) of infection with resistant organism |
- Single-agent or combination empiric regimen (see above) PLUS one of the following:
|
High risk of MRSA |
- Combination empiric regimen (see above)
- PLUS vancomycin
|
Obtain cultures, if necessary, before the administration of empirical IV antibiotics.
For patients with a beta-lactam or carbapenem allergy, consider vancomycin with aztreonam and metronidazole.
Differential diagnoses


| Gastrointestinal etiologies [14] | Nongastrointestinal etiologies [14] |
RUQ |
|
|
LUQ |
|
RLQ |
|
|
LLQ |
|
Epigastrium |
|
|
Periumbilical |
|
|
Suprapubic |
|
|
Diffuse abdominal pain |
|
|
The differential diagnoses listed here are not exhaustive.
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