Acute Abdominal Pain

Aka: Acute Abdominal Pain, Acute Abdomen, Abdominal Pain

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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

VII. 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

VIII. Evaluation

  1. See Acute Abdominal Pain Evaluation

IX. Labs and Diagnostic Studies

  1. See Acute Abdominal Pain Evaluation

X. Imaging

  1. See Acute Abdominal Pain Evaluation

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. 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]

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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