- Nonsurgical causes of acute abdominal pain simulating an acute abdomen account for up to 30% of patients requiring hospital admission.
- Multidetector-row computed tomography (MDCT) is the benchmark imaging modality in the evaluation of acute abdominal pain except in patients with right upper quadrant (RUQ) pain and abnormal liver function tests (LFTs) or in women who are, or may be, pregnant.
- Ultrasound is the initial imaging study of choice in patients with RUQ pain, abnormal LFTs, and suspicion of biliary tract disease.
- Ultrasound is the preferred initial imaging study for young women and those who are pregnant.
- Always perform imaging studies preoperatively in patients with a clinical diagnosis of acute appendicitis.
- Irritable bowel syndrome, functional abdominal pain syndrome, and anxiety disorder may confound accurate diagnosis and are associated with an increased rate of negative appendectomy.
- Narcotic pain medication, if indicated, should not be withheld from a patient with abdominal pain; it will not reduce the recognition of key physical findings and may improve diagnostic accuracy by relaxing the patient.
- The patient's cumulative radiation dose must always be considered before choosing an imaging study, particularly in the young and women of childbearing age.
- Prior abuse should always be considered in patients with recurrent unexplained abdominal pain, regardless of the patient's age or gender.
Acute abdominal pain is defined as severe pain of more than 6 hours' duration in a previously healthy person that requires timely diagnosis and aggressive treatment, usually surgical.
This chapter focuses on the basic principles and challenges in the evaluation of acute, nontraumatic abdominal pain in the adult patient. Emphasis is placed on recent advances in the medical literature and the appropriate tools currently available for improving diagnostic accuracy. The patient with acute abdominal pain remains a clinical challenge for every gastroenterologist. Successful management requires a firm grasp of the patient's history and physical examination and an understanding of appropriate current imaging technology. Clinical scores can be helpful in determining and measuring disease severity and guiding therapy, particularly in acute pancreatitis and inflammatory bowel disease. The clinician should be conditioned to "think outside of the box" and consider the atypical presentation of common disorders.
The management of acute appendicitis provides an ideal example of how the general principles outlined in this chapter can be effectively applied to the care of gastrointestinal illness and is discussed in detail below. The clinician should apply these principles in considering the other conditions discussed in subsequent chapters. It should be remembered that all information is dated and new insights and experience should always be pursued (Table 1–1).
Table 1–1. Differential Diagnosis of Acute Abdominal Pain. ||Download (.pdf)
Table 1–1. Differential Diagnosis of Acute Abdominal Pain.
|Common Conditions||Key Diagnostic Test(s)|
|Acute appendicitis||CT scan, ultrasound|
|Acute diverticulitis||CT scan|
|Acute pancreatitis||Serum amylase/lipase, CT scan|
|Bowel perforation||CT scan|
|Acute mesenteric ischemia||CT ...|