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  1. What are the important features in the history and physical examination that can help to determine the cause of acute abdominal pain?

  2. What tests have the greatest impact in the diagnosis of patients with acute abdominal pain?

  3. What are the important metabolic/endocrine disorders that cause acute abdominal pain simulating an acute abdomen?

  4. What are the important hematologic/immunologic disorders that cause acute abdominal pain simulating an acute abdomen?

Acute abdominal pain, particularly when severe, requires an expeditious evaluation because a missed or delayed diagnosis may lead to significant morbidity and mortality. The first step is to determine whether the patient has a life-threatening cause of acute abdominal pain. After the patient has been stabilized, the emergency physician or hospitalist must then determine whether the patient needs emergent surgery. The decision to obtain an emergency surgical consultation depends on the history and physical examination (with ancillary radiographic examinations of secondary importance), and when signs of an acute abdomen are present, a surgical consult should be requested, with concurrent diagnostic testing as appropriate. In other instances, a thorough history and physical examination is required with close observation and repeat examinations are often needed. Elderly patients and very young patients may present with atypical or nonspecific signs and symptoms that otherwise might be dismissed as insignificant.

Appendicitis, cholecystitis and choledocholithiasis, intestinal obstruction, pancreatitis, mesenteric ischemia, bowel perforation, and diverticulitis account for two-thirds of hospital admissions for acute abdominal pain and are associated with significant morbidity and mortality. In addition, physicians must be mindful of complications following procedures.

Patients may experience visceral pain, parietal pain, and/or referred abdominal pain.

Visceral pain is typically dull or crampy in character. It is caused by stretching, torsion, distention, or contraction of organs. The visceral innervation of the gut and accessory organs comes via the -anchoring mesentery, so pain does not always localize to the quadrant in which the pathology resides, and is often midline. Pain innervation corresponds to dermatomes that match the innervations of the injured organ. Epigastric visceral pain corresponds with organs proximal to the ligament of Treitz, including the hepatobiliary system and the spleen. Periumbilical visceral pain corresponds with injury to organs distal to the ligament of Treitz and the hepatic flexure of the colon. Lower abdominal visceral pain corresponds to injury to organs distal to the hepatic flexure.

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Practice Point
  • Acute cholecystitis
    • Initially there is visceral pain in the epigastric region due to stretch and distention of the gallbladder.
    • Then parietal pain develops due to direct irritation of the peritoneal lining in the right upper quadrant (location).
    • Ultimately, referred pain develops in the right shoulder.
  • Splenic hematoma
    • Initially there is visceral pain in the epigastric region due to stretch and distention of the spleen.
    • Then parietal pain develops due to direct irritation of the peritoneal lining in the left upper quadrant (location).
    • Ultimately, referred pain develops in ...

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