Acute Abdominal Pain3

DOI 10.2310/7800.
S05C01
06/09
2009 BC Decker Inc ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 1 ACUTE ABDOMINAL PAIN 1
1 ACUTE ABDOMINAL PAIN
Alex Nagle, MD, FACS
Acute abdominal pain generally refers to previously undi-
agnosed pain that arises suddenly and is of less than 48
hours duration.
1
It may be caused by a great variety of
intraperitoneal disorders, many of which call for surgical
treatment, as well as by a range of extraperitoneal disorders,
2

which typically do not call for surgical treatment [ see Clin-
ical Evaluation, Tentative Differential Diagnosis, below ].
Abdominal pain that persists for 6 hours or longer is usually
caused by disorders of surgical signicance.
3
The primary
goals in the management of patients with acute abdominal
pain are (1) to establish a differential diagnosis and a plan
for conrming the diagnosis through appropriate imaging
studies, (2) to determine whether operative intervention is
necessary, and (3) to prepare the patient for operation
in a manner that minimizes perioperative morbidity and
mortality.
In many cases, these goals are easily accomplished. On
occasion, however, the evaluation of patients with acute
abdominal pain can be one of the most difcult challenges in
clinical surgery. It is essential to keep in mind that most (at
least two thirds) of the patients who present with acute
abdominal pain have disorders for which surgical intervention
is not required.
2,4,5
In addition, most clinicians depend on
recognition of specic patterns and sequences of symptoms
and signs to determine the need for further testing and to
make decisions regarding the timing of operation; however,
at least one third of patients with acute abdominal pain
exhibit atypical features that render pattern recognition
unreliable.
2,5
Finally, it is not clear that individual clinicians
always or even usually agree on presenting symptoms and
physical signs. In one study of abdominal pain in children,
agreement between individual observers was reached 50% of
the time for the physical sign of rebound tenderness; how-
ever, for ve other signs (abdominal distention, abdominal
tenderness to percussion, abdominal tenderness to palpation,
abdominal guarding, and bowel sounds), interobserver agree-
ment was not reached in more than one third of patients.
These ndings highlight the difculties inherent in evaluation
and management of acute abdominal pain. In addition, they
emphasize the importance of integrating care among different
providers to minimize loss of information and maximize con-
tinuity of care.
Clinical Evaluation
hi story
A careful and methodical clinical history should be obtained.
Key features of the history include the dimensions of pain
(i.e., mode of onset, duration, frequency, character, location,
chronology, radiation, and intensity), as well as the presence
or absence of any aggravating or alleviating factors and asso-
ciated symptoms. Often such a history is more valuable than
any single laboratory or x-ray nding and determines the
course of subsequent evaluation and management.
Unfortunately, when the ability of clinicians to take an
organized and accurate history has been studied, the results
have been disappointing.
6
For this reason, the use of standard-
ized history and physical forms, with or without the aid of
diagnostic computer programs, has been recommended.
710

A large-scale study that included 16,737 patients with acute
abdominal pain demonstrated that integration of computer-
aided diagnosis into management yielded a 20% improvement
in diagnostic accuracy.
7
The study also documented statisti-
cally signicant reductions in inappropriate admissions, nega-
tive laparotomies, serious management errors (e.g., failure to
operate on patients who require surgery), and length of hos-
pital stay, as well as statistically signicant increases in the
number of patients who were immediately discharged home
without adverse effects and the promptness with which those
requiring surgery underwent operation. Although many
factors may have contributed to the observed benets of
computer-aided decision making, it is clear that the use of
structured and standardized means of collecting clinical and
laboratory data was crucial. An example of such a structured
data sheet is the pain chart developed by the World Organiza-
tion of Gastroenterology (OMGE) [ see Figure 1 ]. Because this
pain chart is not exhaustive and does not cover all potential
situations, individual surgeons may want to add to it; how-
ever, they would be well advised not to omit any of the
symptoms and signs on the OMGE data sheet from their rou-
tine examination of patients with acute abdominal pain.
11

The patients own words often provide important clues to
the correct diagnosis. The examiner should refrain from sug-
gesting specic symptoms, except as a last resort. Any ques-
tions that must be asked should be open-endedfor example,
What happens when you eat? rather than Does eating
make the pain worse? Leading questions should be avoided.
When a leading question must be asked, it should be posed
rst as a negative question (i.e., one that calls for an answer
in the negative) because a negative answer to a question is
more likely to be honest and accurate. For example, if peri-
toneal inammation is suspected, the question asked should
be Does coughing make the pain better? rather than Does
coughing make the pain worse?
The mode of onset of abdominal pain may help the exam-
iner determine the severity of the underlying disease. Pain
that has a sudden onset suggests an intra-abdominal catastro-
phe, such as a ruptured abdominal aortic aneurysm (AAA), a
06/09
ABDOMINAL PAIN CHART
NAME REG. NUMBER
MALE FEMALE AGE FORM FILLED BY
MODE OF ARRIVAL DATE TIME
Site of Pain
At Onset
At Present
Radiation
Aggravating Factors
movement
coughing
respiration
food
other
none
Relieving Factors
lying still
vomiting
antacids
food
other
none
Progression of Pain
better
same
worse
Duration
Type
intermittent
steady
colicky
Severity
moderate
severe
Nausea
yes no
Vomiting
yes no
Anorexia
yes no
Indigestion
yes no
Jaundice
yes no
Bowels
normal
constipation
diarrhea
blood
mucus
Micturition
normal
frequency
dysuria
dark
hematuria
Location of Tenderness
Rebound
yes no
Guarding
yes no
Rigidity
yes no
Mass
yes no
Murphys Sign Present
yes no
Bowel Sounds
normal
absent
increased
Rectal-Vaginal Tenderness
left
right
general
mass
none
Previous Similar Pain
yes no
Previous Abdominal Surgery
yes no
Drugs for Abdominal Pain
yes no
Female-LMP
pregnant
vaginal discharge
dizzy/faint
Temp. Pulse
BP
Mood
normal
upset
anxious
Color
normal
pale
flushed
jaundiced
cyanotic
Intestinal Movement
normal
poor/nil
peristalsis
Scars
yes no
Distention
yes no
Initial Diagnosis & Plan
Results
amylase
blood count (WBC)
urine
x-ray
other
Diagnosis & Plan after Investigation
(time)
Discharge Diagnosis
History and examination of other systems on separate case notes.
P
A
I
N
H
I
S
T
O
R
Y
E
X
A
M
I
N
A
T
I
O
N
Figure 1 Shown is a data sheet modied from the abdominal pain chart developed by the World Organization of Gastroenterol-
ogy (OMGE). Adapted from American College of Emergency Physicians.
10
BP = blood pressure; LMP = last menstrual period;
Temp. = temperature; WBC = white blood cells.
06/09
perforated viscus, or a ruptured ectopic pregnancy; a near
loss of consciousness or stamina associated with sudden- onset
pain should heighten the level of concern for such a catastro-
phe. Rapidly progressive pain that becomes intensely focused
in a well-dened area within a period of a few minutes to an
hour or two suggests a condition such as acute cholecystitis
or pancreatitis. Pain that has a gradual onset over several
hours, usually beginning as slight or vague discomfort and
slowly progressing to steady and more localized pain, suggests
a subacute process and is characteristic of processes that lead
to peritoneal inammation. Numerous disorders may be
associated with this mode of onset, including acute appendi-
citis, diverticulitis, pelvic inammatory disease (PID), and
intestinal obstruction.
Pain can be either intermittent or continuous. Intermittent
or cramping pain (colic) is pain that occurs for a short period
(a few minutes), followed by longer periods (a few minutes to
one half-hour) of complete remission during which there is no
pain at all. Intermittent pain is characteristic of obstruction of
a hollow viscus and results from vigorous peristalsis in the wall
of the viscus proximal to the site of obstruction. This pain is
perceived as deep in the abdomen and is poorly localized. The
patient is restless, may writhe about incessantly in an effort to
nd a comfortable position, and often presses on the abdomi-
nal wall in an attempt to alleviate the pain. Whereas the
intermittent pain associated with intestinal obstruction (typi-
cally described as gripping and mounting) is usually severe but
bearable, the pain associated with obstruction of small con-
duits (e.g., the biliary tract, the ureters, and the uterine tubes)
often becomes unbearable. Obstruction of the gallbladder or
the bile ducts gives rise to a type of pain often referred to as
biliary colic; however, this term is a misnomer in that biliary
pain is usually constant because of the lack of a strong mus-
cular coat in the biliary tree and the absence of regular peri-
stalsis.
Continuous or constant pain is pain that is present for hours
or days without any period of complete relief; it is more
common than intermittent pain. Continuous pain is usually
indicative of a process that will lead, or has already led, to
peritoneal inammation or ischemia. It may be of steady
intensity throughout, or it may be associated with intermittent
pain. For example, the typical colicky pain associated with
simple intestinal obstruction changes when strangulation
occurs, becoming continuous pain that persists between epi-
sodes or waves of cramping pain.
Certain types of pain are generally held to be typical of
certain pathologic states. For example, the pain of a perforated
ulcer is often described as burning, that of a dissecting aneu-
rysm as tearing, and that of bowel obstruction as gripping.
One may imagine that the rst type of pain is explained by
the efux of acid, the second by the sudden expansion of the
retroperitoneum, and the third by the churning of hyperperi-
stalsis. Colorful as these images may be, in most cases, the
pain begins in a nondescript way. It is only by carefully fol-
lowing the patients description of the evolution and time
course of the pain that such images may be formed with con-
dence.
For several reasonsatypical pain patterns, dual innervation
by visceral and somatic afferents, normal variations in organ
position, and widely diverse underlying pathologic statesthe
location of abdominal pain is only a rough guide to diagnosis.
It is nevertheless true that in most disorders, the pain tends to
occur in characteristic locations, such as the right upper quad-
rant (cholecystitis), the right lower quadrant (appendicitis), the
epigastrium (pancreatitis), or the left lower quadrant (sigmoid
diverticulitis) [ see Figure 2 ]. It is important to determine the
location of the pain at onset because this may differ from the
location at the time of presentation (so-called shifting pain). In
fact, the chronological sequence of events in the patients history
is often more important for diagnosis than the location of the
pain alone. For example, the classic pain of appendicitis begins
in the periumbilical region and settles in the right lower quad-
rant. Another example is the pain from a perforated ulcer which
can shift to the right lower quadrant as escaping gastroduodenal
content tracks down the right gutter.
It is also important to take into account radiation or refer-
ral of the pain, which tends to occur in characteristic patterns
[ see Figure 3 ]. For example, biliary pain is referred to the right
subscapular area, and the boring pain of pancreatitis typically
radiates straight through to the back. Obstruction of the small
intestine and the proximal colon is referred to the umbilicus,
and obstruction distal to the splenic exure is often referred
to the suprapubic area. Spasm in the ureter often radiates to
the suprapubic area and into the groin. The more severe the
pain is, the more likely it is to be associated with referral to
other areas.
The intensity or severity of the pain is related to the mag-
nitude of the underlying insult. It is important to distinguish
between the intensity of the pain and the patients reaction to
it because there appear to be signicant individual differences
with respect to tolerance of and reaction to pain. Pain that is
intense enough to awaken the patient from sleep usually indi-
cates a signicant underlying organic cause. Past episodes of
pain and factors that aggravate or relieve the pain often pro-
vide useful diagnostic clues. For example, pain caused by
peritonitis tends to be exacerbated by motion, deep breath-
ing, coughing, or sneezing, and patients with peritonitis tend
to lie quietly in bed and avoid any movement. The typical
pain of acute pancreatitis is exacerbated by lying down and
relieved by sitting up. Pain that is relieved by eating or taking
antacids suggests duodenal ulcer disease, whereas diffuse
abdominal pain that appears 30 minutes to 1 hour after meals
suggests intestinal angina.
Associated gastrointestinal symptoms (e.g., nausea, vom-
iting, anorexia, diarrhea, and constipation) often accompany
abdominal pain; however, these symptoms are nonspecic
and therefore may not be of great value in the differential
diagnosis. Vomiting in particular is common: when suf-
ciently stimulated by pain impulses traveling via secondary
visceral afferent bers, the medullary vomiting centers
activate efferent bers and cause reex vomiting. Once
again, the chronology of events is important in that pain
often precedes vomiting in patients with conditions neces-
sitating operation, whereas the opposite is usually the case
in patients with medical (i.e., nonsurgical) conditions.
5,12

This is particularly true for adult patients with acute appen-
dicitis, in whom pain almost always precedes vomiting by
several hours. In children, vomiting is commonly observed
closer to the onset of the pain, although it is rarely the initial
symptom.
06/09
DIFFUSE
Peritonitis
Early Appendicitis
Pancreatitis
Leukemia
Sickle Cell Crisis
Gastroenteritis
Mesenteric Adenitis
Mesenteric Thrombosis
Intestinal Obstruction
Inflammatory Bowel
Disease
Aneurysm
Metabolic Causes
Toxic Causes
UMBILICAL REGION
Early Appendicitis
Gastroenteritis
Pancreatitis
Hernia
Mesenteric Adenitis
Inflammatory Bowel Disease
Aneurysm
HYPOGASTRIC REGION
Cystitis
Diverticulitis
Appendicitis
Prostatism
Salpingitis
Hernia
Ovarian Cyst/Torsion
Endometriosis
Ectopic Pregnancy
Nephrolithiasis
Abdominal Wall Hematoma
EPIGASTRIC REGION
Peptic Ulcer
Gastritis
Pancreatitis
Duodenitis
Gastroenteritis
Early Appendicitis
Mesenteric Adenitis
Inflammatory Bowel
Disease
LEFT UPPER QUADRANT
Gastritis
Pancreatitis
Splenic Enlargement
Splenic Rupture
Splenic Infarction
Splenic Aneurysm
Pyelonephritis
Nephrolithiasis
Herpes Zoster
Myocardial Ischemia
Pneumonia
Empyema
Diverticulitis
LEFT LOWER QUADRANT
Diverticulitis
Appendicitis
Leaking Aneurysm
Ectopic Pregnancy
Mittelschmerz
Salpingitis
Endometriosis
Ureteral Calculi
Pyelonephritis
Nephrolithiasis
Seminal Vesiculitis
Psoas Abscess
Hernia
RIGHT UPPER QUADRANT
Cholecystitis
Choledocholithiasis
Hepatitis
Hepatic Abscess
Hepatomegaly from
Congestive Heart Failure
Peptic Ulcer
Pancreatitis
Retrocecal Appendicitis
Pyelonephritis
Nephrolithiasis
Herpes Zoster
Myocardial Ischemia
Pericarditis
Pneumonia
Empyema
Gastritis
Duodenitis
RIGHT LOWER QUADRANT
Appendicitis
Mesenteric Adenitis
Diverticulitis
Cholecystitis
Perforated Ulcer
Leaking Aneurysm
Ectopic Pregnancy
Salpingitis
Mittelschmerz
Endometriosis
Ureteral Calculi
Pyelonephritis
Nephrolithiasis
Seminal Vesiculitis
Psoas Abscess
Hernia
a b
c
Figure 2 In most disorders that give rise to acute abdominal pain, the pain tends to occur in specic locations. (a) Diffuse pain
suggests a certain set of diagnostic possibilities. (b) Differing groups of disorders give rise to abdominal pain in the epigastric,
umbilical, and hypogastric regions. (c) Disorders that give rise to acute abdominal pain may be grouped according to the
quadrant of the abdomen in which pain tends to occur.
06/09
Similarly, constipation may result from a reex paralytic
ileus when sufciently stimulated visceral afferent bers acti-
vate efferent sympathetic bers (splanchnic nerves) to reduce
intestinal peristalsis. Diarrhea is characteristic of gastroen-
teritis but may also accompany incomplete intestinal or
colonic obstruction. More signicant is a history of obstipa-
tion because if it can be denitely established that a patient
with acute abdominal pain has not passed gas or stool for 24
to 48 hours, it is certain that some degree of intestinal
obstruction is present. Other associated symptoms that
should be noted include jaundice, melena, hematochezia,
hematemesis, and hematuria. These symptoms are much
more specic than the ones just discussed and can be
extremely valuable in the differential diagnosis. Most condi-
tions that cause acute abdominal pain of surgical signicance
are associated with some degree of fever if they are allowed
to continue long enough. Fever suggests an inammatory
process; however, it is usually low grade and often absent
altogether, particularly in elderly and immunocompromised
patients. The combination of a high fever with chills and
rigors indicates bacteremia, and concomitant changes in
mental status (e.g., agitation, disorientation, and lethargy)
suggest impending septic shock.
A history of trauma (even if the patient considers the trau-
matic event trivial) should be actively sought in all cases of
unexplained acute abdominal pain; such a history may not
be readily volunteered (as is often the case with trauma
resulting from domestic violence). The history may be par-
ticularly relevant in a patient taking anticoagulants and pre-
senting with acute onset of abdominal pain accompanied by
tenderness but no clear signs of inammation. Hematoma
within the rectus muscle sheath can easily be mistaken for
appendicitis or other lower abdominal illnesses; hematoma
elsewhere can produce symptoms of obstruction or acute
bleeding into the peritoneum and the retroperitoneum. In
female patients, it is essential to obtain a detailed gyneco-
logic history that includes the timing of symptoms within the
menstrual cycle, the date of the last menses, previous and
current use of contraception, any abnormal vaginal bleeding
or discharge, an obstetric history, and any risk factors for
ectopic pregnancy (e.g., PID, use of an intrauterine device,
or previous ectopic or tubal surgery). Pregnancy should be
excluded in all women of childbearing age with abdominal
pain.
A complete history of previous medical conditions must
be obtained because associated diseases of the cardiac, pul-
monary, and renal systems may give rise to acute abdominal
symptoms and may also signicantly affect the morbidity
and mortality associated with surgical intervention. The use
of regular and as needed medications must also be obtained.
Weight changes, past illnesses, recent travel, and environ-
mental exposure to toxins or infectious agents used should
also be investigated. A history of previous abdominal opera-
tions should be obtained but should not be relied on too
heavily in the absence of operative reports. A careful family
history is important for detection of hereditary disorders
that may cause acute abdominal pain. A detailed social
history should also be obtained that includes any history of
tobacco, alcohol, or illicit drug use, as well as a sexual
history.
tentati ve di fferenti al di agnosi s
Once the history has been obtained, the examiner should
generate a tentative differential diagnosis and carry out the
physical examination in search of specic signs or ndings
that either rule out or conrm the diagnostic possibilities.
Esophagus
Stomach
Pylorus
Colon
Left and Right
Kidneys
Liver and
Gallbladder
Ureter
Perforated Duodenal Ulcer
(Diaphragmatic Irritation)
Biliary Colic
Acute Pancreatitis and
Renal Colic
Uterine and Rectal Pain
Figure 3 Pain of abdominal origin tends to be referred in characteristic patterns.
80
The more severe the pain is, the more
likely it is to be referred. Shown are anterior (left) and posterior (right) areas of referred pain.
06/09
Given the diversity of conditions that can cause acute abdom-
inal pain [ see Table 1 and Table 2 ], there is no substitute for
general awareness of the most common causes of acute
abdominal pain and the inuence of age, gender, and geogra-
phy on the likelihood of any of these potential causes. Although
acute abdominal pain is the most common surgical emer-
gency and most nontrauma-related surgical admissions (and
1% of all hospital admissions) are accounted for by patients
complaining of abdominal pain, little information is available
regarding the clinical spectrum of disease in these patients.
13

Nevertheless, detailed epidemiologic information can be an
invaluable asset in the diagnosis and treatment of acute
abdominal pain. Now that patients from different parts of the
world are increasingly being seen in North American
Table 1 Intraperitoneal Causes of Acute Abdominal Pain
Inammatory
Peritoneal
Chemical and nonbacterial peritonitis
Perforated peptic ulcer/biliary tree,
pancreatitis, ruptured ovarian cyst,
mittelschmerz
Bacterial peritonitis
Primary peritonitis
Pneumococcal, streptococcal,
tuberculous
Spontaneous bacterial peritonitis
Perforated hollow viscus
Esophagus, stomach, duodenum,
small intestine, bile duct, gallbladder, colon,
urinary bladder
Hollow visceral
Appendicitis
Cholecystitis
Peptic ulcer
Gastroenteritis
Gastritis
Duodenitis
Inammatory bowel disease
Meckel diverticulitis
Colitis (bacterial, amebic)
Diverticulitis
Solid visceral
Pancreatitis
Hepatitis
Pancreatic abscess
Hepatic abscess
Splenic abscess
Mesenteric
Lymphadenitis (bacterial, viral)
Epiploic appendagitis
Pelvic
Pelvic inammatory disease
(salpingitis)
Tubo-ovarian abscess
Endometritis
Mechanical (obstruction, acute distention)
Hollow visceral
Intestinal obstruction
Adhesions, hernias, neoplasms, volvulus
Intussusception, gallstone ileus, foreign bodies
Bezoars, parasites
Biliary obstruction
Calculi, neoplasms, choledochal cyst, hemobilia
Solid visceral
Acute splenomegaly
Acute heptomegaly (congestive heart failure,
Budd-Chiari syndrome)
Mesenteric
Omental torsion
Pelvic
Ovarian cyst
Torsion or degeneration of broid
Ectopic pregnancy
Hemoperitoneum
Ruptured hepatic neoplasm
Spontaneous splenic rupture
Ruptured mesentery
Ruptured uterus
Ruptured graaan follicle
Ruptured ectopic pregnancy
Ruptured aortic or visceral aneurysm
Ischemic
Mesenteric thrombosis
Hepatic infarction (toxemia, purpura)
Splenic infarction
Omental ischemia
Strangulated hernia
Neoplastic
Primary or metastatic intraperitoneal neoplasms
Traumatic
Blunt trauma
Penetrating trauma
Iatrogenic trauma
Domestic violence
Miscellaneous
Endometriosis
Adapted from McFadden DW et al.
81
06/09
Table 2 Extraperitoneal Causes of Acute Abdominal Pain
Genitourinary Neurogenic
Pyelonephritis Herpes zoster
Perinephric abscess Tabes dorsalis
Renal infarct Nerve root compression
Nephrolithiasis Spinal cord tumors
Ureteral obstruction (lithiasis, tumor) Osteomyelitis of the spine
Acute cycstitis Abdominal epilepsy
Prostatitis Abdominal migraine
Seminal vesiculitis Multiple sclerosis
Epididymitis Inammatory
Orchitis Schnlein-Henoch purpura
Testicular torsion Systemic lupus erythematosus
Dysmenorrhea Polyarteritis nodosa
Threatened abortion Dermatomyositis
Pulmonary Scleroderma
Pneumonia Infectious
Empyema Bacterial
Pulmonary embolus Parasitic (malaria)
Pulmonary infarction Viral (measles, mumps, infectious mononucleosis)
Pneumothorax Rickettsial (Rocky Mountain spotted fever)
Cardiac Hematologic
Myocardial ischemia Sickle cell crisis
Myocardial infarction Acute leukemia
Acute rheumatic fever Acute hemolytic states
Acute pericarditis Coagulopathies
Metabolic Pernicious anemia
Acute intermittent porphyria Other dyscrasias
Familial Mediterranean fever Vascular
Hypolipoproteinemia Vasculitis
Hemochromatosis Periarteritis
Hereditary angioneurotic edema Toxins
Endocrine Bacterial toxins (tetanus, Staphylococcus)
Diabetic ketoacidosis Insect venom (black widow spider)
Hyperparathyroidism (hypercalcemia) Animal venom
Acute adrenal insufciency (Addisonian crisis) Heavy metals (lead, arsenic, mercury)
Hyperthyroidism or hypothyroidism Poisonous mushrooms
Musculoskeletal Drugs
Rectus sheath hematoma Withdrawal from narcotics
Arthritis/diskitis of thoracolumbar spine Retroperitoneal
Psychogenic Retroperitoneal hemorrhage (spontaneous adrenal hemorrhage)
Hypochondriasis Psoas abscess
Somatization disorders
Factitious
Munchausen syndrome
Malingering
06/09
emergency rooms, it is important to consider endemic
diseases, including tuberculosis,
14,15
parasitic diseases,
1618

bezoars from unusual dietary habits,
19,20
and unusual malig-
nancies.
21,22

The value of detailed epidemiologic knowledge notwith-
standing, it is worthwhile to keep in mind the truism that
common things are common. Regarding which things
are common, the most extensive information currently
available comes from the ongoing survey begun in 1977 by
the Research Committee of the OMGE. As of the last prog-
ress report on this survey, which was published in 1988, more
than 200 physicians at 26 centers in 17 countries had accu-
mulated data on 10,320 patients with acute abdominal pain
[ see Table 3 ].
23
The most common diagnosis in these patients
was nonspecic abdominal pain (NSAP)that is, the retro-
spective diagnosis of exclusion in which no cause for the pain
can be identied.
24,25
NSAP accounted for 34% of all patients
seen; the four most common diagnoses accounted for more
than 75%. The most common surgical diagnosis in the
OMGE survey was acute appendicitis, followed by acute
cholecystitis, small bowel obstruction, and gynecologic disor-
ders. Relatively few patients had perforated peptic ulcer, a
nding that conrms the current downward trend in the inci-
dence of this condition. Cancer was found to be a signicant
cause of acute abdominal pain. There was little variation in
the geographic distribution of surgical causes of acute abdom-
inal pain (i.e., conditions necessitating operation) among
developed countries. In patients who required surgery, the
most common causes were acute appendicitis (42.6%), acute
cholecystitis (14.7%), small bowel obstruction (6.2%), perfo-
rated peptic ulcer (3.7%), and acute pancreatitis (4.5%).
23

The OMGE surveys nding that NSAP was the most
common diagnosis in patients with acute abdominal pain has
been conrmed by several srudies
12,13,25
; the nding that acute
appendicitis, cholecystitis, and intestinal obstruction were the
three most common diagnoses in patients with acute abdom-
inal pain who require operation has also been amply con-
rmed [ see Table 3 ].
1,12,13

The data described so far provide a comprehensive picture
of the most likely diagnoses for patients with acute abdominal
pain in many centers around the world; however, this picture
does not take into account the effect of age on the relative
likelihood of the various potential diagnoses. It is well known
that the disease spectrum of acute abdominal pain is different
in different age groups, especially in the very old
4,26,27
and the
very young.
2830
In the OMGE survey, well over 90% of cases
of acute abdominal pain in children were diagnosed as having
acute appendicitis (32%) or NSAP (62%).
28
Similar age-
related differences in the spectrum of disease have been
conrmed by other studies,
16
as have various gender-related
differences.
This variation in the disease spectrum is readily apparent
when the 10,320 patients from the OMGE survey are
segregated by age [ see Table 4 ]. In patients 50 years of age
Table 3 Frequency of Specic Diagnoses in Patients with Acute Abdominal Pain
Diagnosis
Frequency in Individual Studies (% of Patients)
OMGE
23

(N = 10,320)
Wilson et al
82

(N = 1,196)
Irvin
13

(N = 1,190)
Brewer et al
12

(N = 1,000)
de Dombal
1

(N = 552)
Hawthorn
83

(N = 496)
Nonspecic abdominal pain 34.0 45.6 34.9 41.3 50.5 36.0
Acute appendicitis 28.1 15.6 16.8 4.3 26.3 14.9
Acute cholecystitis 9.7 5.8 5.1 2.5 7.6 5.9
Small bowel obstruction 4.1 2.6 14.8 2.5 3.6 8.6
Acute gynecologic disease 4.0 4.0 1.1 8.5
Acute pancreatitis 2.9 1.3 2.4 2.9 2.1
Urologic disorders 2.9 4.7 5.9 11.4 12.8
Perforated peptic ulcer 2.5 2.3 2.5 2.0 3.1
Cancer 1.5 3.0
Diverticular disease 1.5 1.1 3.9 2.0 3.0
Dyspepsia 1.4 7.6 1.4 1.4
Gastroenteritis 0.3 6.9 5.1
Inammatory bowel disease 0.8 2.1
Mesenteric adenitis 3.6 1.5
Gastritis 2.1 1.4
Constipation 2.4 2.3
Amebic hepatic abscess 1.2 1.9
Miscellaneous 6.3 1.3 5.2 15.5 4.0 8.0
OMGE = World Organization of Gastroenterology.
06/09
Table 4 Frequency of Specic Diagnoses in Younger
and Older Patients with Acute
Abdominal Pain in the OMGE Study
Diagnosis
Frequency (% of Patients)
Age < 50 yr
(N = 6,317)
Age 50 yr
(N = 2,406)
Nonspecic
abdominal pain
39.5 15.7
Appendicitis 32.0 15.2
Cholecystitis 6.3 20.9
Obstruction 2.5 12.3
Pancreatitis 1.6 7.3
Diverticular disease < 0.1 5.5
Cancer < 0.1 4.1
Hernia < 0.1 3.1
Vascular disease < 0.1 2.3
OMGE = World Organization of Gastroenterology.
Adapted from de Dombal FT et al
23
and Telfer S et al.
27
or older,
27
cholecystitis was more common than either NSAP
or acute appendicitis; small bowel obstruction, diverticular
disease, and pancreatitis were all approximately ve times
more common than in patients younger than 50 years. Her-
nias were also a much more common problem in older
patients. In the entire group of patients, only 1 in every 10
instances of intestinal obstruction was attributable to a
hernia, whereas in patients 50 years of age or older, 1 in
every 3 instances was caused by an undiagnosed hernia.
Cancer was 40 times more likely to be the cause of acute
abdominal pain in patients 50 years of age or older; vascular
diseases (including myocardial infarction, mesenteric isch-
emia, and ruptured AAA) were 25 times more common in
patients 50 years of age or older and 100 times more common
in patients older than 70 years. What is more, outcome was
clearly related to age: mortality was signicantly higher in
patients older than 70 years (5%) than in those younger than
50 years (< 1%). Whereas the peak incidence of acute
abdominal pain occurred in patients in their teens and twen-
ties,
28
the great majority of deaths occurred in patients older
than 70 years.
27

physi cal exami nati on
In the physical examination of a patient, as in the taking of
the history, there is no substitute for organization and
patience; the amount of information that can be obtained is
directly proportional to the gentleness and thoroughness of
the examiner. The physical examination begins with a brief
but thorough evaluation of the patients general appearance
and ability to answer questions. The degree of obvious pain
should be estimated. The patients position in bed should be
noted. A patient who lies motionless with exed hips and
knees is more likely to have generalized peritonitis. A restless
patient who writhes about in bed is more likely to have col-
icky pain.
The area of maximal pain should be identied before the
physical examination is begun. The examiner can easily do
this by simply asking the patient to cough and then to point
with two ngers to the area where pain seems to be focused.
This allows the examiner to avoid the area in the early stages
of the examination and to conrm it at a later stage without
causing the patient unnecessary discomfort in the meantime.
The physical examination should be directed, in the sense
that it should address critical ndings that would conrm or
exclude the likeliest disorders in the differential diagnosis. In
this context, however, it should be complete. Some processes
that can cause abdominal pain occur within the chest (e.g.,
pneumonia, ischemic heart disease or arrhythmia, esophageal
muscular disorders); thus, auscultation of the lungs and the
heart is integral to the examination. A pelvic examination
should be performed in women, and an examination of the
rectum and the groin should be performed in all patients. It
should not be assumed that advanced imaging technology
(e.g., computed tomography [CT], magnetic resonance
imaging [MRI], or ultrasonography [US]) will provide the
diagnosis most quickly or with the highest level of condence.
The sensitivity and specicity (not to mention the cost-
effectiveness) of any laboratory or imaging study are grounded
in the intelligent gathering and categorization of signs and
symptoms.
31,32

Before attention is directed to the patients abdomen, signs
of systemic illness should be sought. Systemic signs of shock
(e.g., diaphoresis, pallor, hypothermia, tachypnea, tachycardia
with orthostasis, and frank hypotension) usually accompany a
rapidly progressive or advanced intra-abdominal condition
and, in the absence of extra-abdominal causes, are indications
for immediate laparotomy. The absence of any alteration in
vital signs, however, does not necessarily exclude a serious
intra-abdominal process.
Examination of the abdomen begins with the patient rest-
ing in a comfortable supine position. A right-handed exam-
iner should stand on the patients right side, and the patients
abdomen should be level with the elbow at rest. In some cases,
to make sure that the examination is unhurried and the
patients anxiety is allayed, the examiner may nd it useful to
sit at the bedside. The examination should include inspec-
tion, auscultation, percussion, and palpation of all areas of
the abdomen, the anks, and the groin (including all hernia
orices) in addition to rectal and genital examinations (and,
in female patients, a full gynecologic examination). A system-
atic approach is crucial: an examiner who methodically
follows a set pattern of abdominal examination every time
will be rewarded more frequently than one who improvises
haphazardly with each patient.
The rst step in the abdominal examination is careful
inspection of the anterior and posterior abdominal walls, the
anks, the perineum, and the genitalia for previous surgical
scars (possible adhesions), hernias (incarceration or strangula-
tion), distention (intestinal obstruction), obvious masses (dis-
tended gallbladder, abscesses, or tumors), ecchymosis or abra-
sions (trauma), striae (pregnancy or ascites), an everted
umbilicus (increased intra-abdominal pressure), visible pulsa-
tions (aneurysm), visible peristalsis (obstruction), limitation of
movement of the abdominal wall with ventilatory movements
(peritonitis), or engorged veins (portal hypertension).
The next recommended step in the abdominal examination
is auscultation. Although it is important to note the presence
(or absence) of bowel sounds and their quality, auscultation
06/09
is probably the least rewarding aspect of the physical
examination. Severe intra-abdominal conditions, even
intra-abdominal catastrophes, may occur in patients with
normal bowel sounds, and patients with silent abdomens may
have no signicant intra-abdominal pathology at all. In gen-
eral, however, the absence of bowel sounds indicates a
paralytic ileus; hyperactive or hypoactive bowel sounds often
are variations of normal activity; and high-pitched bowel
sounds with splashes, tinkles (echoing as in a large cavern),
or rushes (prolonged, loud gurgles) indicate mechanical
bowel obstruction.
The third step is percussion to search for any areas of dull-
ness, uid collections, sections of gas-lled bowel, or pockets
of free air under the abdominal wall. Tympany may be pres-
ent in patients with bowel obstruction or hollow viscus per-
foration. Percussion can be useful as a way of estimating
organ size and of determining the presence of ascites (sig-
naled by a uid wave or shifting dullness). Gentle percussion
over the four quadrants of the abdomen can also be used to
elicit a sign of peritoneal irritation, and patients tolerate this
maneuver reasonably well. Pain associated with mild levels of
percussion is a good indicator of peritonitis if the maneuver
is performed in the same way each time. In general, however,
maneuvers associated with palpation are best for determining
whether peritonitis is present.
The last step, palpation, is the most informative aspect of
the physical examination. Palpation of the abdomen must be
done very gently to avoid causing additional pain early in the
examination. It should begin as far as possible from the area
of maximal pain and then should gradually advance toward
this area, which should be the last to be palpated. The exam-
iner should place the entire hand on the patients abdomen
with the ngers together and extended, applying pressure with
the pulps (not the tips) of the ngers by exing the wrists and
the metacarpophalangeal joints. It is essential to determine
whether true involuntary muscle guarding (muscle spasm) is
present. This determination is made by means of gentle palpa-
tion over the abdominal wall while the patient takes a long,
deep breath. If guarding is voluntary, the underlying muscle
immediately relaxes under the gentle pressure of the palpating
hand. If, however, the patient has true involuntary guarding,
the muscle remains in spasm (i.e., taut and rigid) throughout
the respiratory cycle (so-called boardlike abdomen). True
involuntary guarding is indicative of localized or generalized
peritonitis. It must be remembered that muscle rigidity is
relative: for example, muscle guarding may be less pronounced
or absent in debilitated and elderly patients who have poor
abdominal musculature. In addition, the evaluation of muscle
guarding is dependent on the patients cooperation.
Palpation is also useful for determining the extent and
severity of the patients tenderness. Diffuse tenderness indi-
cates generalized peritoneal inammation. Mild diffuse tender-
ness without guarding usually indicates gastroenteritis or some
other inammatory intestinal process without peritoneal
inammation. Localized tenderness suggests an early stage of
disease with limited peritoneal inammation. Rebound tender-
ness is elicited by applying gentle but deep pressure to the
region of interest and then letting go abruptly. As a means of
distraction, the examiner may use the stethoscope to apply the
pressure. The main difculties associated with palpation are
that the deep pressure may increase anxiety and that the sur-
prise of the sudden withdrawal may elicit pain where perito-
neal irritation is not the cause.
Careful palpation can elicit several specic signs [ see
Table 5 ], such as the Rovsing sign (pain in the right lower
quadrant when the left lower quadrant is palpated deeply),
which is associated with acute appendicitis, and the Murphy
sign (arrest of inspiration when the right upper quadrant is
Table 5 Common Abdominal Signs and Findings Noted on Physical Examination
Sign or Finding Description Associated Clinical Condition(s)
Aaron sign Referred pain or feeling of distress in epigastrium or precordial
region on continued rm pressure over the McBurney point
Acute appendicitis
Ballance sign Presence of dull percussion note in both anks, constant on
left side but shifting with change of position on right side
Ruptured spleen
Bassler sign Sharp pain elicited by pinching appendix between thumb
of examiner and iliacus muscle
Chronic appendicitis
Beevor sign Upward movement of umbilicus Paralysis of lower portions of rectus
abdominis muscles
Blumberg sign Transient abdominal wall rebound tenderness Peritoneal inammation
Carnett sign Disappearance of abdominal tenderness when anterior
abdominal muscles are contracted
Abdominal pain of intra-abdominal origin
Chandelier sign Intense lower abdominal and pelvic pain on manipulation
of cervix
Pelvic inammatory disease
Charcot sign Intermittent right upper quadrant abdominal pain, jaundice,
and fever
Choledocholithiasis
Chaussier sign Severe epigastric pain in gravid female Prodrome of eclampsia
Claybrook sign Transmission of breath and heart sounds through
abdominal wall
Ruptured abdominal viscus
Courvoisier sign Palpable, nontender gallbladder in presence of clinical
jaundice
Periampullary neoplasm
Cruveilhier sign Varicose veins radiating from umbilicus (caput medusae) Portal hypertension
06/09
Table 5 (continued) Common Abdominal Signs and Findings Noted on Physical Examination
Sign or Finding Description Associated Clinical Condition(s)
Cullen sign Periumbilical darkening of skin from blood Hemoperitoneum (especially in ruptured
ectopic pregnancy)
Cutaneous
hyperesthesia
Increased abdominal wall sensation to light touch Parietal peritoneal inammation secondary to
inammatory intra-abdominal pathology
Dance sign Slight retraction in area of right iliac fossa Intussusception
Danforth sign Shoulder pain on inspiration Hemoperitoneum (especially in ruptured
ectopic pregnancy)
Direct abdominal
wall tenderness
Localized inammation of abdominal wall,
peritoneum, or an intra-abdominal viscus
Fothergill sign Abdominal wall mass that does not cross midline and
remains palpable when rectus muscle is tense
Rectus muscle hematoma
Grey Turner sign Local areas of discoloration around umbilicus and anks Acute hemorrhagic pancreatitis
Iliopsoas sign Elevation and extension of leg against pressure of examiners
hand causes pain
Appendicitis (retrocecal) or an inammatory
mass in contact with psoas
Kehr sign Left shoulder pain when patient is supine or in the
Trendelenburg position (pain may occur spontaneously
or after application of pressure to left subcostal region)
Hemoperitoneum (especially ruptured
spleen)
Kustner sign Palpable mass anterior to uterus Dermoid cyst of ovary
Mannkopf sign Acceleration of pulse when a painful point is pressed
on by examiner
Absent in factitious abdominal pain
McClintock sign Heart rate > 100 beats/min 1 hr postpartum Postpartum hemorrhage
Murphy sign Palpation of right upper abdominal quadrant during
deep inspiration results in inspiratory arrest
Acute cholecystitis
Obturator sign Flexion of right thigh at right angles to trunk and
external rotation of same leg in supine position
result in hypogastric pain
Appendicitis (pelvic appendix); pelvic
abscess; an inammatory mass in contact
with muscle
Puddle sign Alteration in intensity of transmitted sound in intra-abdominal
cavity secondary to percussion when patient is positioned
on all fours and stethoscope is gradually moved toward
ank opposite percussion
Free peritoneal uid
Ransohoff sign Yellow pigmentation in umbilical region Ruptured common bile duct
Rovsing sign Pain referred to the McBurney point on application of
pressure to descending colon
Acute appendicitis
Subcutaneous crepitance Palpable crepitus in abdominal wall Subcutaneous emphysema or gas gangrene
Summer sign Increased abdominal muscle tone on exceedingly gentle
palpation of right or left iliac fossa
Early appendicitis; nephrolithiasis; uretero-
lithiasis; ovarian torsion
Ten Horn sign Pain caused by gentle traction on right spermatic cord Acute appendicitis
Toma sign Right-sided tympany and left-sided dullness in supine
position as a result of peritoneal inammation and
subsequent mesenteric contraction of intestine to
right side of abdominal cavity
Inammatory ascites
Adapted from Hickey MS et al.
6
deeply palpated), which is associated with acute cholecystitis.
These signs are indicative of localized peritoneal inamma-
tion. Similarly, specic maneuvers can elicit signs of localized
peritoneal irritation. The psoas sign is elicited by placing the
patient in the left lateral decubitus position and extending the
right leg. In settings where appendicitis is suspected, pain on
extension of the right leg indicates that the psoas is irritated
and thus that the inamed appendix is in a retrocecal posi-
tion. The obturator sign is elicited by raising the exed right
leg and rotating the thigh internally. In settings where appen-
dicitis is suspected, pain on rotation of the right thigh indi-
cates that the obturator is irritated and thus that the inamed
appendix is in a pelvic position. The Kehr sign is elicited
when the patient is placed in the Trendelenburg position.
Pain in the shoulder indicates irritation of the diaphragm by
a noxious uid (e.g., gastric contents from a perforated ulcer,
pus from a ruptured appendix, or free blood from a fallopian
tube pregnancy). Another useful maneuver is the Carnett
test, in which the patient elevates his or her head off the bed,
thus tensing the abdominal muscles. When the pain is caused
by abdominal wall conditions (e.g., rectal sheath hematoma),
tenderness to palpation persists, but when the pain is caused
by intraperitoneal conditions, tenderness to palpation
decreases or disappears (the Carnett sign).
06/09
Rectal, genital, and (in women) pelvic examinations are
essential to the evaluation of all patients with acute abdomi-
nal pain. The rectal examination should include evaluation of
sphincter tone, tenderness (localized versus diffuse), and
prostate size and tenderness, as well as a search for the pres-
ence of hemorrhoids, masses, fecal impaction, foreign bodies,
and gross or occult blood. The genital examination should
search for adenopathy, masses, discoloration, edema, and
crepitus. The pelvic examination in women should check for
vaginal discharge or bleeding, cervical discharge or bleeding,
cervical mobility and tenderness, uterine tenderness, uterine
size, and adnexal tenderness or masses. Although a carefully
performed pelvic examination can be invaluable in differenti-
ating nonsurgical conditions (e.g., pelvic inammatory dis-
ease and tubo-ovarian abscess) from conditions necessitating
prompt operation (e.g., acute appendicitis), the possibility
that a surgical condition is present should not be prematurely
dismissed solely on the basis of a nding of tenderness on a
pelvic or rectal examination.
Investigative Studies
Laboratory tests and imaging studies rarely, if ever, establish
a denitive diagnosis by themselves; however, if used in the cor-
rect clinical setting, they can conrm or exclude specic diag-
noses suggested by the history and the physical examination.
laboratory tests
In all patients except those in extremis, a complete blood
count, blood chemistries, and a urinalysis are routinely
obtained before a decision to operate. The hematocrit is
important in that it allows the surgeon to detect signicant
changes in plasma volume (e.g., dehydration caused by vom-
iting, diarrhea, or uid loss into the peritoneum or the intes-
tinal lumen), preexisting anemia, or bleeding. An elevated
white blood cell (WBC) count is indicative of an inamma-
tory process and is a particularly helpful nding if associated
with a marked left shift; however, the presence or absence of
leukocytosis should never be the single deciding factor as to
whether the patient should undergo an operation. A low
WBC count may be a feature of viral infections, gastroenteri-
tis, or NSAP. Other tests, such as C-reactive protein assay,
may be useful for increasing condence in the diagnosis of an
acute inammatory condition. An important consideration in
the use of any such test is that derangements develop over
time, becoming more likely as the illness progresses; thus,
serial examinations might be more useful than a single test
result obtained at an arbitrary point. Indeed, for the diagnosis
of acute appendicitis, serial observations of the leukocyte
count and the C-reactive protein level have been shown to
possess greater predictive value than single observations.
33

Serum electrolyte, blood urea nitrogen, and creatinine con-
centrations are useful in determining the nature and extent of
uid losses. Blood glucose and other blood chemistries may
also be helpful. Liver function tests (serum bilirubin, alkaline
phosphatase, and transaminase levels) are mandatory when
abdominal pain is suspected of being hepatobiliary in origin.
Similarly, amylase and lipase determinations are mandatory
when pancreatitis is suspected, although it must be remem-
bered that amylase levels may be low or normal in patients
with pancreatitis and may be markedly elevated in patients
with other conditions (e.g., intestinal obstruction, mesenteric
thrombosis, and perforated ulcer).
Urinalysis may reveal red blood cells (RBCs) (suggestive of
renal or ureteral calculi), WBCs (suggestive of urinary tract
infection or inammatory processes adjacent to the ureters,
such as retrocecal appendicitis), increased specic gravity
(suggestive of dehydration), glucose, ketones (suggestive of
diabetes), or bilirubin (suggestive of hepatitis). A pregnancy
test should be obtained in any woman of childbearing age
who is experiencing acute abdominal pain.
Electrocardiography is mandatory in elderly patients and in
patients with a history of cardiomyopathy, dysrhythmia, or
ischemic heart disease. Abdominal pain may be a manifesta-
tion of myocardial disease, and the physiologic stress of acute
abdominal pain can increase myocardial oxygen demands
and induce ischemia in patients with coronary artery
disease.
i magi ng
Until relatively recently, initial radiologic evaluation of the
patient with acute abdominal pain included plain lms of the
abdomen in the supine and standing positions and chest
radiographs.
34
Currently, CT scanning (when available) is
generally considered more likely to be helpful in most situa-
tions.
35,36
Still, some situations remain in which plain lms
may be a more useful and safe form of investigationas, for
example, when a strangulating obstruction is thought to be
the most likely diagnosis and plain lms are used for rapid
conrmation. If the diagnosis of strangulating obstruction is
in doubt, however, CT scanningparticularly with the newer
generations of scanning instrumentsis useful for making a
denitive diagnosis and for identifying clinically unsuspected
strangulation.
3739

When performed in the correct clinical setting, imaging
studies may conrm diagnoses such as pneumonia (signaled by
pulmonary inltrates); intestinal obstruction (air-uid levels
and dilated loops of bowel); intestinal perforation (pneumo-
peritoneum); biliary, renal, or ureteral calculi (abnormal cal-
cications); appendicitis (fecalith); incarcerated hernia (bowel
protruding beyond the connes of the peritoneal cavity); mes-
enteric infarction (air in the portal vein); chronic pancreatitis
(pancreatic calcications); acute pancreatitis (the so-called
colon cutoff sign); visceral aneurysms (calcied rim); retro-
peritoneal hematoma or abscess (obliteration of the psoas
shadow); and ischemic colitis (so-called thumbprinting on
the colonic wall).
Although in most settings, CT is the preferred modality for
primary evaluation of acute abdominal pain, there are certain
settings in which US should be considered. When gallstones
are considered a likely diagnosis, US is more apt to be diag-
nostic than CT is, given that about 85% of gallstones are not
detectable by x-rays. In disorders of the female genitourinary
tract, US is also quite sensitive and specic for diagnoses
such as ovarian cyst, fallopian tube pregnancy, and intrauter-
ine pregnancy. Although there are reassuring reports that the
risks of radiation from CT scanning can be managed in
children and pregnant women with abdominal pain,
40,41
theo-
retical concerns remain regarding the teratogenicity of the
radiation dose.
42
Accordingly, it would seem prudent to con-
sider US the preferred initial imaging test for such patients.
In these circumstances, CT is employed only if the diagnosis
06/09
remains unresolved and if the potential delay in diagnosis
(from not obtaining a CT scan) is likely to cause harm.
Working or Presumed Diagnosis
The tentative differential diagnosis developed on the basis
of the clinical history is rened on the basis of the physical
examination and the investigative studies performed, and a
working or presumed diagnosis is generated. Once a working
diagnosis has been established, subsequent management
depends on the accepted treatment for the particular condi-
tion believed to be present. In general, the course of manage-
ment follows four basic pathways [ see Management: Surgical
versus Nonsurgical Treatment, below ], depending on whether
the patient (1) has an acute surgical condition that necessi-
tates immediate laparotomy, (2) is believed to have an
underlying surgical condition that does not necessitate
immediate laparotomy but does call for urgent or early oper-
ation, (3) has an uncertain diagnosis that does not necessi-
tate immediate or urgent laparotomy and that may prove to
be nonsurgical, or (4) is believed to have an underlying non-
surgical condition.
It must be emphasized that the patient must be constantly
reevaluated (preferably by the same examiner) even after the
working diagnosis has been established. If the patient does not
respond to treatment as expected, the working diagnosis must
be reconsidered, and the possibility that another condition
exists must be immediately entertained and investigated by
returning to the differential diagnosis.
Management: Surgical versus Nonsurgical Treatment
acute surgi cal abdomen
A thorough but expeditious approach to patients with
acute abdominal pain is essential because in some patients,
action must be taken immediately and there is not enough
time for an exhaustive evaluation. As outlined (see above),
such an approach should include a brief initial assessment,
a complete clinical history, a thorough physical examination,
and targeted laboratory and imaging studies. These steps
can usually be completed in less than 1 hour and should be
insisted on in the evaluation of most patients. In most cases,
it is wise to resist the temptation to rush to the operating
room with an incompletely evaluated, unprepared, and
unstable patient. Sometimes, the anxiety of the patient or
the impatience of the health care providers requesting the
surgeons consultation creates an unwarranted feeling of
urgency. Often, however, the anxiety or impatience is on the
part of the surgeon and, if indulged, may be a cause of sub-
sequent regret.
Very few abdominal crises mandate immediate operation,
and even with these conditions, it is still necessary to spend
a few minutes on assessing the seriousness of the problem
and establishing a probable diagnosis. Among the most
common of the abdominal catastrophes that necessitate
immediate operation are ruptured AAAs or visceral aneu-
rysms, ruptured ectopic pregnancies, and spontaneous
hepatic or splenic ruptures. The relative rarity of such condi-
tions notwithstanding, it must always be remembered that
patients with acute abdominal pain may have a progressive
underlying intra-abdominal disorder causing the acute pain
and that unnecessary delays in diagnosis and treatment
can adversely affect outcome, often with catastrophic conse-
quences.
subacute surgi cal abdomen
When immediate operation is not called for, the physician
must decide whether urgent laparotomy or nonurgent but
early operation is necessary. Urgent laparotomy implies oper-
ation within 4 hours of the patients arrival; thus, there is
usually sufcient time for adequate resuscitation, with proper
rehydration and restoration of vital organ function, before the
procedure. Indications for urgent laparotomy may be encoun-
tered during the physical examination, may be revealed by the
basic laboratory and radiologic studies, or may not become
apparent until other investigative studies are performed.
Involuntary guarding or rigidity during the physical examina-
tion, particularly if spreading, is a strong indication for urgent
laparotomy. Other indications include increasing severe local-
ized tenderness, progressive tense distention, physical signs of
sepsis (e.g., high fever, tachycardia, hypotension, and mental
status changes), and physical signs of ischemia (e.g., fever and
tachycardia). Basic laboratory and radiologic indications for
urgent laparotomy include pneumoperitoneum, massive or
progressive intestinal distention, signs of sepsis (e.g., marked
or rising leukocytosis, increasing glucose intolerance, and
acidosis), and signs of continued hemorrhage (e.g., a falling
hematocrit). Additional ndings that constitute indications
for urgent laparotomy include free extravasation of radiologic
contrast material, mesenteric occlusion on angiography,
endoscopically uncontrollable bleeding, and positive results
from peritoneal lavage (i.e., the presence of blood, pus, bile,
urine, or gastrointestinal contents). Acute appendicitis, per-
forated hollow viscera, and strangulated hernias are examples
of common conditions that necessitate urgent laparotomy.
If early operation is contemplated, it may still be prudent
to obtain additional studies to obtain information related to
the site of the lesion or to associated anatomic pitfalls. In
deciding whether to order such studies, it is important to
consider not only whether the additional information
obtained will increase condence in the diagnosis but also
whether the extra time, expense, and discomfort involved
will be justied by the quality and usefulness of the informa-
tion.
43
During a short, dened period of resuscitation, it may
be possible to employ CT scanning to identify the location
of the inamed appendix in difcult (i.e., retrocecal or pelvic)
locations. Knowing the location of the appendix and its mor-
phology can be helpful in directing the incision in an open
operation or determining the most expeditious exposure in a
laparoscopic procedure. CT scanning may also be used to
identify an atypical site of a visceral perforation (e.g., the
proximal stomach, the distal or posterior wall of the duode-
num, or the transverse colon), thereby guiding placement of
the incision and obviating needless dissection of tissue planes.
In the setting of distal bowel obstruction, an expeditious
Gastrogran (Bracco Diagnostics, Princeton, NJ) enema or
CT scan may alert the surgeon to the possibility of an oth-
erwise undetectable malignancy (e.g., cecal carcinoma caus-
ing distal bowel obstruction). In cases in which ischemic
bowel is suspected, the site of vascular blockage can be local-
ized by using a CT angiogram imaging protocol. In each of
these examples, the information gained may permit the
06/09
surgeon to plan the operation, to optimize time spent under
anesthesia, and to minimize postoperative discomfort after
laparotomy.
The use of preoperative imaging has become increasingly
important as an operative planning tool, particularly when
laparoscopic approaches are contemplated for management of
acute abdominal emergencies. In the 1990s and the rst few
years of the 21st century, a number of trials were performed
to determine whether laparoscopy or open operation should
be the approach of choice when the primary clinical diagnosis
is acute appendicitis. This topic has been reviewed extensively
in the literature
4446
and in a 2004 update of a Cochrane meta-
analysis.
47
In some environments, the answer to this question
remains unclear.
48,49
In many settings, however, the current
consensus is that uncomplicated appendicitis can be treated
laparoscopically, with a clear expectation of less postoperative
pain, a shorter hospital stay, and an earlier return to work and
regular activities. These advantages, although signicant, do
not indicate that a laparoscopic approach is to be preferred in
all or most clinical settings or that it is necessarily more
cost-effective than an open approach.
47
Laparoscopic appen-
dectomy requires a high level of organization with respect to
operating room resources, and this level of organization may
be difcult to achieve in institutions where the procedure is
not performed regularly (particularly in the middle of the
night). In addition, it is not clear whether patients with
appendicitis that is complicated by a well-established abscess
or bowel obstruction benet from laparoscopic approaches.
Anatomic considerations also enter into the decision whe-
ther to perform the procedure laparoscopically. For instance,
it can be very difcult to separate a perforated retrocecal
appendix from adherent colon in a safe manner. In many
cases, it is prudent not to persist in attempting to extract the
appendix without a standard open incision, excellent exposure,
and controlled technique. The importance of anatomic con-
siderations underscores the usefulness of preoperative CT in
identifying pathologic anatomy, associated abnormalities, and
potential pitfalls for either open or laparoscopic approaches.
The advantages of laparoscopy in the management of other
abdominal emergencies are less clear-cut. It is important that
the surgeon determine not only whether the particular clinical
scenario is amenable to a laparoscopic approach but also
whether the experience of the entire team and that of the
institution as a whole are sufcient for what may be an
advanced procedure performed in an acute situation. With this
caveat in mind, various investigators have demonstrated that
laparoscopy can be employed safely and with good clinical
results in selected patients with perforated peptic ulcers.
5054

Two prospective, randomized, controlled trials comparing
open repair of perforated peptic ulcers with laparoscopic repair
found that the latter was safe and reliable and was associated
with shorter operating times, less postoperative pain, fewer
chest complications, shorter postoperative hospital stays, and
earlier return to normal daily activities than the former.
52,54

acute abdomi nal pai n requi ri ng observati on
It is widely recognized that of all patients admitted for
acute abdominal pain, only a minority require immediate or
urgent operation.
2,12
It is therefore both cost-effective and
prudent to adopt a system of evaluation that allows for
thought and investigation before denitive treatment in all
patients with acute abdominal pain except those identied
early on as needing immediate or urgent laparotomy. The
traditional wisdom has been that spending time on observa-
tion opens the door for complications (e.g., perforating
appendicitis, intestinal perforation associated with bowel
obstruction, or strangulation of an incarcerated hernia).
However, clinical trials evaluating active in-hospital observa-
tion of patients with acute abdominal pain of uncertain origin
have demonstrated that such observation is safe, is not accom-
panied by an increased incidence of complications, and results
in fewer negative laparotomies.
55
Many institutions now
employ CT scanning liberally in patients with uncertain diag-
noses; this practice should greatly minimize the incidence of
diagnostic failures or delays in patients with acute conditions
necessitating surgical intervention.
32

The initial resuscitation and assessment are followed by
appropriate imaging studies and serial observation. Specic
monitoring measures are chosen (e.g., examination of the
abdomen, measurement of urine output, a WBC count, and
repeat CT scans), and end points of therapy should be identi-
ed. Active observation allows the surgeon to identify most of
the patients whose acute abdominal pain is caused by NSAP
or by various specic nonsurgical conditions. It must be
emphasized that active observation involves more than simply
admitting the patient to the hospital and passively watching
for obvious problems: it implies an active process of thought-
ful, discriminating, and meticulous reevaluation (preferably by
the same examiner) at intervals ranging from minutes to a few
hours, complemented by appropriately timed additional
investigative studies.
A major point of contention in the management of patients
with acute abdominal pain is the use of narcotic analgesics
during the observation period. The main argument for with-
holding pain medication is that it may obscure the evolution
of specic ndings that would lead to the decision to operate.
The main argument for giving narcotic analgesics is that in a
controlled setting where patients are being observed by expe-
rienced clinicians, outcomes are not compromised and
patients are more comfortable.
56
It has also been suggested
that providing early pain relief may allow the more critical
clinical signs to be more clearly identied
57
and that severe
pain persisting despite adequate doses of narcotics suggests a
serious condition for which operative intervention is likely to
be necessary.
In my view, the decision whether to provide or withhold
narcotic analgesia must be individualized.
58
The current con-
sensus is that for most patients undergoing evaluation and
observation for acute abdominal pain, it is safe to provide med-
ication in doses that would take the edge off the pain without
rendering the patient unable to cooperate during the observa-
tion period. It may be especially desirable to provide medica-
tion in a manner that allows the patient to be comfortable
while lying in the CT scanner. In these cases, the goal of pain
relief is to make it easier to obtain accurate information that
will facilitate and expedite the diagnosis and the development
of a treatment plan. Given the high diagnostic yield and accu-
racy of the new generation of CT scanners, it is generally safe
to provide pain medication while obtaining the diagnosis.
On occasion, however, reex administration of pain medi-
cation solely with the aim of relieving pain may be undesirable
or even harmful. For example, in situations for which advanced
06/09
imaging is unavailable, physical examination may be so crucial
to decision making that any risk of obscuring important
physical ndings is deemed unacceptable; therefore, pain
medication should be withheld. In addition, narcotic analge-
sia should be used cautiously in patients with acute intestinal
obstruction when strangulation is a concern.
59
These patients
present with abdominal pain that is out of proportion to the
physical ndings, a syndrome whose differential diagnosis
includes acute intestinal ischemia, pancreatitis, ruptured
aortic aneurysm, ureteral colic, and various medical causes
(e.g., sickle cell crisis and porphyria). A period of resuscita-
tion and evaluation, in conjunction with advanced imaging
studies (e.g., CT), may then yield a tentative diagnosis of
intestinal obstruction caused by adhesions (e.g., if the patient
has a history of abdominal surgery and no evidence of her-
niation or obturation) without evidence of bowel ischemia. In
this setting, the decision whether to admit the patient for
observation rather than immediate operation depends on the
extent to which the surgeon is condent that the obstruction
is not a closed loop.
59
However, within a relatively short
period (perhaps 4 to 24 hours), the surgeon must determine
whether any indications for operation will arise, and the main
parameters for observation include the WBC count, the urine
output, and the development of peritoneal ndings. In such
cases, it may well be prudent to withhold pain medication
until there is a high level of condence that the timing of
surgery will not be delayed.
A nal point is that over the course of a 24- to 48-hour
observation period, the patients condition may neither dete-
riorate nor improve, and supplemental investigation may be
considered. Diagnostic laparoscopy has been recommended in
cases in which surgical disease is suspected but its probability
is not high enough to warrant open laparotomy.
60,61
It is par-
ticularly valuable in young women of childbearing age, in
whom gynecologic disorders frequently mimic acute
appendicitis.
6264
A 1998 report showed that diagnostic lap-
aroscopy had the same diagnostic yield as open laparotomy
in 55 patients with acute abdomen; 34 (62%) of these patients
were safely managed with laparoscopy alone, with no increase
in morbidity and with a shorter average hospital stay.
63
Diag-
nostic laparoscopy has also been shown to be useful for
assessing acute abdominal pain in acutely ill patients in the
intensive care unit.
60,65

In patients with AIDS,
66,67
a number of unusual diagnoses
may be related to or coincident with an episode of abdominal
pain. The differential diagnosis includes lymphoma, Kaposi
sarcoma, tuberculosis and variants thereof, and opportunistic
bacterial, fungal, and viral (especially cytomegaloviral) infec-
tions. Laparoscopy has been used for the purposes of diagno-
sis, biopsy, and treatment in patients with an established
AIDS diagnosis who manifest acute abdominal pain
syndrome.
66,67
The complication rate and mortality associated
with surgery are related to the underlying illness, and out-
comes have improved steadily over the years.
68
It is important
to note that patients who are infected with HIV but have no
clinical manifestations of AIDS are evaluated and managed
in the same fashion as patients without HIV infection when
they present with acute abdominal pain. The differential
diagnosis and the outcomes are essentially no different, unless
there are reasons to think that the new onset of pain in an
HIV-infected patient is a manifestation of AIDS.
58,68

Subacute or Chronic Relapsing Abdominal Pain: Role of
Outpatient Evaluation and Management
For every patient who requires hospitalization for acute
abdominal pain, at least two or three others have self-limiting
conditions for which neither operation nor hospitalization is
necessary. Much or all of the evaluation of such patients, as
well as any treatment that may be needed, can now be com-
pleted in the outpatient department. To treat acute abdominal
pain cost-effectively and efciently, the surgeon must be able
not only to identify patients who need immediate or urgent
laparotomy or laparoscopy but also to reliably identify those
whose condition does not present a serious risk and who
therefore can be managed without hospitalization. The reli-
ability and intelligence of the patient, the proximity and avail-
ability of medical facilities, and the availability of responsible
adults to observe and assist the patient at home are factors
that should be carefully considered before the decision is
made to evaluate or treat individuals with acute abdominal
pain as outpatients.
suspected nonsurgi cal abdomen
Numerous disorders cause acute abdominal pain but do
not call for surgical intervention. These nonsurgical condi-
tions are often extremely difcult to differentiate from surgi-
cal conditions that present with almost indistinguishable
characteristics.
2
For example, the acute abdominal pain of
lead poisoning or acute porphyria is difcult to differentiate
from the intermittent pain of intestinal obstruction in that
marked hyperperistalsis is the hallmark of both. As another
example, the pain of acute hypolipoproteinemia may be
accompanied by pancreatitis, which, if not recognized, can
lead to unnecessary laparotomy. Similarly, acute and pros-
trating abdominal pain accompanied by rigidity of the abdom-
inal wall and a low hematocrit may lead to unnecessary urgent
laparotomy in patients with sickle cell anemia crises. To fur-
ther complicate the clinical picture, cholelithiasis is also often
found in patients with sickle cell anemia.
In addition to numerous extraperitoneal disorders [ see
Table 2 ], nonsurgical causes of acute abdominal pain include
a wide variety of intraperitoneal disorders, such as acute gas-
troenteritis (from enteric bacterial, viral, parasitic, or fungal
infection), acute gastritis, acute duodenitis, hepatitis, mesen-
teric adenitis, salpingitis, Fitz-HughCurtis syndrome, mit-
telschmerz, ovarian cyst, endometritis, endometriosis, threat-
ened abortion, spontaneous bacterial peritonitis, and
tuberculous peritonitis. As noted (see above), acute abdomi-
nal pain in immunosuppressed patients or patients with AIDS
is now encountered with increasing frequency and can be
caused by a number of unusual conditions (e.g., cytomegalo-
virus enterocolitis, opportunistic infections, lymphoma, and
Kaposi sarcoma), as well as by the more usual ones.
Although such disorders typically are not treated by opera-
tive means, operation is sometimes required when the diagno-
sis is uncertain or when a surgical illness cannot be excluded
with condence. In such cases, laparoscopy can be very help-
ful, permitting relatively complete and systematic exploration
without involving the potential morbidity or the longer postop-
erative recovery and rehabilitation period associated with open
exploration.
6972
From the surgeons point of view, an optimal
outcome for laparoscopic exploration in these settings is one in
06/09
which a diagnosis is established by means of visualization, with
or without biopsy, and in which symptoms improve as a con-
sequence of a therapy directed by the laparoscopic ndings.
Overall, candidate lesionsincluding appendiceal pathology
(e.g., chronic appendicitis or carcinoid tumor), adhesions, her-
nias, endometriosis, mesenteric lymphadenopathyare identi-
ed in about 50% of cases, with pelvic adhesions being the
most common nding. From the patients point of view, how-
ever, establishing a precise diagnosis may not be particularly
critical, and symptomatic improvement, by itself, may sufce
to render the outcome successful. Indeed, a number of reports
have emphasized that laparoscopy often leads to improvement
in symptoms even if no lesion is identied or treated.
69,70
This
point may be illustrated by considering pelvic adhesions.
Given the frequency with which laparoscopic exploration
identies pelvic adhesions, adhesiolysis might be expected to
alleviate abdominal pain in many cases. However, it is unclear
whether adhesiolysis is therapeutically benecial when there is
no rm evidence that the adhesions are contributing to the
pain syndrome. In one prospective, randomized trial, 100
patients with laparoscopically identied adhesions were
randomly allocated to either a group that underwent adhesi-
olysis or one that did not.
73
Both groups reported substantial
pain relief and a signicantly improved quality of life, but
there were no differences in outcome between them, which
suggested that the benet of laparoscopy could not be
attributed to adhesiolysis. Longer-term studies also failed to
support the hypothesis that pelvic adhesions are responsible
for chronic pelvic pain.
74
However, in a study conducted con-
currently with the aforementioned randomized trial, 224
consecutive patients underwent laparoscopically assisted
adhesiolysis, and 74% of the 224 obtained short-term relief.
75

Factors that contributed to a successful outcome were gender,
age, and adhesions severe enough to have led to inadvertent
enterotomy and a consequent need for open exploration.
It may, therefore, be possible to identify specic subgroups
that would benet from the addition of adhesiolysis to explor-
atory laparoscopy.
A similar issue arises with respect to pathologic conditions
of the appendixnamely, whether appendectomy should be
performed when no other source of the abdominal pain can
be identied. Early enthusiasm for appendectomy in patients
with chronic right lower quadrant pain was sparked by obser-
vations of acute or chronic inammation in specimens that
seemed visibly normal.
76,77
In subsequent reports, however,
this enthusiasm was tempered by the recognition that these
pathologic ndings were not very prevalent and that appen-
dectomy did not always reduce the pain.
78,79
No randomized
trial of appendectomy for chronic abdominal pain has been
performed in a clearly dened patient group, as has been
done for adhesiolysis.
73

At present, the surgeon can only use his or her best judg-
ment as to the likelihood that a given episode of abdominal
pain may originate from a set of visible adhesions or a visu-
ally normal appendix. It should be remembered that unnec-
essary or potentially meddlesome interventions are always
best avoided; however, it should also be remembered that
failure to alleviate chronic relapsing abdominal pain will
lead to a program of chronic pain management, including
long-term management with potentially addictive and ener-
vating agents. Thus, if adhesiolysis or appendectomy can be
performed with the expectation of low morbidity and with-
out conversion to laparotomy, it seems reasonable to per-
form these procedures during laparoscopy if no other source
of pain can be identied.
Financial Disclosures: None Reported.
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Acknowledgments
Figures 2 and 3 Tom Moore.
The majority of this chapter is based on previ-
ous iterations written for ACS Surgery . The
author wishes to thank the previous authors,
specically Drs. Delcore, Cheung, and
Soybel.

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Acute Abdominal Pain3

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DOI 10.2310/7800.

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