20:48 5/12/24 Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department - UpToDate

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Evaluation of the adult with nontraumatic abdominal or

flank pain in the emergency department
AUTHORS: John L Kendall, MD, FACEP, Maria E Moreira, MD
SECTION EDITORS: Korilyn S Zachrison, MD, MSc, Bharti Khurana, MD, MBA, FACR, FASER
DEPUTY EDITOR: Michael Ganetsky, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2024.

This topic last updated: Oct 01, 2024.

INTRODUCTION

Abdominal and/or flank pain is the chief complaint in 5 to 10 percent of emergency department
(ED) visits, and patients often require extensive evaluations, including testing, administration of
analgesia, stabilization, and specialty consultation [1-4]. In many cases, the differential
diagnosis is wide, ranging from benign to life-threatening conditions. Causes include medical,
surgical, intra-abdominal, and extra-abdominal ailments. Associated symptoms often lack
specificity, and atypical presentations of common diseases are frequent.

Despite sophisticated diagnostic modalities, undifferentiated abdominal pain remains the

diagnosis for approximately 25 percent of patients discharged from the ED and between 35 and
41 percent for those admitted to the hospital [2,5-7]. Approximately 80 percent of patients
discharged with undifferentiated abdominal pain improve or become pain free within two
weeks of presentation [7].

Older adults, patients with immunocompromise or diabetes, and female patients of

childbearing age pose special diagnostic challenges. Older adults and patients with diabetes are
at greater risk for potentially life-threatening conditions and often present with nonspecific
complaints and atypical symptoms [8,9].

This topic will discuss the evaluation of the adult patient presenting to the ED with nontraumatic
abdominal or flank pain. The outpatient evaluation of adults with abdominal pain, a synopsis of
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causes of abdominal pain, an approach to pelvic pain, and evaluation of blunt abdominal
trauma are found separately.

● (See "Evaluation of the adult with abdominal pain".)

● (See "Causes of abdominal pain in adults".)
● (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients".)
● (See "Acute pelvic pain in nonpregnant adult females: Evaluation".)
● (See "Blunt abdominal trauma in adults: Initial evaluation and management".)

OVERVIEW OF THE EVALUATION

Rapid assessment for abdominal catastrophe — The evaluation of an adult emergency

department (ED) patient with abdominal or flank pain starts with obtaining a history and
performing a physical examination. We simultaneously and rapidly assess if the patient may be
having a life-threatening abdominal catastrophe. Potential indicators include shock (eg,
hypotension, tachycardia, tachypnea), presence of peritonitis, significant distress from pain, or
altered mental status; these warrant starting resuscitation simultaneously with obtaining
further history and examination. (See 'Patient with suspected life-threatening abdominal
catastrophe' below.)

History — A thorough history focuses the differential diagnosis and helps determine the need
for further testing. It is important to characterize the pain as precisely as possible, including
timing of onset, continuous or intermittent pattern, prior episodes of similar pain, quality,
location, radiation, aggravating and alleviating factors, and associated symptoms. Patient
factors and clinical features of high-risk abdominal pain are presented in the table ( table 1).
High risk symptoms include acute onset, initial maximal severity, and pain preceding vomiting.
Symptoms in older patients are less likely to be characteristic for the underlying cause of their
pain (ie, "atypical" symptoms). (See 'Older adults' below.)

● Quality and timing of pain — The quality and timing of the pain (eg, intensity at onset,
acute versus chronic) help determine the acuity and focus the evaluation on specific organ
systems. Severe, sudden-onset pain or constant, worsening pain lasting over six hours
(but less than 48 hours) suggests a surgical cause, while nonsurgical causes tend to have
milder, intermittent pain with longer chronicity. Abdominal pain can be classified as
visceral, parietal (ie, somatic), or referred depending on its neurologic basis, which is
discussed in detail separately ( table 2). (See "Causes of abdominal pain in adults",
section on 'Pathophysiology of abdominal pain'.)

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Pain intensity at onset provides clues to disease severity and involved structures [1,10,11].
Pain with maximum intensity at onset is concerning for a vascular process (eg, ruptured
abdominal aortic aneurysm [AAA]), obstruction of a small tubular structure (eg,
nephrolithiasis), or reproductive organ pathology (eg, ovarian cyst rupture or torsion) [12].
Intense tearing pain suggests aortic dissection or rupture. Pain with gradual onset
suggests an inflammatory or infectious process (eg, appendicitis, diverticulitis) or
obstruction of a large tubular structure (eg, intestine). Colicky pain may be more
associated with gallstones or kidney stones.

The timing of pain can help to determine the urgency of further testing, although
standardized definitions of acute and chronic abdominal pain do not exist.

• First episode of pain lasting less than one week – We consider this to be acute pain
that generally requires an extensive ED evaluation unless the history and examination
determine a clear cause. (See 'Cause identified by history and physical' below.)

• Recurrent presentations of acute pain – This may be classified as acute, subacute, or

chronic pain, and the ED evaluation often depends on the testing and imaging
obtained during prior episodes and whether the pain has resolved. Causes may be
benign (eg, irritable bowel syndrome, nonincarcerated hernia, nephrolithiasis,
abdominal migraines, cyclical vomiting syndrome, cannabis hyperemesis syndrome) or
more serious (eg, intermittent ovarian torsion, mesenteric ischemia, biliary disease).
High-quality evidence does not exist to define a low-risk patient subset with recurrent
abdominal pain that clearly does not need computed tomography (CT) imaging [13].

• Pain that has remained unchanged for months or years – We consider this to be
chronic pain that may not require extensive ED evaluation if the patient has had prior
testing and imaging. However, a patient with chronic abdominal or flank pain can still
present with an acute exacerbation of a chronic problem or a new and unrelated
problem, which the history must differentiate. The diagnostic approach to chronic
abdominal pain is discussed separately. (See "Evaluation of the adult with abdominal
pain", section on 'Diagnostic approach to chronic abdominal pain'.)

● Location of pain — The location and radiation of pain helps narrow the differential
diagnosis. The provided tables summarize the causes of pain by characteristic location in
the abdomen ( table 3) and pelvis ( table 4), and the figure demonstrates patterns of
referred pain ( figure 1). Causes of abdominal pain by location are discussed in detail
separately. (See "Causes of abdominal pain in adults".)

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Localization by itself, however, is not sufficiently sensitive to definitively exclude intra-

abdominal pathology [10,14,15]. As an example, in one study, 24 percent of patients
diagnosed with appendicitis had no right lower quadrant pain or tenderness [15]. Right
upper quadrant pain is often associated with the liver or gallbladder, although pain from
biliary colic can be poorly localized, and patients may complain of lower chest, epigastric,
or back discomfort [16].

Pain location can change over time, reflecting progression of disease. As a classic example,
appendicitis begins as periumbilical visceral pain (reflecting its embryologic origin) then
progresses to right lower quadrant parietal pain as the inflamed appendix (if anterior or
pelvic) irritates the peritoneum. Retrocecal appendicitis may not cause any focal peritoneal
irritation.

Thoracic diseases, such as pneumonia, pulmonary embolism (PE), or myocardial infarction,

can cause upper abdominal pain, particularly in older patients [17]. Many extra-abdominal
causes of acute abdominal pain ( table 5), such as diabetic ketoacidosis and
hypercalcemia, often present with nonlocalizing pain.

● Aggravating and alleviating factors — Examples that help with the differential diagnosis
include the following:

• The pain of peptic ulcer disease may change after meals, such as improving with
duodenal ulcers or worsening with gastric ulcers. Eating may also exacerbate biliary
colic and mesenteric ischemia.

• Pancreatitis pain may improve when the patient sits upright and worsen when the
patient reclines.

• A patient with peritonitis often lies still and may note that coughing worsens their pain.
Pain that worsens going over bumps during the drive to the ED suggests peritonitis
and is roughly 80 percent sensitive, but only 52 percent specific, for appendicitis [18].

• A patient with nephrolithiasis is often restless and cannot find a comfortable position,
but this can also occur with vascular catastrophes such as AAA.

• Pain and vomiting that improves with hot showers is characteristic for cannabis
hyperemesis syndrome.

• Pain associated with increased physical activity may be cardiac or possibly related to a
rectus muscle strain/hematoma.

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● Associated symptoms — These include fever, chills, fatigue, weight loss, anorexia,
nausea, vomiting, diarrhea, obstipation, constipation, dysuria, diaphoresis, urinary
urgency/frequency, hematuria, vaginal discharge/bleeding, penile discharge, and scrotal
pain. Examples of diseases that cause abdominal pain with these symptoms are presented
in the table ( table 6).

Cough, dyspnea, or chest pain suggests an extra-abdominal process such as pneumonia,

PE, or myocardial infarction. Extra-abdominal causes may also have abdominal-type
associated symptoms, such as nausea or vomiting. Selected extra-abdominal causes of
acute abdominal pain are listed in the table ( table 5).

● Past medical and social histories and medications – Examples of medical comorbidities,
prior surgeries, medications, and misused drugs that increase the risk of diseases that
cause abdominal or flank pain are presented in the table ( table 7).

Medications associated with constipation are provided in the table ( table 8). In an ED
patient, however, constipation should be a diagnosis of exclusion after appropriate
imaging has been performed or the pain has resolved after a bowel movement.

Victims of intimate partner violence may present to the ED with abdominal or pelvic pain
[19,20]. (See "Intimate partner violence: Diagnosis and screening".)

● Past surgical history – A history of previous abdominal surgery increases the risk for
small bowel obstruction (SBO), which is from adhesions in 50 to 70 percent of cases. (See
"Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in
adults".)

Various complications can develop from bariatric surgery, gender-affirming surgery, or

receiving an organ transplant, even many years after the procedure. (See 'Organ
transplant recipient' below and 'Bariatric surgery' below and "Gender-affirming surgery:
Feminizing procedures" and "Gender-affirming surgery: Masculinizing procedures".)

A variety of postoperative complications can cause abdominal pain, such as ileus, surgical
site infections, hematoma/seroma formation, and nerve injury. (See "Postoperative ileus"
and "Overview of the evaluation and management of surgical site infection" and
"Complications of abdominal surgical incisions".)

● Trauma – It is helpful to ask whether the patient sustained any injuries, procedures, or
instrumentation in the prior month. Intra-abdominal injuries may not manifest for days to
weeks after the event. Splenic rupture is an example, but delayed presentations of

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perforated bowel, bowel hematomas, pancreatitis, intrabdominal abscess, and injuries to

the liver, gallbladder, and genitourinary tract have all been reported. Clinical
manifestations of diaphragmatic injury, which is often not diagnosed immediately
following the injury, can be delayed for months to even years. (See "Blunt abdominal
trauma in adults: Initial evaluation and management" and "Initial evaluation and
management of blunt thoracic trauma in adults" and "Recognition and management of
diaphragmatic injury in adults".)

● Obstetric/gynecologic history – It is critical to determine pregnancy status and

gestational age if the patient is pregnant. Pregnancy broadens the differential diagnosis to
include complications of pregnancy (such as an ectopic gestation); round ligament pain;
preeclampsia; hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome;
and issues related to spontaneous pregnancy loss. Symptoms in later pregnancy may be
atypical as the gravid uterus displaces the traditional location of other intraabdominal
organs. (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum
patients".)

We maintain a heightened suspicion for unsafe abortion in a reproductive-age pregnant

patient with clinical findings related to the genital tract, as many patients will not report
the procedure or the pregnancy. (See "Unsafe abortion", section on 'History'.)

In a nonpregnant female, it is important to ask about menstrual history (eg, last menstrual
period, last normal menstrual period, cycle length), dyspareunia, and dysmenorrhea.
Recurrent, acute pain related to menstrual cycles suggests a reproductive organ-related
etiology. (See "Acute pelvic pain in nonpregnant adult females: Evaluation" and "Chronic
pelvic pain in adult females: Evaluation".)

Monthly recurrent pain in a female patient may be associated with the patient's menstrual
cycle. Endometriosis pain can be anywhere in the abdomen and is usually recurrent each
month. (See "Endometriosis in adults: Clinical features, evaluation, and diagnosis".)

Females undergoing ovulation induction can develop ovarian hyperstimulation syndrome

from multiple, large ovarian cysts precipitating acute fluid shifts with depletion of
intravascular fluid. (See "Pathogenesis, clinical manifestations, and diagnosis of ovarian
hyperstimulation syndrome".)

● Family history – Examples of family history that may be relevant to the differential
diagnosis include the following:

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• Inflammatory bowel disease in a patient with abdominal pain and bloody diarrhea (see
"Definitions, epidemiology, and risk factors for inflammatory bowel disease")

• Familial Mediterranean fever in a patient with recurring attacks of fever and serosal
inflammation of the peritoneum, pleura, or synovium (see "Clinical manifestations and
diagnosis of familial Mediterranean fever")

• Hereditary angioedema in a patient with recurrent abdominal pain and pseudo-

obstruction (see "Hereditary angioedema (due to C1 inhibitor deficiency):
Epidemiology, clinical manifestations, exacerbating factors, and prognosis")

● Sick contacts and travel history – Recent travel or similar symptoms among family or
friends are important clues indicative of an infectious, environmental, or food-borne
etiology. Patients are often in contact with a person with gastroenteritis before developing
symptoms themselves. (See "Acute viral gastroenteritis in adults" and "Causes of acute
infectious diarrhea and other foodborne illnesses in resource-abundant settings".)

● Occupational history – We do not routinely obtain an occupational history in ED patients,

but this may help to identify unusual causes of pain. For example, lead poisoning in an
adult (eg, construction worker) can present with abdominal pain, constipation, and
anorexia. (See "Overview of environmental health" and "Lead exposure, toxicity, and
poisoning in adults", section on 'Clinical manifestations'.)

● Mental health and psychiatric history – Abdominal pain may be related to increased
stress or emotional disturbances. Eating disorders, Munchausen syndrome, somatic
symptom disorder, and conversion disorder may also cause abdominal pain. However,
these should not interfere with a thorough evaluation of abdominal pain. (See "Eating
disorders: Overview of epidemiology, clinical features, and diagnosis" and "Factitious
disorder imposed on self (Munchausen syndrome)" and "Somatic symptom disorder:
Epidemiology, clinical features, and course of illness" and "Functional neurological
symptom disorder (conversion disorder) in adults: Clinical features, assessment, and
comorbidity".)

Physical examination

● General appearance and vital signs

• Temperature – Fever increases the suspicion for infection or inflammatory process.

Pain often causes tachypnea, which can cause a falsely lower oral temperature
measurement [21]. We check a rectal temperature if there is concern about an

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inaccurate reading. Certain patient populations, such as older adults and those with
immunocompromise, may be unable or less likely to develop a fever. (See
"Pathophysiology and treatment of fever in adults".)

• Blood pressure and heart rate – Hypotension is an ominous finding in a patient with
abdominal or flank pain and may reflect a shock state (eg, hemorrhagic, hypovolemic,
septic, endocrine) ( table 9). Tachycardia is an early compensatory mechanism in a
patient with shock (although may be blunted by certain medications such as beta
blockers). The presence of either should prompt resuscitation simultaneously with the
evaluation. (See 'Patient with suspected life-threatening abdominal catastrophe' below
and "Evaluation of and initial approach to the adult patient with undifferentiated
hypotension and shock".)

Some patients with acute peritoneal irritation (eg, ruptured ovarian cyst, ectopic
pregnancy) and hypotension may not be tachycardic, or may even be bradycardic, likely
from a parasympathetic nervous system (ie, vagal) reflex [22]. (See "Evaluation and
management of ruptured ovarian cyst", section on 'Clinical findings'.)

• Respiratory rate – An elevated respiratory rate may be due to pain or from a

compensatory reaction to an underlying metabolic acidosis.

• General appearance – The patient's general appearance not only provides clues to the
diagnosis but also guides the urgency of resuscitation, analgesia, and imaging. The
patient who is restless, curled up, and agitated may have renal colic. A patient lying
perfectly still in bed with knees bent or experiencing worsening pain when the
examiner lightly bumps the stretcher raises concern for peritonitis. Signs of shock (eg,
pallor, diaphoresis, altered mental status) warrant resuscitation simultaneously with
the evaluation. Signs of systemic disease (eg, spider angiomata in cirrhosis, cachexia in
malignancy) are often readily apparent.

● Abdominal examination

• Inspection – General inspection may reveal signs of previous surgeries (eg, incision
scar), abdominal pulsations, or distension. Periumbilical ecchymosis (Cullen sign) can
occur with pancreatitis, rectus sheath hematoma, perforated ulcer, and intra-peritoneal
hemorrhage. Abdominal wall pathology such as a hernia can be obvious if incarcerated
but may require asking the patient to increase abdominal pressure (ie, Valsalva
maneuver, cough) to elicit the bulge. Examining the patient while they are standing
may also help identify hernias. (See "Overview of abdominal wall hernias in adults",
section on 'Clinical features'.)
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• Palpation – Abdominal palpation identifies the location and degree of tenderness and
detects signs of peritoneal irritation, such as involuntary guarding and muscular
rigidity. Serial examinations can improve diagnostic accuracy [23].

Our approach is to lightly palpate an area away from the site of pain, then extend
towards the area of maximal pain. Once the area of maximal tenderness is localized,
we perform maneuvers to elicit peritoneal signs, such as percussion or releasing after
deep palpation. If light palpation does not identify a specific area of tenderness,
palpate deeper to identify findings such as hepatomegaly, splenomegaly, aortic
dilatation, or deep tenderness (such as may occur with retrocecal appendicitis).
Percussion may help identify ascites, obstruction, and enlarged organs. In patients with
obesity, due to the increased intra-abdominal and subcutaneous adipose tissue, organs
may be more difficult to palpate.

A rigid abdomen is cause for concern, but traditional techniques for assessing rebound
tenderness have limited sensitivity and specificity for identifying peritonitis [24,25].
Gentler methods to elicit signs of peritoneal irritation include having the patient cough,
stand on their toes and drop their heels to the ground, or gently shaking the pelvis or
the stretcher [26,27]. The heel test can also be performed by striking a recumbent
patient's heel. However, studies of these tests are limited, and their test characteristics
remain uncertain [28,29].

Voluntary guarding can occur from nervousness or pain and can be abated via
reassurance, warming the clinician's hands prior to palpating, or asking the patient to
flex their hips or take a deep breath during the exam.

Patients who are extremely ticklish can be supported by interweaving the clinician's
fingers with the patient's fingers to conduct the exam.

Palpating the aorta is safe but generally has limited utility with the availability of point-
of-care ultrasound. An abnormal width of aortic pulsation suggests an AAA. (See
"Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Abdominal
palpation' and 'Role of point-of-care ultrasound' below.)

Other examination maneuvers that can be selectively performed include the following:

- Although insensitive, the psoas (right lower quadrant pain with passive right hip
extension), obturator (right lower quadrant pain with passive right knee flexion
and right hip flexion/internal rotation), and Rovsing signs (right lower quadrant
with palpation of the left lower quadrant) have good specificity for appendicitis.

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(See "Acute appendicitis in adults: Clinical manifestations and differential

diagnosis", section on 'Physical examination'.)

- Murphy sign (worsening pain and tenderness during deep inspiration with right
upper quadrant palpation) is sensitive but not specific for acute cholecystitis. (See
"Acute calculous cholecystitis: Clinical features and diagnosis", section on 'Physical
examination'.)

- The presence of Carnett sign (increased abdominal tenderness when the

abdominal wall muscles are contracted) suggests pathology within the abdominal
wall instead of intraperitoneal. In one small study, Carnett sign was found to be 95
percent accurate at differentiating abdominal wall pain from visceral pain [30].

• Abdominal auscultation – In the ED, this is generally of limited utility since bowel
sound findings do not alter the decision to image a patient with abdominal distension.
We will occasionally auscultate with light to deep pressure as a means to elicit
tenderness with the patient distracted. Periodic rushes of high-pitched "tinkling" bowel
sounds or the complete absence of bowel sounds, in the presence of abdominal
distention, are signs of bowel obstruction [31]. An abdominal bruit, though rarely
appreciated, is indicative of partially obstructed and turbulent blood flow which may be
found in renal and splenic artery stenosis, abdominal aortic disease, or other
intrabdominal vascular disease.

● Extra-abdominal examination — Examining the following organ systems can provide

clues to intra-abdominal and extra-abdominal causes of pain:

• Genital – In a male with lower abdominal or flank pain, examine the scrotum for
testicular edema and tenderness, epididymal tenderness, scrotal masses, and
cremasteric reflexes. Some patients, particularly young adults, may not initially reveal
scrotal symptoms. (See "Acute scrotal pain in adults: Evaluation and management of
major causes".)

Perform a pelvic examination in a female with pain and tenderness in the lower half of
the abdomen (with shared decision-making with the patient if they believe this exam is
unnecessary). There are no pre-examination criteria to determine if the pelvic
examination can be deferred or will provide useful information [4]. (See "The
gynecologic history and pelvic examination", section on 'Pelvic examination'.)

• Rectal – We selectively perform a rectal examination, since this has questionable utility
in a patient with undifferentiated abdominal or flank pain without gastrointestinal

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bleeding [32,33]. The rectal examination is useful when there is a concern for
gastrointestinal bleeding, when there is obstipation (to exclude fecal impaction or
foreign body), or when identifying rectal tenderness may change management (eg, a
patient may have rectal tenderness and not abdominal tenderness with retrocecal
appendicitis).

• Heart and lungs – Auscultate the heart and lungs and palpate a pulse. Atrial fibrillation
or valvular disease can increase suspicion for mesenteric ischemia secondary to
vascular embolization. Localized decreased or coarse breath sounds raise suspicion for
pneumonia.

• Musculoskeletal, back, and flank – Percuss the costovertebral angles as tenderness

suggests pyelonephritis. Passively range the hips since intra-articular, retroperitoneal,
or psoas-related infectious and inflammatory processes can refer pain to the lower
abdomen or flank. Flank ecchymosis (Grey-Turner sign ( image 1)) can occur with
retroperitoneal hemorrhage, such as from a ruptured AAA or hemorrhagic pancreatitis.

• Eyes – Examine the sclera for icterus.

• Skin – Examine for rashes, especially over the abdomen, back, and perineum.
Engorged blood vessels, telangiectasias, petechiae, or jaundice may indicate liver
disease. Zoster presents with a rash in the dermatomal distribution of the pain, but the
pain often precedes the rash by several days, complicating the diagnosis. (See
"Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on
'Clinical manifestations'.)

Role of point-of-care ultrasound — Emergency physician-performed point-of-care ultrasound

has become an important diagnostic tool for patients presenting with abdominal pain. Since
ultrasound is rapid and can be performed at the bedside, it is especially helpful in the unstable
patient or when there is concern for abdominal catastrophe. However, test characteristics vary
depending on the operator, the patient body habitus, and indication [34]. Point-of-care
ultrasound can guide further evaluation, initial treatment, and consultations in the following
situations:

● When there is concern for hemoperitoneum, such as from ruptured ectopic pregnancy or
hemorrhagic ovarian cyst ( image 2). (See "Emergency ultrasound in adults with
abdominal and thoracic trauma", section on 'Abdominal examination'.)

● To identify an AAA ( image 3), although ultrasound cannot exclude a leak or rupture
since it has limited utility for detecting retroperitoneal bleeding. (See "Clinical features and

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diagnosis of abdominal aortic aneurysm", section on 'Diagnosis'.)

● In a pregnant patient to identify an intrauterine pregnancy ( image 4) and potentially an

adnexal or tubal ectopic pregnancy ( image 5). (See "Ultrasonography of pregnancy of
unknown location".)

● In a hypotensive patient; in addition to hemoperitoneum, ultrasound can identify cardiac

and thoracic etiologies and assess the inferior vena cava diameter as an indicator of fluids
status. (See "Evaluation of and initial approach to the adult patient with undifferentiated
hypotension and shock", section on 'Point-of-care ultrasonography' and "Novel tools for
hemodynamic monitoring in critically ill patients with shock", section on 'Vena cava
assessment'.)

● In a patient with right upper quadrant pain, to identify gallstones or radiographic signs of
cholecystitis ( image 6 and image 7). However, emergency physician-performed
point-of-care ultrasound may be more helpful in establishing the diagnosis of acute
cholecystitis and expediting care rather than excluding the diagnosis. A meta-analysis (7
studies, 1,772 patients) found the sensitivity and specificity of point-of-care ultrasound for
cholecystitis was 71 (95% CI 62-78) and 94 (95% CI 88-98) percent, respectively [35]. (See
"Overview of gallstone disease in adults", section on 'Transabdominal ultrasound' and
"Acute calculous cholecystitis: Clinical features and diagnosis", section on
'Ultrasonography'.)

● In a patient with urinary retention, to confirm a distended bladder. (See "Acute urinary
retention", section on 'Initial evaluation'.)

● In a patient with flank pain, the presence of unilateral hydronephrosis suggests an

obstructive kidney stone ( image 8). (See "Kidney stones in adults: Diagnosis and acute
management of suspected nephrolithiasis", section on 'Ultrasound of the kidneys and
bladder'.)

Depending on operator experience with the following indications, point-of-care ultrasound can
be performed for initial screening but ultimately may need radiology confirmation:

● In a nonpregnant female, to identify ovarian and uterine pathology and ovarian blood flow
(on color Doppler). (See "Ovarian and fallopian tube torsion", section on 'Ultrasound' and
"Adnexal mass: Ultrasound categorization".)

● In a male with acute scrotal pain, the absence of Doppler flow suggests testicular torsion.
(See "Acute scrotal pain in adults: Evaluation and management of major causes".)

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● In a patient with right lower quadrant pain, ultrasound can identify appendicitis, but it is
often technically challenging to find the appendix. (See "Acute appendicitis in adults:
Diagnostic evaluation", section on 'Ultrasound'.)

● In a patient with suspected SBO, ultrasound can identify dilated loops of bowel. (See
"Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in
adults", section on 'Bedside imaging study'.)

● In patients with suspected pancreatitis, ultrasound may detect a pancreatic pseudocyst.

(See "Approach to walled-off pancreatic fluid collections in adults", section on 'Radiologic
imaging'.)

● Abdominal free air can be identified on ultrasound, but it is not the accepted study of
choice for this indication. (See "Indications for bedside ultrasonography in the critically ill
adult patient", section on 'Detection of abdominal free air'.)

● Lower lobe pneumonia or a hemo/pneumothorax may be identified by lung ultrasound.

(See "Clinical evaluation and diagnostic testing for community-acquired pneumonia in
adults", section on 'Ultrasound and other studies' and "Bedside pleural ultrasonography:
Equipment, technique, and the identification of pleural effusion and pneumothorax",
section on 'Evaluation for pneumothorax'.)

Ancillary studies — These are useful adjuncts but should not be used to definitively exclude a
diagnosis.

● Laboratory tests — We obtain laboratory studies in most patients unless the history and
physical examination establish the cause of the pain (eg, incarcerated hernia with
improvement of pain after reduction, zoster rash in same distribution as pain). The
threshold for ordering a broader range of tests is lower in the patient with
immunosuppression, older age, and significant underlying disease (eg, diabetes, cancer,
human immunodeficiency virus [HIV], cirrhosis). Laboratory tests to evaluate acute
abdominal and flank pain include the following:

• Pregnancy test – Either a urine or serum qualitative human chorionic gonadotropin

(hCG) test is required in all females of childbearing age with abdominal pain. Both tests
are extremely sensitive. Patient self-assessment of pregnancy status is not reliable [36].
Obtain a quantitative serum hCG in a pregnant patient without a previously
documented intrauterine pregnancy. (See "Ectopic pregnancy: Clinical manifestations
and diagnosis", section on 'Human chorionic gonadotropin'.)

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• Complete blood count (CBC) – Although frequently ordered, the CBC is nonspecific
and rarely alters management [37-39]. A leukocytosis or neutrophil left shift can
support the presence of an acute infectious or inflammatory process. While up to 80
percent of patients with acute appendicitis have a leukocytosis, 70 percent of patients
with other causes of right lower quadrant abdominal pain also have a leukocytosis
[39,40]. Healthy pregnant patients typically have a mild leukocytosis. (See "Maternal
adaptations to pregnancy: Hematologic changes", section on 'White blood cells'.)

• Basic electrolytes – Electrolytes are frequently measured but rarely alter

management. They can identify metabolic acidosis (eg, diabetic ketoacidosis [DKA]) and
electrolyte or free water losses. In patients with diabetes, disruption of typical glucose
levels or glucose control patterns may result from acute intrabdominal pathology (as
opposed to being a symptom of DKA) [41]. Electrolytes can assess for impaired kidney
function, which is a risk factor for contrast-induced acute kidney injury. (See
"Prevention of contrast-induced acute kidney injury associated with computed
tomography", section on 'Risk factors'.)

• Serum lactate, venous blood gas – Although nonspecific, an elevated serum lactate
can indicate sepsis or bowel ischemia and can be used to follow the response to
resuscitation. A venous blood gas can accurately measure blood pH from a metabolic
acidosis accompanying intrabdominal pathology and provide an additional marker for
resuscitation response. (See "Overview of intestinal ischemia in adults", section on
'Laboratory studies' and "Sepsis syndromes in adults: Epidemiology, definitions, clinical
presentation, diagnosis, and prognosis", section on 'Laboratory signs'.)

• Liver and pancreatic enzymes – Measure these in a patient with upper abdominal
pain. As compared with amylase, serum lipase is more sensitive and specific for
pancreatitis, but elevations may be caused by other diseases. Marked liver enzyme
elevation suggests acute hepatitis (eg, viral) but can occur with underlying chronic liver
disease (eg, Wilson disease), ischemic or drug-induced liver injury (eg, acetaminophen),
rhabdomyolysis, malignancy, or an autoimmune disorder. Elevation in the serum total
bilirubin and alkaline phosphatase concentrations suggest a cholestatic pattern and
are uncommon in uncomplicated cholecystitis. (See "Approach to the patient with
abnormal liver tests" and "Clinical manifestations, diagnosis, and natural history of
acute pancreatitis" and "Approach to the patient with elevated serum amylase or
lipase".)

• Coagulation studies and blood type – Obtain these in a patient with gastrointestinal
bleeding or with a high index of suspicion that an operation will be necessary. A
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pregnant patient with vaginal bleeding should have a blood type and Rh checked.

• Erythrocyte sedimentation rate, C-reactive protein – Although nonspecific these

acute phase reactants may be elevated in inflammatory and infectious processes. (See
"Acute phase reactants".)

• D-dimer – Can be elevated in vascular occlusive diseases, such as acute aortic

syndromes [42,43]. (See "Clinical features and diagnosis of abdominal aortic
aneurysm", section on 'Laboratory studies and biomarkers' and "Clinical features and
diagnosis of acute aortic dissection", section on 'D-dimer'.)

• Urinalysis – The presence of pyuria or hematuria suggests a urinary tract infection

(UTI) but can also occur with any inflammatory process adjacent to a ureter. For
example, 20 to 48 percent of patients with appendicitis have blood, leukocytes, or
bacteria in their urine [44,45]. Many older adults have chronic, mild pyuria. Hematuria
may be present in as many as 87 percent of patients with AAA, which can lead to a
misdiagnosis of nephrolithiasis [46]. (See "Acute simple cystitis in adult females" and
"Acute simple cystitis in adult and adolescent males".)

• Sexually transmitted infection (STI) testing – During the pelvic examination in a

female with lower abdominal pain, swabs can be obtained for nucleic acid amplification
testing for gonorrhea, chlamydia, and trichomas. (See "Clinical manifestations and
diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on
'Nucleic acid amplification' and "Clinical manifestations and diagnosis of Chlamydia
trachomatis infections in adults and adolescents", section on 'Nucleic acid amplification
testing (test of choice)' and "Trichomoniasis: Clinical manifestations and diagnosis",
section on 'Preferred tests'.)

● Chest radiograph (CXR) — Obtain a CXR in a patient with abdominal pain who also has
associated cardiothoracic symptoms (eg, cough, dyspnea, chest pain) to assess for
pneumonia, pneumothorax, or other pleural-based processes. Pleural irritation from a
basilar lung infiltrate can cause sharp abdominal pain that is aggravated by cough or deep
inspiration. An upright CXR can also visualize pneumoperitoneum occurring from hollow
viscous perforation. (See "Clinical evaluation and diagnostic testing for community-
acquired pneumonia in adults" and 'Imaging' below.)

● Electrocardiogram (ECG) – Obtain an ECG in a patient with upper abdominal pain who
has older age, immunosuppression, or significant underlying disease (eg, diabetes, cancer,
HIV, cirrhosis). Some patients with an acute coronary syndrome, especially older adults
and those with diabetes, present with epigastric pain, nausea, or vomiting rather than
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chest pain. Abdominal pain is the presenting complaint for an acute myocardial infarction
in approximately one-third of these atypical cases. Newly diagnosed atrial fibrillation raises
concern for acute mesenteric arterial occlusion caused by embolism from dislodged
thrombus from the left atrium. (See "Initial evaluation and management of suspected
acute coronary syndrome (myocardial infarction, unstable angina) in the emergency
department" and "Acute mesenteric arterial occlusion", section on 'Arterial embolism'.)

● Abdominal paracentesis – In a patient with ascites and abdominal pain or tenderness, a

diagnostic paracentesis should be performed and ascitic fluid analyzed to exclude
spontaneous bacterial peritonitis. (See "Diagnostic and therapeutic abdominal
paracentesis" and "Spontaneous bacterial peritonitis in adults: Diagnosis", section on
'Obtaining ascitic fluid'.)

Overview of common imaging modalities — The decision to image an ED patient with

abdominal or flank pain is a clinical judgement based on whether there are entities on the
differential diagnosis that must be excluded during the current visit or can wait for outpatient
follow-up. This is often a complex decision-making process and may require shared decision-
making with the patient in equivocal cases. Decisions regarding the need and timing of imaging
are based on suspected etiologies and are discussed in more detail below. (See 'Patient with
suspected life-threatening abdominal catastrophe' below and 'Patient without abdominal
catastrophe' below.)

Most patients with abdominal tenderness or distension, pain requiring multiple opioid doses,
high-risk features ( table 1), or leukocytosis will require imaging. It can be helpful to have a
discussion with the radiologist if unsure which study to order or whether contrast
administration is necessary. Common ED imaging modalities include the following:

● CT scan — This is the modality of choice in the ED evaluation of undifferentiated

abdominal pain [47]. Approximately two-thirds of patients presenting to the ED with acute
abdominal pain have a disease that can be diagnosed by CT [48]. One small study found
that CT correctly diagnosed the cause of pain among patients with an "acute abdomen" in
90 percent of cases compared with 76 percent of cases diagnosed correctly by history and
physical examination alone [49]. CT is particularly useful in older adults, establishing or
suggesting the diagnosis in 75 percent of cases and 85 percent of emergency surgical
conditions [8]. Unenhanced CT is extremely sensitive in identifying free air [47].

• Role of intravenous (IV) contrast — Routine administration of IV contrast improves

the diagnostic accuracy of CT for many diagnoses [50]. However, acute kidney injury
may develop after administration of iodinated contrast material, primarily in patients

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with an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2. If unsure, the
radiologist can help determine if IV contrast is necessary. (See "Patient evaluation prior
to oral or iodinated intravenous contrast for computed tomography" and "Prevention
of contrast-induced acute kidney injury associated with computed tomography".)

• Role of oral contrast — Improvements in the image quality provided by multislice

helical CT scanners have raised questions about the need for oral contrast. Most
institutions do not routinely use oral contrast because of associated delays in study
acquisition, need for nasogastric tube insertion in a patient unable to tolerate orally
administered contrast, and prolonged ED stay with questionable diagnostic benefit
[51,52]. The CT can be repeated with oral contrast in the rare case of an equivocal IV
contrast-enhanced CT. However, oral contrast may increase diagnostic yield in patients
with little body fat, those with extensive bowel anatomy changing surgery, and those
with suspected inflammatory bowel disease.

One prospective study compared the performance of noncontrast and oral contrast-
enhanced CT in a convenience sample of patients with acute abdominal pain and found
the two modalities had a simple agreement of 79 percent (95% CI 70-87) [53]. Another
prospective study of a convenience sample of 72 ED patients presenting with acute
nontraumatic abdominal pain who were initially evaluated with a noncontrast CT found
no missed consequential diagnoses (defined as causing death or requiring abdominal
surgery) in the seven days following ED evaluation [54].

● Radiology-performed ultrasound – Ultrasound is the study of choice to evaluate the

biliary tract, pregnancy, and reproductive organs but can also be used to identify
appendicitis and obstructive uropathy (such as from nephrolithiasis).

● Magnetic resonance imaging (MRI) – MRI is an accurate alternative to CT for excluding

intra-abdominal pathology (eg, appendicitis) when trying to avoid radiation exposure (eg,
pregnancy). (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum
patients", section on 'Imaging'.)

Magnetic resonance angiography (MRA) is an option in patients with an allergy to

iodinated contrast and a heightened concern for mesenteric ischemia. (See "Overview of
intestinal ischemia in adults", section on 'Advanced abdominal imaging'.)

● Plain abdominal radiographs — We do not routinely obtain plain abdominal radiographs

for abdominal or flank pain as this practice is extremely low yield [55,56]. Plain
radiographs can expedite the evaluation when bowel obstruction, bowel perforation, or a
radiopaque foreign body is suspected but cannot be relied upon to exclude these
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disorders [57]. In an ED patient without these indications and for whom a CT is planned,
plain abdominal radiographs are unhelpful, may delay definitive diagnosis, and can
sometimes be misleading [58,59].

PATIENT WITH SUSPECTED LIFE-THREATENING ABDOMINAL CATASTROPHE

Differential diagnosis of abdominal catastrophe — The following are abdominal processes

that can cause ischemia, sepsis, or hemorrhage and become a life-threatening abdominal
catastrophe (manifestations and risk factors are summarized in the table ( table 10)):

● Abdominal aortic aneurysm (AAA) – Can present with abdominal, back, or flank pain
and/or hematuria while rupture typically produces acute, severe pain and hypotension.
Pain can be migratory and associated with distal neurologic symptoms. (See "Clinical
features and diagnosis of abdominal aortic aneurysm" and "Epidemiology, risk factors,
pathogenesis, and natural history of abdominal aortic aneurysm", section on 'Risk factors
for the development of AAA'.)

● Descending aortic dissection – Abdominal pain can develop if the dissection extends or
causes splenic, kidney, or bowel infarction. (See "Clinical features and diagnosis of acute
aortic dissection".)

● Mesenteric ischemia – This can be differentiated into four entities (see "Overview of
intestinal ischemia in adults"):

• Mesenteric arterial occlusion (embolic or thrombotic) - classically described as having

minimal findings on abdominal examination ("pain out of proportion to the exam") (see
"Acute mesenteric arterial occlusion")
• Nonocclusive mesenteric ischemia (low flow state or vasoconstriction) (see
"Nonocclusive mesenteric ischemia")
• Venous thrombosis (see "Mesenteric venous thrombosis in adults")
• Chronic mesenteric ischemia (intestinal angina) (see "Chronic mesenteric ischemia")

● Hollow viscous perforation and/or peritonitis – The most common cause of stomach
and duodenal perforation is peptic ulcer disease, but perforation can also complicate
appendicitis, diverticulitis, bowel obstruction, ischemic bowel, toxic megacolon, severe
retching (ie, esophageal perforation, Boerhaave syndrome), and other processes. Mortality
increases in older adults (who are often unaware they have peptic ulcer disease until a
complication develops) and with delays in diagnosis. (See "Overview of gastrointestinal
tract perforation" and "Overview of complications of peptic ulcer disease" and
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"Management of acute appendicitis in adults", section on 'Unstable patients or patients

with free perforation' and "Acute colonic diverticulitis: Surgical management", section on
'Perforation with generalized peritonitis' and "Boerhaave syndrome: Effort rupture of the
esophagus".)

● Bowel strangulation and/or intestinal gangrene – When this complicates processes

such as bowel obstruction, volvulus, or incarcerated hernia, mortality rates increase with
increasing delays in surgery. (See "Etiologies, clinical manifestations, and diagnosis of
mechanical small bowel obstruction in adults" and "Large bowel obstruction" and "Gastric
volvulus in adults" and "Cecal volvulus" and "Sigmoid volvulus" and "Overview of
abdominal wall hernias in adults" and "Clinical manifestations, diagnosis, and prognosis of
Crohn disease in adults", section on 'Clinical features'.)

● Intra-abdominal abscess – Diverticulitis is the most common cause, and other common
sites include liver, kidney, genital tract, and psoas muscle. (See "Pyogenic liver abscess"
and "Invasive liver abscess syndrome caused by Klebsiella pneumoniae" and "Renal and
perinephric abscess" and "Tubo-ovarian abscess: Management and complications" and
"Posthysterectomy pelvic abscess" and "Psoas abscess" and "Clinical manifestations and
diagnosis of acute colonic diverticulitis in adults", section on 'Abscess'.)

● Biliary sepsis – Can be from cholangitis or acute cholecystitis. (See "Acute cholangitis:
Clinical manifestations, diagnosis, and management" and "Acute calculous cholecystitis:
Clinical features and diagnosis".)

● Splenic rupture – Some causes include infectious mononucleosis, trauma, and endoscopic
manipulation. (See "Management of splenic injury in the adult trauma patient" and
"Infectious mononucleosis".)

● Necrotizing pancreatitis – This complication of acute pancreatitis increases risk for organ
failure and shock and has a higher mortality. (See "Clinical manifestations, diagnosis, and
natural history of acute pancreatitis" and "Management of acute pancreatitis", section on
'Management of complications'.)

● Urinary sepsis – Common causes include pyelonephritis, obstructing nephrolithiasis,

urinary tract abnormalities, and recent instrumentation. (See "Acute complicated urinary
tract infection (including pyelonephritis) in adults and adolescents", section on
'Complications' and "Kidney stones in adults: Diagnosis and acute management of
suspected nephrolithiasis", section on 'Complications'.)

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● Ectopic pregnancy – Classic triad amenorrhea, pelvic pain, and vaginal bleeding is often
not present. (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Ectopic
pregnancy: Epidemiology, risk factors, and anatomic sites".)

● Other pregnancy complications – These include acute placental abruption, necrotic

retained products of conception leading to sepsis or toxic shock syndrome, complications
of pregnancy termination (including unsafe abortion), and uterine rupture. (See "Acute
placental abruption: Pathophysiology, clinical features, diagnosis, and consequences" and
"Retained products of conception in the first half of pregnancy", section on 'Patients who
are hemodynamically unstable' and "Overview of pregnancy termination", section on
'Complications' and "Unsafe abortion", section on 'Management' and "Uterine rupture:
Unscarred uterus" and "Uterine rupture: After previous cesarean birth".)

● Spontaneous bacterial peritonitis (SBP) – SBP should be excluded with a diagnostic

abdominal paracentesis in a patient with cirrhosis and fever, hypothermia, abdominal
pain, altered mental status, diarrhea, ileus, or hypotension. (See "Spontaneous bacterial
peritonitis in adults: Clinical manifestations" and "Spontaneous bacterial peritonitis in
adults: Diagnosis".)

● Fournier gangrene – This is a necrotizing fasciitis of the perineum that begins abruptly
with severe pain, redness, edema, and induration and spreads rapidly to the anterior
abdominal wall and the gluteal muscles. (See "Necrotizing soft tissue infections".)

● Toxic megacolon – This typically presents with at least one week of severe bloody
diarrhea followed by acute colonic dilatation. (See "Toxic megacolon".)

● Toxic shock syndrome – Commonly includes abdominal pain, nausea, vomiting, and
diarrhea in addition to the characteristic manifestations of fever, rash, hypotension, and
multiorgan dysfunction. This has been associated with retained female hygiene products.
(See "Staphylococcal toxic shock syndrome".)

● Ruptured hemorrhagic ovarian cyst – Most hemorrhagic cysts stop bleeding

spontaneously, and shock is uncommon. (See "Evaluation and management of ruptured
ovarian cyst", section on 'Hemodynamic instability'.)

Resuscitation — Rapidly initiate treatment when there is a concern for an abdominal

catastrophe. This includes emergency department (ED) patients with peritonitis, hypotension or
other signs of shock, or toxic appearance. Algorithms summarizing the approach to abdominal
pain in adult males, nonpregnant females ( algorithm 1), and pregnant females with

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hemodynamic instability or peritonitis ( algorithm 2) are provided. The resuscitation is

performed simultaneously with the initial evaluation and includes the following:

● Address airway, breathing, and circulation ("ABCs") and obtain laboratory studies –
Stabilize airway and breathing as needed. Place the patient on a cardiac monitor and
provide supplemental oxygen. Establish large-bore venous access to obtain laboratory
studies and start intravenous (IV) fluids (ie, crystalloid). Vasopressors may be needed for
suspected sepsis when fluids do not improve hemodynamics. Administer stress-dose
glucocorticoids (eg, dexamethasone, hydrocortisone) if adrenal insufficiency is suspected
(eg, chronic glucocorticoid therapy, history of primary adrenal insufficiency). Perform a
bedside fingerstick glucose in any seriously ill patient or a patient with known diabetes to
assess for hyperglycemia and possible diabetic ketoacidosis. Obtain an electrocardiogram
to screen for cardiac and electrolyte problems. Do not allow oral consumption of food or
drink in anticipation of possible surgical intervention. (See 'Ancillary studies' above and
"The decision to intubate" and "Evaluation and management of suspected sepsis and
septic shock in adults", section on 'Initial therapy' and "Treatment of adrenal insufficiency
in adults", section on 'Adrenal crisis'.)

● Perform point-of-care ultrasound – We rapidly perform a bedside ultrasound to examine

for an AAA, free intraperitoneal fluid (concerning for hemoperitoneum), pericardial
effusion, or hydronephrosis and to measure the inferior vena cava diameter as an
indicator of fluids status. (See 'Role of point-of-care ultrasound' above and "Novel tools for
hemodynamic monitoring in critically ill patients with shock", section on 'Vena cava
assessment'.)

● Transfuse blood products if concern for hemorrhage – Transfuse blood products in a

hemodynamically unstable patient suspected to be hemorrhaging (eg, ruptured AAA,
gastrointestinal hemorrhage, ectopic pregnancy, ovarian cyst). (See "Massive blood
transfusion" and "Use of blood products in the critically ill".)

● Administer empiric antibiotics – Administer empiric broad-spectrum antimicrobial

therapy as soon as possible to a critically ill patient with concern for abdominal sepsis or
peritonitis. In general, empiric regimens for intra-abdominal infections include
antimicrobial activity against enteric streptococci, coliforms, and anaerobes. Tables
summarizing empiric antibiotic regimens for high-risk ( table 11) and health care-
associated intra-abdominal infections ( table 12) are provided. A table and algorithm for
empiric broad-spectrum antimicrobial regimens for urinary sources are also provided
( table 13 and algorithm 3). (See "Antimicrobial approach to intra-abdominal
infections in adults", section on 'Empiric antimicrobial therapy' and "Acute complicated
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urinary tract infection (including pyelonephritis) in adults and adolescents", section on

'Empiric antimicrobial therapy'.)

Specialty consultation — We consult procedural specialists early in the patient's ED course

since surgical intervention and/or percutaneous drainage are often necessary to obtain source
control of intra-abdominal infections (other than spontaneous bacterial peritonitis [SBP]) or to
obtain hemostasis of intra-peritoneal hemorrhage. Do not delay consultation while awaiting
definitive imaging when there is high clinical suspicion for an abdominal catastrophe.
Depending on the preliminary diagnosis, we consult either a general or vascular surgeon,
gynecologist, urologist, gastroenterologist, or interventional radiologist, such as in the
following circumstances:

● Percutaneous abscess drainage is preferred for an intrabdominal abscess, but surgical

intervention may be required to close an anatomic breach or debride infected necrotic
tissue. (See "Antimicrobial approach to intra-abdominal infections in adults", section on
'Source control and drainage'.)

● An obstructing infected kidney stone is a urologic emergency that requires rapid

decompression either by a ureteral stent or a percutaneous nephrostomy tube. (See
"Kidney stones in adults: Surgical management of kidney and ureteral stones", section on
'Emergency surgery'.)

● A ruptured AAA or ectopic pregnancy will often require definitive surgical hemostasis. (See
"Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm",
section on 'Ruptured AAA' and "Tubal ectopic pregnancy: Surgical treatment", section on
'Indications'.)

● Septic shock from cholecystitis is typically treated with percutaneous cholecystostomy or

surgical cholecystectomy. (See "Treatment of acute calculous cholecystitis", section on
'Gallbladder drainage'.)

● Cholangitis often requires biliary drainage with an endoscopic retrograde

cholangiopancreatography (ERCP). (See "Acute cholangitis: Clinical manifestations,
diagnosis, and management", section on 'Biliary drainage'.)

● Ovarian or testicular torsion requires urgent intervention from a gynecologist or urologist,

respectively. (See "Ovarian and fallopian tube torsion", section on 'Management' and
"Acute scrotal pain in adults: Evaluation and management of major causes", section on
'Management'.)

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● Some processes may need gastroenterology consultation for urgent upper endoscopy (eg,
bleeding gastric/peptic ulcer) or colonoscopy (eg, inflammatory bowel disease, sigmoid
volvulus). (See "Overview of upper gastrointestinal endoscopy
(esophagogastroduodenoscopy)", section on 'Indications' and "Overview of colonoscopy in
adults", section on 'Indications'.)

Imaging — In a patient with concern for an abdominal catastrophe, the choice of imaging
(beyond point-of-care ultrasound) depends upon the acuity of the presentation, the patient's
capacity to tolerate a study, stability for transport to radiology, risk of not diagnosing the
etiology versus risk of transport to radiology, and consultant requirements for operative
planning. The timing of imaging may need to be coordinated with the procedural consultant
and/or intensivist, since resuscitation may need to be continued until the patient is stable for
advanced imaging or a definitive procedure.

● In a patient who stabilizes with initial resuscitation, it is reasonable to follow the imaging
approach discussed below. (See 'Patient without abdominal catastrophe' below.)

● In a patient with concern for sepsis of abdominal origin or hollow viscous perforation,
obtain a portable upright chest radiograph (CXR), which is the initial screening study for
pneumoperitoneum ( image 9). Immediate surgical consultation is required if
pneumoperitoneum is identified. An upright CXR detects as little as 1 to 2 mL of free air
after the patient has been upright for 5 to 10 minutes compared with approximately 5 mL
detected by a plain abdominal radiograph [48,60]. An upright lateral CXR is even more
sensitive for pneumoperitoneum ( image 10 and image 11) [61]. (See "Overview of
gastrointestinal tract perforation", section on 'Chest imaging'.)

The location of the perforation determines the likelihood of detecting pneumoperitoneum,

which is present in only two-thirds of gastroduodenal perforation and in only one-third of
perforation of the distal small bowel or large bowel. Sensitivity decreases further in
patients with previous abdominal surgery or a walled-off perforation [60].

A left lateral decubitus radiograph can be obtained in patients too ill for upright films and
may detect pneumoperitoneum under the diaphragm above the liver edge ( image 12).
Detection can be improved by placing a nasogastric tube and injecting 50 mL of air or
water-soluble contrast, but this is rarely performed unless the patient is too unstable to be
moved for computed tomography (CT) scan.

● In a patient without a diagnosis and management plan after point-of-care ultrasound

and/or upright CXR (if performed), we obtain an abdominopelvic CT scan, which is the
imaging modality most likely to provide the diagnosis in a patient with an abdominal
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catastrophe. In a hemodynamically stable patient, the risk of not diagnosing the etiology
will often outweigh the risk of transporting the patient to radiology. IV contrast is
preferred if concerned for an AAA, aortic dissection, or mesenteric ischemia, but
hemorrhage from leaking or ruptured AAA can also be visualized on nonenhanced CT
( image 13). (See 'Overview of common imaging modalities' above.)

In a patient suspected of having a ruptured AAA, CT confirms the rupture and evaluates
feasibility of endovascular repair. However, in a hemodynamically unstable patient with a
known AAA or point-of-care ultrasound-visualized AAA, CT imaging is desirable for the
surgeon but is not absolutely required prior to intervention. Imaging decisions in the
unstable patient should be made in consultation with the surgeon or proceduralist. (See
"Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Imaging
symptomatic patients'.)

● In a patient with biliary, kidney, pregnancy-related, or ovarian pathology, the surgeon or

proceduralist may request a radiology-performed ultrasound for further evaluation. If the
patient is hemodynamically unstable and point-of-care ultrasound images confirm a
diagnosis, we discuss with the surgeon or proceduralist whether the risks of definitive
treatment delay and patient transport to radiology for an additional study are outweighed
by any additional information that study may provide.

PATIENT WITHOUT ABDOMINAL CATASTROPHE

Evaluation in pregnant patients — The approach to acute abdominal or pelvic pain in a

hemodynamically stable pregnant patient without peritonitis is provided in the algorithm
( algorithm 4) and discussed in detail separately. (See "Approach to acute abdominal/pelvic
pain in pregnant and postpartum patients".)

Testing decisions must account for the physiologic changes that occur in pregnancy and the
desire to avoid ionizing radiation exposure. As examples, a pregnant patient can have fewer
clinical findings and may not demonstrate peritoneal signs, possibly because the peritoneum is
desensitized to irritation from the gradual growth and stretching [62,63]. Round ligament pain,
nausea, and vomiting can occur early in pregnancy. White blood cell counts increase to a
normal range of 10,000 to 14,000 cells/mm3. There is a modest increase in baseline heart rate
(10 to 15 beats per minutes). (See "Approach to acute abdominal/pelvic pain in pregnant and
postpartum patients", section on 'Physiologic changes of pregnancy that impact differential
diagnosis'.)

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The enlarged uterus can make localizing pain challenging, although with appendicitis, the area
around the McBurney point is still the most common location of tenderness regardless of
gestational age. (See "Acute appendicitis in pregnancy", section on 'Clinical features'.)

● Abdominal and pelvic ultrasound – We start with an ultrasound to evaluate the

pregnancy (if documented intrauterine pregnancy), to evaluate for ectopic pregnancy (if
undocumented intrauterine pregnancy), and to assess for other causes such as
appendicitis, nephrolithiasis, gallbladder disease, and uterine rupture. (See "Approach to
acute abdominal/pelvic pain in pregnant and postpartum patients", section on 'Imaging'
and "Ultrasonography of pregnancy of unknown location" and "Ectopic pregnancy: Clinical
manifestations and diagnosis", section on 'Transvaginal ultrasound'.)

● Abdominopelvic magnetic resonance imaging (MRI) – If the cause of abdominal pain is

not consistent with an obstetric etiology (eg, appendicitis), or other potentially serious
abdominal pathology cannot be excluded clinically or by ultrasound, we obtain an
abdominopelvic MRI (without gadolinium), which is as accurate as computed tomography
(CT) for the diagnosis of many disorders but does not expose the patient to ionizing
radiation. CT can be performed when clinical findings and ultrasound examination are
equivocal and MRI is not available. (See "Approach to acute abdominal/pelvic pain in
pregnant and postpartum patients", section on 'Imaging'.)

Evaluation in nonpregnant patients — An algorithm summarizing the approach to abdominal

pain in adult males and nonpregnant females ( algorithm 1) is provided.

Cause identified by history and physical — In a patient in whom the history, examination,
and laboratory studies (if performed) identify a clear etiology, further testing can often be
deferred or avoided. Examples of such scenarios include the following:

● A patient with umbilical or inguinal pain and bulge that resolves after reduction of the
hernia. However, an incarcerated hernia that is not easily reduced can cause severe pain
and require immediate surgical consultation. (See "Overview of abdominal wall hernias in
adults" and "Classification, clinical features, and diagnosis of inguinal and femoral hernias
in adults".)

● A patient with a zoster rash in the dermatomal distribution of the pain. (See
"Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Clinical
manifestations'.)

● A patient with crampy diffuse abdominal pain, no abdominal tenderness, and complete
resolution of pain after a bowel movement. However, constipation is a diagnosis of

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exclusion in an emergency department (ED) patient with ongoing pain.

● A patient with non-bloody diarrhea (with or without vomiting and fever) that is more
prominent than the abdominal pain, especially if there was recent travel or similar
symptoms among close contacts. Although common, gastroenteritis and foodborne
diseases are typically diagnoses of exclusion in the ED, but imaging can often be avoided
in a patient with improving symptoms and a low suspicion for alternate etiology. (See
"Acute viral gastroenteritis in adults" and "Approach to the adult with acute diarrhea in
resource-abundant settings" and "Approach to the adult with acute diarrhea in resource-
limited settings" and "Causes of acute infectious diarrhea and other foodborne illnesses in
resource-abundant settings".)

● A young patient (eg, <40 years old) with intermittent, burning epigastric pain that occurs
several hours after meals, associated gastroesophageal reflux, normal laboratory studies,
and a nontender abdominal examination. However, we do not definitively diagnose an ED
patient with gastritis, reflux, or peptic ulcer disease since upper gastrointestinal
endoscopy confirms the diagnosis and is not routinely performed in the ED. Also,
intermittent upper abdominal pain can be a symptom of other diseases, such as biliary
colic and acute coronary syndrome. In these circumstances, especially when imaging is
deferred, it is prudent to diagnose nonspecific abdominal pain, provide clear ED return
precautions, and encourage outpatient follow-up for re-evaluation. (See "Peptic ulcer
disease: Clinical manifestations and diagnosis".)

● A young male patient with right lower quadrant pain/tenderness or a patient with left
lower quadrant pain/tenderness and a prior history of diverticular disease may be
diagnosed clinically with appendicitis or diverticulitis, respectively. These scenarios are
discussed further below. (See 'Other patients (eg, lower abdominal pain)' below.)

● A young patient with a history of kidney stones confirmed on prior imaging, no suspicion
for a serious alternative diagnosis (eg, cholecystitis, appendicitis, abdominal aortic
aneurysm (AAA), typical pain syndrome, hematuria, and no fever or signs of shock. (See
'Flank pain or abnormal testicular exam' below.)

Cause not identified by history and physical

Suspected acute vascular process — A patient with severe, sudden-onset abdominal

pain that is out of proportion to findings on examination, especially with a history of
atherosclerosis or dysrhythmia, should be evaluated for an acute vascular process. (See
'Differential diagnosis of abdominal catastrophe' above.)

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● Preferred imaging: CT angiography (CTA) – We obtain an intravenous (IV) contrast-

enhanced chest/abdomen/pelvis CTA in a patient with heightened concern for mesenteric
ischemia, aortic dissection, or abdominal aortic aneurysm (AAA). A CTA accurately
visualizes the mesenteric vasculature, shows changes consistent with bowel infarction,
and is less invasive compared with standard angiography [64]. A CTA also reliably identifies
other abdominal pathology when ischemia is not the cause of abdominal pain [65]. (See
"Overview of intestinal ischemia in adults", section on 'Advanced abdominal imaging' and
"Chronic mesenteric ischemia", section on 'Vascular imaging' and "Clinical features and
diagnosis of acute aortic dissection", section on 'Cardiovascular imaging'.)

● Alternative imaging options

• Abdominopelvic CT (non-angiography) – Although not as accurate as a CTA, an IV

contrast-enhanced or nonenhanced CT can still be diagnostic. CT has a sensitivity of
nearly 100 percent in diagnosing AAA, and compared with ultrasound, it is not limited
by bowel gas or body habitus. Hemorrhage from leaking or ruptured AAA can be
visualized on nonenhanced CT, making IV contrast unnecessary in emergency
situations or when IV contrast may be contraindicated. (See "Clinical features and
diagnosis of abdominal aortic aneurysm", section on 'Imaging symptomatic patients'.)

An IV contrast-enhanced abdominopelvic CT will screen for ischemia and evaluate for

other potential etiologies in a patient with a less specific clinical presentation [51]. (See
"Overview of intestinal ischemia in adults", section on 'Advanced abdominal imaging'.)

• Magnetic resonance angiography (MRA) – MRA may be necessary in a patient with an

allergy to iodinated contrast and a heightened concern for mesenteric ischemia. MRA is
also more sensitive than CT for diagnosing mesenteric venous thrombosis. (See
"Overview of intestinal ischemia in adults", section on 'Advanced abdominal imaging'
and "Mesenteric venous thrombosis in adults", section on 'Imaging'.)

Plain radiographs in patients with mesenteric ischemia are often unremarkable and
therefore should not be obtained in patients with a suspected acute vascular process. The
presence of radiographic findings suggests late disease and correlates with increased
mortality. Findings include ileus, "thumbprinting" (large bowel wall thickening with
edematous haustra at regular intervals), and intramural air (pneumatosis intestinalis). In
one study, patients with these findings had a mortality of 78 percent compared with 29
percent in patients with normal radiographs [66].

Suspected intestinal obstruction — Signs and symptoms suggesting bowel obstruction

include nausea, vomiting, cramping periumbilical or diffuse abdominal pain, increased
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belching, obstipation, and abdominal distension. (See "Etiologies, clinical manifestations, and
diagnosis of mechanical small bowel obstruction in adults", section on 'Clinical presentations'
and "Large bowel obstruction", section on 'Clinical presentations'.)

Imaging decisions are guided by the acuity of the presentation and history of prior episodes of
obstruction, especially if abdominopelvic CT scans were obtained during prior episodes. We
obtain plain abdominal radiographs (including upright chest radiograph [CXR]) in a patient
suspected of having a bowel obstruction to quickly confirm the diagnosis, expedite
consultation, and exclude findings that indicate the need for immediate intervention (eg,
pneumoperitoneum, volvulus, pneumatosis intestinalis). This is typically followed by
abdominopelvic CT to further characterize the nature, severity, and potential etiologies of the
obstruction. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small bowel
obstruction in adults", section on 'Preferred initial studies for most patients' and "Large bowel
obstruction", section on 'Imaging'.)

● Initial imaging in most patients: Plain abdominal radiographs — These are

approximately 80 percent sensitive and 70 to 80 percent specific for diagnosing a small
bowel obstruction (SBO) but can be "normal, nonspecific, or misleading" in 10 to 20
percent of patients. An SBO is likely if the small bowel is dilated >2.5 cm, there is gaseous
distention, or air-fluid levels are present ( image 14 and image 15) [67]. The
radiographic finding of a curvilinear array of small gas bubbles ("string of beads" sign),
which occurs from air collecting between the valvulae conniventes floating in a fluid-filled
bowel, is pathognomonic for SBO [60]. (See "Etiologies, clinical manifestations, and
diagnosis of mechanical small bowel obstruction in adults", section on 'Plain radiography'.)

It is reasonable to not obtain plain radiographs if CT will be performed regardless,

especially if the patient does not have clinical signs of bowel ischemia or perforation and
has not had prior CT imaging showing obstruction. Obtaining radiographs may prolong
the ED evaluation. Additionally, abdominal radiographs are in the higher range of average
effective radiation dose compared with plain radiographs of other areas (eg, chest) [68].

● Additional imaging in most patients: Abdominopelvic CT – IV-contrast enhanced

abdominopelvic CT is needed in most patients to further characterize the nature, severity,
and potential etiologies of the obstruction ( image 16 and image 17). CT without
contrast enhancement can possibly diagnose SBO. In a patient with suspected partial or
intermittent SBO, the surgeon may request an oral and IV contrast-enhanced CT since the
presence or absence of contrast distal to the site of suspected obstruction helps guide
management. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small
bowel obstruction in adults", section on 'Abdominal CT'.)
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However, in a patient with plain radiographs confirming obstruction, a CT may not be

necessary and should be obtained in discussion with the consulting surgeon. For example,
plain radiographs may be sufficient in a patient with recurrent intermittent obstructions,
especially if they are followed closely by a surgeon and have had multiple prior CT scans in
the setting of prior obstructions that have resolved with conservative measures. (See
"Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in
adults", section on 'Recurrent intermittent obstruction'.)

Right upper quadrant or epigastric pain — Imaging of a patient with right upper
quadrant or epigastric pain depends on the results of liver enzymes and lipase and whether the
patient has had a cholecystectomy. Causes of right upper quadrant pain ( table 14) and
epigastric pain ( table 15) often include diseases of the liver and biliary system, pancreas, and
stomach and are discussed in detail separately. (See "Causes of abdominal pain in adults",
section on 'Upper abdominal pain syndromes'.)

● Patient without previous cholecystectomy or with elevation of liver enzymes or

lipase: Right upper quadrant ultrasound – A right upper quadrant ultrasound is the
first-line study in these patients. An ultrasound can help delineate pathology within the
gallbladder and liver, assess for biliary dilatation, and determine whether gallstones are
the cause of acute pancreatitis. For detection of gallstones, an ultrasound is more sensitive
than CT, which has a sensitivity that ranges from 55 to 80 percent and can miss gallstones
that are isodense with bile. (See "Overview of gallstone disease in adults", section on
'Transabdominal ultrasound' and "Clinical manifestations, diagnosis, and natural history of
acute pancreatitis", section on 'Abdominal ultrasound'.)

● Patient with previous cholecystectomy and normal liver enzymes and lipase or as
second-line study: Abdominal CT – An abdominal CT (IV-contrast enhanced) is the typical
second-line study if the right upper quadrant ultrasound does not identify the cause of
pain and the patient is felt to need further imaging (eg, high-risk features ( table 1),
persistent pain or tenderness, leukocytosis, pain is not consistent with gastritis). A CT can
identify causes and complications of pancreatitis or a contained duodenal perforation. In
general, a CT obtained for right upper quadrant pain is less likely to be abnormal
compared with other indications [15]. (See "Overview of gallstone disease in adults",
section on 'General approach'.)

Flank pain or abnormal testicular exam — A table summarizing the differential

diagnosis of flank pain in an adult patient with a normal genitourinary examination is provided
( table 16). An abnormal scrotal examination suggests genitourinary pathology, which can
present with lower abdominal pain, flank pain, and/or hematuria. The presence of hematuria
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suggests renal, ureteral, or bladder pathology but may be related to non-genitourinary

intrabdominal pathology, such as appendicitis. (See "Acute scrotal pain in adults: Evaluation and
management of major causes" and "Evaluation of hematuria in adults".)

● Abnormal scrotal examination: Scrotal ultrasound – We obtain a scrotal ultrasound in a

male with an abnormal scrotal examination to evaluate for torsion, epididymitis,
hydroceles, or masses. Testicular torsion is more common in younger males but can still
occur in older males, in whom an incarcerated inguinal hernia is more common. In a
patient with high clinical suspicion for torsion, we consult a urologist prior to imaging
confirmation. (See "Acute scrotal pain in adults: Evaluation and management of major
causes".)

● Suspected nephrolithiasis: Kidney ultrasound or abdominopelvic CT – Most patients

with suspected nephrolithiasis should have imaging to identify the stone and/or assess for
hydronephrosis. However, renal colic can be a clinical diagnosis; thus, we may forego
imaging in young patients without suspicion for a serious alternative diagnosis (eg,
cholecystitis, appendicitis, AAA) or patients with recurrent stones who have been
previously managed conservatively (eg, analgesia, hydration). We prefer kidney ultrasound
in patients with kidney stones visualized on imaging during prior episodes, pregnant
patients, and those felt to be at low risk for serious alternative diagnoses. In other
patients, those with high-risk features (eg, obesity [males >129 kg, females >113 kg],
kidney transplant, dialysis dependency, a solitary kidney, and age >76 years [69]), and
patients with a urinalysis suggesting infection, we perform a noncontrast abdominopelvic
CT. If ultrasound or CT is available, we do not perform abdominal radiography (ie, kidneys-
ureters-bladder radiograph) because it has low sensitivity for detecting nephrolithiasis (72
percent for stones >5 mm but only 8 to 29 percent for a stone of any size) [70,71].

• Kidney ultrasound – An ultrasound-first approach (either emergency physician point-

of-care or radiology performed) is safe and effective, and it limits cumulative radiation
exposure in low-risk populations with suspected nephrolithiasis [69]. However,
compared with noncontrast abdominopelvic CT, ultrasound is less accurate at
identifying kidney ( image 18) and ureteral calculi. In patients presenting with acute
flank pain, ultrasound is nearly 100 percent sensitive for obstructive uropathy (ie,
hydronephrosis ( image 8), ureteral dilatation ( image 19), perinephric fluid). A
larger ureteral calculi (>5 mm) is less likely to be present if ultrasound does not
visualize hydronephrosis, but these secondary obstructive signs of nephrolithiasis may
not develop in the first two hours or with a smaller calculi [72]. Thus, a CT is sometimes
performed after a negative ultrasound if a definitive diagnosis is desired, a

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complication (eg, infection) is suspected, the patient has unyielding pain, or if the CT is
needed for treatment planning. (See "Kidney stones in adults: Diagnosis and acute
management of suspected nephrolithiasis", section on 'Ultrasound of the kidneys and
bladder'.)

• Abdominopelvic CT – A noncontrast CT reliably detects nephrolithiasis and

hydronephrosis ( image 20 and image 21) and can aid with spontaneous passage
prognosis by assessing the stone size and location. CT can also exclude ruptured AAA, a
catastrophic renal colic mimic, and thus is especially valuable in patients without prior
abdominal imaging and with AAA risk factors (eg, advancing age, male sex, tobacco
use, other large vessel aneurysms, family history of AAA, atherosclerosis,
hypertension). If we have a high suspicion that the pain is from nephrolithiasis, we
perform a noncontrast CT because contrast-enhanced parenchyma with early excretion
into the pelvicalyceal system can occasionally obscure calculi within the collecting
system. In other patients, performing an IV contrast-enhanced CT is reasonable since it
allows for evaluating other etiologies of flank pain while preserving high sensitivity for
identifying calculi large enough to be at risk of not passing spontaneously [73]. (See
"Kidney stones in adults: Diagnosis and acute management of suspected
nephrolithiasis", section on 'Noncontrast CT'.)

● Other pathology suspected (eg, renal, retroperitoneal): Abdominopelvic CT or CT

urography (CTU) – In a patient who has flank pain not suspected to be from
nephrolithiasis and is clinically judged to need imaging (eg, pain is not consistent with
muscle strain or herpes zoster), we obtain an abdominopelvic CT (with IV contrast). This
study will identify most important etiologies such as AAA, obstructive uropathy,
perinephric abscess, renal infarction, and retroperitoneal hemorrhage.

A CTU is indicated in a patient with unexplained hematuria or increased risk of urinary

malignancy (see "Evaluation of hematuria in adults", section on 'Risk factors for
malignancy'). CTU describes an imaging acquisition protocol of the abdomen and pelvis in
which noncontrast images are obtained initially, followed by IV-contrast enhanced images
and delayed excretory phase imaging that opacifies the collecting system, ureters, and
urinary bladder. CTU protocols vary slightly with each site, and a discussion with the
radiologist is likely to be helpful to determine if the contrast-enhanced images are
necessary. (See "Evaluation of hematuria in adults", section on 'Imaging studies'.)

Lower abdominal pain in female patient — Further evaluation is guided by history and
findings on abdominal and pelvic examination. Examples of clinical factors that favor various
etiologies of pain include the following:
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● Dysuria, urinary urgency or frequency, pyuria, hematuria, vaginal or endocervical

discharge, or cervical motion tenderness favors cervicitis, pelvic inflammatory disease
(PID), or urinary tract infection (UTI) (see 'Suspected UTI, cervicitis, or PID' below)

● Sudden onset of sharp, severe pain with maximal intensity at onset, pelvic location of pain,
vaginal bleeding, or adnexal tenderness favors gynecologic cause other than cervicitis or
pelvic inflammatory disease (see 'Other gynecologic cause suspected' below)

● Migration of pain, nausea, vomiting, or anorexia favors appendicitis over a gynecologic

cause [74-76] (see 'Nongynecologic cause suspected' below)

The differential diagnosis of acute pelvic pain in adult females by age group ( table 17) and by
clinical features ( table 18) are summarized in the tables and discussed in detail separately.
(See "Causes of abdominal pain in adults", section on 'Females'.)

Suspected UTI, cervicitis, or PID — A patient with a history, examination, and

laboratory studies indicative of cervicitis, PID, or UTI may not need imaging and can be treated
with oral antibiotics and close outpatient follow-up. Additional testing (eg, pelvic ultrasound, CT,
or MRI) may be warranted for a patient who is acutely ill (eg, fever, peritonitis, hypotension), has
a presentation atypical for PID or UTI (eg, abnormal site or duration of symptoms), or has not
improved significantly within 72 hours after starting empiric antibiotic therapy. These findings
suggest the possibility of a complication of PID (eg, tubo-ovarian abscess) or an alternate
diagnosis (eg, appendicitis), which can be difficult to differentiate from PID without imaging
[74]. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis" and "Acute simple
cystitis in adult females".)

Other gynecologic cause suspected

● First-line: Pelvic (+/- abdominal) ultrasound – In a nonpregnant female with pelvic or

lower abdominal pain whose presentation suggests a gynecologic cause of pain, we
obtain a pelvic ultrasound to evaluate for ovarian torsion or ruptured ovarian cyst. If there
is clinical suspicion, a concurrent abdominal ultrasound can be obtained to evaluate for
appendicitis, nephrolithiasis, or a tubo-ovarian abscess. (See "Ovarian and fallopian tube
torsion", section on 'Ultrasound' and "Evaluation and management of ruptured ovarian
cyst", section on 'Imaging studies' and "Tubo-ovarian abscess: Epidemiology, clinical
manifestations, and diagnosis", section on 'Imaging studies' and "Kidney stones in adults:
Diagnosis and acute management of suspected nephrolithiasis", section on 'Ultrasound of
the kidneys and bladder' and "Acute appendicitis in adults: Clinical manifestations and
differential diagnosis", section on 'Ultrasound findings'.)

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● Second-line: abdominopelvic CT – An abdominopelvic CT (IV-contrast enhanced) is the

typical second-line study if the ultrasound does not identify the cause of pain and the
patient is felt to need further imaging (eg, high-risk features ( table 1), leukocytosis,
persistent pain [especially if requiring multiple opioid doses], abdominal tenderness or
distension).

Nongynecologic cause suspected — A nonpregnant female with a normal pelvic

examination and abdominal pain concerning for a nongynecologic cause is best evaluated with
an abdominopelvic CT. (See 'Other patients (eg, lower abdominal pain)' below.)

High-risk patients

Older adults — We have a low threshold to obtain imaging in older adults with
abdominal or flank pain because serious abdominal pathology is more likely, misdiagnosis is
common, and associated mortality is increased. The characteristic presentation of diseases
provides the initial basis for assessment and imaging, even in older patients, but clinicians must
remain mindful of atypical presentations of common diseases and extra-abdominal causes of
pain (eg, myocardial infarction).

● Epidemiology – Older patients (ie, ≥65 years) with abdominal pain have a six- to eightfold
increase in mortality compared with younger patients [8,18]. Approximately one-half to
two-thirds require hospitalization, one-fifth to one-third require surgical intervention, and
5 percent die within two months [3,9,18,28,77,78]. A study of the United States National
Hospital Ambulatory Medical Care Survey from 2013 to 2017 found that 3.6 percent of
patients 65 years or older were admitted directly from the ED to the operating room [79].

Misdiagnosis of abdominal pain is common in older adults, especially in those ≥75 years,
and associated with higher mortality compared with younger patients [18,80].

● Atypical presentations – Older patients are more likely to have symptoms of disease that
are not characteristic compared with younger individuals (ie, "atypical" symptoms) and
clinical presentations that underestimate the severity of disease, such as not mounting a
fever or tachycardia in response to infection or inflammation [78,81,82]. Older patients are
more likely to take medications, such as beta-blockers and glucocorticoids, and have
comorbidities such as diabetes that can mask characteristic symptoms and signs.

As examples, older adults with a perforated ulcer can present without the typical sudden
onset of pain [16]. Older adults with appendicitis often present without characteristic
findings (eg, pain migration) and are less likely to have a leukocytosis [16,83-85]. Older

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adults with an intra-abdominal infection are four times more likely than younger patients
to present with hypothermia [9].

Biliary tract disease is among the most common causes of abdominal pain in older adults
but also frequently presents without characteristic abdominal pain or tenderness. Older
adults diagnosed surgically with cholecystitis presented more often with nausea or
vomiting instead of pain; 84 percent had neither epigastric nor right upper quadrant pain
[82]. A Murphy sign may not be present, and liver enzymes are less frequently abnormal in
older adults with cholecystitis [86-88].

● Physical examination differences – Physical examination cannot reliably predict or

exclude significant disease in older adults [28]. In a study of hospitalized older adults with
peritonitis, only 34 percent manifested guarding or rebound tenderness [29]. With
increasing age, the loss of spinal afferent innervation can limit hollow viscous and
peritoneal nociception [89,90].

Malignancy — We have a low threshold to obtain imaging in a patient with an active

malignancy and abdominal or flank pain. Chemotherapy and radiation therapy themselves can
produce abdominal pain, but this should be a diagnosis of exclusion. For example, vincristine
can cause severe, colicky abdominal pain for up to 10 days after administration. However,
serious pathology is also possible, such as neutropenic enterocolitis (typhlitis), which typically
occurs during the neutrophil count nadir in a patient receiving chemotherapy for leukemia. (See
"Clinical presentation and risk factors for chemotherapy-associated diarrhea, constipation, and
intestinal perforation" and "Neutropenic enterocolitis (typhlitis)".)

HIV infection — The diagnostic evaluation of abdominal and flank pain in the adult
with human immunodeficiency virus (HIV) is similar to adults without HIV but is also guided by
immunologic function based on the CD4 cell count and the presence of antiretroviral
medications. We have a low threshold to obtain imaging in a patient with advanced
immunodeficiency (CD4 cell count <100 cells/microL). Of HIV-positive patients presenting with
abdominal pain, 38 percent will require admission [91]. The differential diagnosis includes
common etiologies (eg, appendicitis, diverticulitis, undifferentiated abdominal pain) but there is
also an elevated risk of medication induced pancreatitis, multiple opportunistic infections (eg,
cytomegalovirus [CMV], Mycobacterium avium complex [MAC], cryptosporidium) and neoplasms
(eg, Kaposi sarcoma, lymphoma) [91,92]. Additionally, some protease inhibitors (eg, atazanavir)
can cause radiolucent kidney stones that are not visualized on CT. (See "AIDS-related
cytomegalovirus gastrointestinal disease" and "Mycobacterium avium complex (MAC) infections
in persons with HIV" and "Cryptosporidiosis: Epidemiology, clinical manifestations, and
diagnosis" and "AIDS-related Kaposi sarcoma: Clinical manifestations and diagnosis" and "HIV-
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related lymphomas: Clinical manifestations and diagnosis" and "Crystal-induced acute kidney
injury", section on 'Protease inhibitors'.)

Sickle cell disease — We have a low threshold to obtain imaging if the abdominal or
flank pain is not typical of previous pain episodes. A patient with sickle cell disease can have
intermittent abdominal pain as part of a vaso-occlusive episode but is also at increased risk of
having gallstones, cholecystitis, acute hepatic sequestration, acute splenic sequestration, renal
papillary necrosis, UTI, pyelonephritis, or opioid-induced constipation. (See "Evaluation of acute
pain in sickle cell disease", section on 'Abdominal pain' and "Hepatic manifestations of sickle cell
disease".)

Organ transplant recipient — An organ transplant recipient with abdominal or flank

pain often requires imaging (eg, CT, MRI) because transplanted organs are denervated and lose
normal lymphatic drainage and thus do not have characteristic manifestations of pathology.
Additionally, immunosuppressive agents can mask signs and symptoms of peritonitis or
systemic infection. Common and opportunistic abdominal infections can develop, such as
cytomegalovirus colitis, hepatitis B and C viral infections, gastrointestinal parasites (eg,
Cryptosporidium and Microsporidium), and UTIs, particularly in kidney transplant recipients. Post-
surgical undrained fluid collections or blockage or leaks of anastomoses can cause pain or
become infected. Acute kidney rejection can present with allograft pain and tenderness. Kidney
transplant recipients with pain and tenderness over their kidney allograft, and selected patients
diagnosed with a UTI should have an ultrasound of the allograft. (See "Urinary tract infection in
kidney transplant recipients", section on 'Imaging/urologic evaluation in selected patients' and
"Infection in the solid organ transplant recipient" and "Kidney transplantation in adults:
Evaluation and diagnosis of acute kidney allograft dysfunction".)

Immunosuppressive agents increase risk of various malignancies that can present with
abdominal or flank pain. For example, kidney transplant recipients are at increased risk of renal
cell carcinoma, anogenital cancers, and post-transplant lymphoproliferative disorders that can
cause abdominal pain if extranodal masses arise in the stomach or intestine. (See "Overview of
care of the adult kidney transplant recipient", section on 'Malignancy' and "Epidemiology,
clinical manifestations, and diagnosis of post-transplant lymphoproliferative disorders".)

Bariatric surgery — Many complications of bariatric surgery cause abdominal pain

and can present weeks, months, or years after the surgery. A contrast-enhanced (often both IV
and oral) abdominopelvic CT is typically necessary, but imaging decisions should be made in
consultation with the patient's bariatric surgeon. Imaging with CT is essentially required if the
surgeon cannot be reached or the specifics of the procedure are unavailable (eg, surgery
performed internationally). Some patients will need endoscopy or laparoscopic exploration even
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if the CT is normal. In addition to bowel obstruction, other potential complications include (see
"Metabolic and bariatric operations: Early morbidity and mortality" and "Bariatric operations:
Late complications with acute presentations" and "Bariatric operations: Late complications with
subacute presentations") [93-95]:

● Roux-en-Y gastric bypass – Gastric remnant distension, stomal stenosis, marginal

ulceration
● Gastric banding – Stomal obstruction, port infection, band erosion or movement
● Sleeve gastrectomy – Gastric leaks, gastric outlet syndrome

Other patients (eg, lower abdominal pain) — In a patient with abdominal or flank pain
who does not fit into any of the above categories, the decision to image and choice of study
differs based on the patient's sex, age, and location of pain. In general, we obtain imaging in a
patient with high-risk features ( table 1), leukocytosis or other laboratory abnormalities,
persistent pain (especially if requiring multiple opioid doses), abdominal tenderness or
distension; and at a surgeon’s request. In a patient with no indications for imaging, further
management is based on shared decision-making and may include discharge with clear ED
return precautions or observation for serial abdominal examinations.

The differential diagnoses of lower abdominal pain ( table 19), diffuse abdominal pain
( table 20), and left upper quadrant pain ( table 21) are provided in the tables and discussed
in detail separately. (See "Causes of abdominal pain in adults", section on 'Lower abdominal
pain syndromes' and "Causes of abdominal pain in adults", section on 'Diffuse abdominal pain
syndromes' and "Causes of abdominal pain in adults", section on 'Left upper quadrant pain'.)

In a young male patient with a high clinical suspicion for appendicitis (right lower quadrant
abdominal pain and tenderness, anorexia, nausea/vomiting, leukocytosis, modified Alvarado
score ≥4 ( table 22)), we obtain surgical consultation prior to imaging. The surgeon may
request imaging based on clinical suspicion and the local acceptable nontherapeutic operative
rate. (See "Acute appendicitis in adults: Diagnostic evaluation".)

Mesenteric lymphadenitis (ie, inflammation of the mesenteric lymph nodes) is a common

benign cause of nonspecific abdominal pain but can mimic appendicitis [96]. It is a diagnosis of
exclusion in the ED and can often be identified by the presence of enlarged lymph nodes on
abdominopelvic CT or abdominal ultrasound (the latter may not be sufficient to exclude
appendicitis). Causes include viral infections (the most common), bacterial infections (eg,
gastroenteritis), inflammatory bowel disease, and lymphoma. If caused by a viral infection, the
course is self-limited, resolving within several weeks. (See "Causes of acute abdominal pain in
children and adolescents", section on 'Mesenteric lymphadenitis'.)

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● First-line: Abdominopelvic CT – In a male or nonpregnant female with suspected

nongynecologic etiology with lower abdominal (especially right lower quadrant), left upper
quadrant, or diffuse abdominal pain, an IV contrast-enhanced abdominopelvic CT is the
study with the best accuracy. Even in the absence of IV contrast, CT is still helpful to
diagnose appendicitis and other conditions since inflammatory changes in mesenteric fat
are a secondary finding in many processes (eg, pericecal and periappendiceal fat in case of
appendicitis). However, such inflammatory changes can be obscured in young, slender
patients with little retroperitoneal and mesenteric fat. We do not routinely administer oral
contrast, which is discussed further above. (See 'Overview of common imaging modalities'
above.)

In a patient with left lower quadrant pain, an IV contrast-enhanced abdominopelvic CT is

the most accurate modality to diagnose diverticulitis [97]. While CT is not necessary for all
patients with suspected diverticulitis, it is helpful to confirm the diagnosis in a patient
without a previous history of diverticular disease and to assess for complications (eg,
perforation, abscess formation) in a patient with known disease but severe symptoms.
When symptoms are consistent with prior diverticulitis episodes, we will use shared
decision-making regarding treatment and reassessment versus immediate imaging. (See
"Clinical manifestations and diagnosis of acute colonic diverticulitis in adults", section on
'Diagnostic approach'.)

● Alternative imaging options

• Abdominal ultrasound – An abdominal ultrasound, if used for the appropriate

indication, is an alternative imaging option that avoids exposing the patient to ionizing
radiation or IV contrast. It can evaluate the aorta, liver, spleen, biliary tract, pregnancy,
reproductive organs, bladder, kidneys, and appendix but is not typically helpful in
evaluating bowel pathology.

When used to diagnose appendicitis, test performance is variable and depends on

patient-specific (eg, body habitus, discomfort and alertness, appendix location relative
to overlying bowel) and operator-specific (eg, experience) variables. Ultrasound has a
reported sensitivity of approximately 85 percent and a specificity of 90 percent. Rates of
indeterminate examinations are high, with 50 to 85 percent of normal appendices not
visualized. (See "Acute appendicitis in adults: Diagnostic evaluation", section on
'Ultrasound'.)

• MRI – MRI is an accurate alternative to CT for excluding intra-abdominal pathology (eg,

appendicitis) when trying to avoid radiation exposure or administering CT contrast. Use

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of MRI to diagnose appendicitis is discussed separately. (See "Acute appendicitis in

adults: Diagnostic evaluation", section on 'Magnetic resonance imaging'.)

ANALGESIA

We offer the patient targeted analgesia to facilitate the emergency department (ED) evaluation.
The goal of analgesia is to reduce the pain to manageable levels, improve patient comfort, and
possibly improve the accuracy of the abdominal examination by minimizing voluntary guarding.
The goal is not to eliminate all pain or make the patient somnolent.

Non-opioid therapy is often preferable to minimize opioid use and avoid adverse effects.
Common options include the following:

● Acetaminophen – This is helpful as part of multimodal analgesia for all patients with
acute pain and without contraindications, such as severe hepatic insufficiency or active
liver disease. It can also be administered intravenously (IV) to patients who cannot take
oral medications. (See "Nonopioid pharmacotherapy for acute pain in adults", section on
'Acetaminophen'.)

● Nonsteroidal antiinflammatory drugs (NSAIDs) – Parenteral ketorolac is a first-line

analgesic for renal colic. NSAIDs, including ketorolac, can be helpful for acute abdominal
pain in many other circumstances but should be used cautiously since they can exacerbate
gastritis, peptic ulcer disease, and acute kidney injury. (See "Kidney stones in adults:
Diagnosis and acute management of suspected nephrolithiasis", section on 'Pain control'
and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal anti-
inflammatory drugs'.)

● Antacids – These usually contain a combination of magnesium hydroxide, aluminum

hydroxide, or calcium carbonate and can rapidly relieve pain from gastroesophageal reflux
disease. The "GI cocktail" commonly used in the ED is a mixture of viscous lidocaine, an
antacid (eg, Maalox), and occasionally an anticholinergic agent (eg, Donnatal). However,
pain improvement after an antacid is nondiagnostic since pain from biliary colic and acute
coronary syndrome can resolve spontaneously, but the relief may be attributed to the
effects of the antacid [98]. (See "Antiulcer medications: Mechanism of action,
pharmacology, and side effects", section on 'Antacids'.)

When feasible, non-pharmacologic treatment of abdominal pain should be offered, such as

application of heat to the lower abdomen for relief of dysmenorrhea. (See "Dysmenorrhea in
adult females: Treatment", section on 'Heat'.)
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Opioid analgesia may be required for a patient with severe pain or pain that does not improve
with these measures. Morphine, hydromorphone, or fentanyl (which is preferable when shorter
duration or fewer hemodynamic effects are desired) are reasonable choices when an opioid is
felt to be necessary. We give opioids in intermittent doses titrated to effect with close
monitoring of respiration.

Multiple trials have disproved the notion that analgesia interferes with the assessment of
abdominal pain [99-103]. Opioids can alter the physical examination of patients with acute
abdominal pain, but they do not result in more frequent incorrect management decisions [102].

Alternative, less frequently used options for analgesia include the following:

● First-generation antipsychotic agents – In a patient with recalcitrant pain, especially

associated with vomiting or the cannabis hyperemesis syndrome, droperidol (0.625 or 1.25
mg) or haloperidol (0.05 to 0.1 mg/kg, maximum single dose 2.5 mg) is often helpful. (See
"Cannabinoid hyperemesis syndrome".)

● Ketamine – A small trial of adults with primarily nontraumatic abdominal or flank pain
found that a nondissociative dose of ketamine (0.3 mg/kg) produced comparable
analgesia to morphine (0.1 mg/kg) without serious adverse events [104]. A trial with 200
patients with renal colic found that ketamine 0.2 mg/kg combined with morphine 0.1
mg/kg, compared with morphine alone, reduced pain severity, need for redosing, and
vomiting [105]. Ketamine can alternatively be nebulized, which may be as effective as
intravenous administration for pain management. A trial with 150 patients with acute pain
(102 patients with abdominal or flank pain) found that ketamine 0.75 mg/kg via breath-
actuated nebulizer, compared with ketamine 0.3 mg/kg IV, produced a similar reduction in
pain scores without serious adverse events [106]. (See "Nonopioid pharmacotherapy for
acute pain in adults", section on 'Ketamine'.)

● Morphine with patient-controlled analgesia (PCA) – Although not used routinely,

several trials of ED patients with nontraumatic abdominal pain have found that morphine
PCA produced greater reductions in pain and no differences in adverse events when
compared with standard management using the same medication [107,108].

The Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2)
recommend an opioid-minimizing approach for analgesia in patients with low-risk, recurrent,
undifferentiated abdominal pain [109]. The GRACE-2 definition of recurrent pain is two or more
prior similar episodes within 12 months, with the time elapsed from the first episode to the
current episode being greater than 30 days. Patients with the following characteristics were
excluded from the low-risk category:
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• Unstable vital signs

• History and physical examination findings suggesting acute abdominal pathology
• Age <18 years or ≥65 years
• Pregnancy
• Acute trauma within seven days
• Organ transplantation
• Immunosuppression
• Abdominal surgery within 30 days
• Active cancer
• Inflammatory bowel disease
• Previous bowel obstruction
• Severe active psychiatric illness

DISPOSITION

In a patient whose cause of pain is identified, the disposition is relatively straightforward and
based on management of the specific etiology. However, in a patient with an unrevealing
evaluation, the disposition depends upon age, comorbidities, extent of pain, need for pain
management, whether imaging was performed, certainty of imaging results, likelihood of
serious disease, availability of expedited follow-up care, and reliability and social supports. This
generally involves shared decision-making with the patient.

Less common causes of abdominal pain ( table 23), many of which are not typically
diagnosed during an emergency department (ED) visit, are discussed separately. (See
"Causes of abdominal pain in adults", section on 'Less common causes'.)

● Patient with normal cross-sectional imaging (computed tomography [CT] or

magnetic resonance imaging [MRI]) and laboratory results – We will reassure and
discharge most patients with nonspecific abdominal or flank pain, even older adults, who
have normal cross-sectional imaging and laboratory results. A normal abdominopelvic CT
increases physician comfort with not identifying a specific cause for the abdominal pain
and with discharging a patient who might otherwise be admitted for observation [110].
Discharged patients must be provided with clear, written instructions of potential danger
signs and where and when to return for emergency care or re-evaluation. One common
approach is to instruct the patient to follow up for re-evaluation with their primary care
clinician in 12 to 48 hours or to return to the ED if they cannot not be seen by their
outpatient clinician in that timeframe.

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After an appropriate ED evaluation, most patients with a diagnosis of nonspecific

abdominal pain have a benign condition that resolves without further intervention
[7,111,112]. For example, in a study of 1411 patients discharged from the ED with
nonspecific abdominal pain, 112 patients (8 percent) returned to the ED with abdominal
pain [113]. Of these, 85 patients were again diagnosed with nonspecific pain while 17 (1
percent) had an operation, eight were diagnosed with cholelithiasis, five with appendicitis,
and two with gastrointestinal cancer.

● Patient with continued concern for serious pathology despite normal imaging – If
there remains doubt about the nature or seriousness of the underlying cause, especially in
older adults or those with comorbidities, we will admit to the hospital or observe the
patient for a prolonged period (eg, at least 6 to 12 hours) in the ED. In a patient with
abdominal pain of unclear etiology, observation and reassessment can often determine
the cause or exclude serious pathology. For example, several studies found that a period
of observation increased the diagnostic accuracy for appendicitis [23,114].

● Patient with uncontrolled pain – It can be challenging to determine the disposition of a

patient who is requiring multiple intravenous (IV) opioid doses for pain management
without a specific diagnosis identified after a thorough ED evaluation. Guidelines suggest
an opioid-minimizing approach for analgesia in patients with low-risk, recurrent,
undifferentiated abdominal pain [109]. We suggest having a discussion with the patient
regarding the risks of continued opioid therapy versus their limited benefit prior to
making the decision to admit for pain control or discharging with a prescription for oral
opioids. (See 'Analgesia' above and "Evaluation of the adult with abdominal pain", section
on 'Diagnostic approach to chronic abdominal pain' and "Use of opioids in the
management of chronic pain in adults", section on 'Indications for opioid therapy'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Nontraumatic
abdominal pain in adults".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.”
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading

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level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on “patient info” and the keyword(s) of interest.)

● Basics topic (see "Patient education: Abdominal pain (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Initial evaluation – The evaluation of an adult emergency department (ED) patient with
abdominal or flank pain starts with obtaining a history, performing a physical
examination, and rapidly assessing if the patient may have an abdominal catastrophe
(clues include hypotension or other signs of shock, peritonitis, toxic appearance). High-risk
features of abdominal pain must be appreciated ( table 1). (See 'Overview of the
evaluation' above.)

● History – The quality, timing, and location of pain help determine the acuity and focus the
differential diagnosis ( table 2 and figure 1 and table 3 and table 16). Pain that
is severe and maximum intensity at onset is concerning for a vascular emergency (eg,
aortic rupture or dissection, mesenteric ischemia, pulmonary embolism), obstruction of a
small tubular structure (eg, ureter), or reproductive organ pathology (eg, ovarian torsion,
ruptured ovarian cyst). The presence of associated symptoms ( table 6), pre-existing
medical and surgical conditions, medications, and social history ( table 7) increases a
patient's risk for various diseases. (See 'History' above.)

● Physical examination – Abdominal palpation localizes the tenderness and detects signs
of peritoneal irritation, such as involuntary guarding and muscular rigidity. A rigid
abdomen is cause for concern, but traditional techniques for assessing rebound
tenderness have limited sensitivity and specificity for identifying peritonitis. (See 'Physical
examination' above.)

● Role of point-of-care ultrasound – Emergency physician-performed point-of-care

ultrasound has become an important tool for the evaluation of patients with abdominal
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pain. Ultrasound is especially helpful in the unstable patient or when there is concern for
abdominal catastrophe. It can identify hemoperitoneum, abdominal aortic aneurysm
(AAA), intrauterine pregnancy, gallstones, a distended urinary bladder, pericardial effusion,
and hydronephrosis and measure inferior vena cava diameter as an indicator of fluids
status. (See 'Role of point-of-care ultrasound' above.)

● Ancillary studies – Unless the history and physical examination establish the cause of
pain, most patients will need laboratory studies, which are discussed in the text. (See
'Ancillary studies' above.)

● Patient with suspected abdominal catastrophe – Abdominal processes that can cause
ischemia, sepsis, or hemorrhage and become a life-threatening abdominal catastrophe
are presented in the table ( table 10). An approach in a pregnant patient with
hemodynamic instability or peritonitis is presented in the algorithm ( algorithm 2). (See
'Differential diagnosis of abdominal catastrophe' above.)

Start treatment simultaneously with the initial evaluation when there is a concern for an
abdominal catastrophe. Establish venous access, start intravenous (IV) fluids (ie,
crystalloid), obtain laboratory studies, and perform point-of-care ultrasound. Patients may
need vasopressors, stress-dose glucocorticoids, blood product transfusion, and/or empiric
broad-spectrum antibiotics. (See 'Resuscitation' above.)

We consult procedural specialists early in the patient's ED course since surgical

intervention and/or percutaneous drainage are usually necessary to obtain source control
of intra-abdominal infections or to obtain hemostasis of intraperitoneal hemorrhage. (See
'Specialty consultation' above.)

Obtain a portable upright chest radiograph (CXR) since the presence of

pneumoperitoneum confirms the diagnosis of hollow viscous perforation. Abdominopelvic
computed tomography (CT) is the preferred study in a patient with a suspected abdominal
catastrophe and undifferentiated abdominal. (See 'Imaging' above.)

● Patient without abdominal catastrophe – Further evaluation depends on the patient's

pregnancy status. The approach to acute abdominal or pelvic pain in a hemodynamically
stable pregnant patient without peritonitis is provided in the algorithm ( algorithm 4)
and discussed in detail separately. (See "Approach to acute abdominal/pelvic pain in
pregnant and postpartum patients", section on 'Acute abdominal pain related to
pregnancy or the reproductive tract'.)

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The evaluation of the adult male and nonpregnant female is provided in the algorithm
( algorithm 1) and discussed further in the text. (See 'Cause not identified by history and
physical' above.)

Further testing can sometimes be deferred or avoided when the history, examination, and
laboratory studies (if performed) identify a clear etiology. Example scenarios are provided
in the text. (See 'Cause identified by history and physical' above.)

● High-risk conditions – Risk factors for serious causes of abdominal and flank pain include
older age, immunocompromise, human immunodeficiency virus (HIV) infection, active
malignancy, taking chronic glucocorticoids or immunosuppressants, alcohol misuse,
recipient of an organ transplant, sickle cell disease, prior abdominal (especially bariatric)
surgeries, cardiovascular disease, and recent instrumentation. (See 'High-risk patients'
above.)

● Analgesia – We offer the patient targeted analgesia to facilitate the ED evaluation.

Analgesics, including opioids, do not interfere with the assessment of abdominal pain and
do not result in more frequent incorrect management decisions. The goal of analgesia is
to reduce pain to manageable levels, improve patient comfort, and possibly improve the
accuracy of the examination by minimizing voluntary guarding. The goal is not to
eliminate all pain. We minimize opioid administration in patients with low-risk, recurrent,
undifferentiated abdominal pain. (See 'Analgesia' above.)

● Disposition – In a patient who does not have a specific etiology identified, the disposition
depends upon age, comorbidities, extent of pain, need for pain management, whether
imaging was performed, certainty of imaging results, likelihood of serious disease,
availability of expedited follow-up care, and reliability and social supports. We will reassure
and discharge most patients with nonspecific abdominal pain, even older adults, who have
a normal CT and laboratory results. If there remains doubt about the nature or
seriousness of the underlying cause, especially in older adults or those with high-risk
conditions, we will admit to the hospital or observe the patient in the ED. (See 'Disposition'
above.)

Use of UpToDate is subject to the Terms of Use.

Topic 290 Version 57.0

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GRAPHICS

Features of high risk abdominal pain

History
Age over 65

Immunocompromise (eg, HIV, chronic glucocorticoid treatment)

Alcohol use disorder (risk of hepatitis, cirrhosis, pancreatitis)

Cardiovascular disease (eg, CAD, PVD, hypertension, atrial fibrillation)

Major comorbidities (eg, cancer, diverticulosis, gallstones, IBD, pancreatitis, kidney failure)

Prior surgery or recent GI instrumentation (risk of obstruction, perforation)

Early pregnancy (risk of ectopic pregnancy)

Pain characteristics
Sudden onset

Maximal at onset

Pain then subsequent vomiting

Constant pain of less than two days duration

Exam findings
Tense or rigid abdomen

Involuntary guarding

Signs of shock

CAD: coronary artery disease; HIV: human immunodeficiency virus; IBD: inflammatory bowel disease;
PVD: peripheral vascular disease.

Graphic 68577 Version 3.0

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Quality of abdominal pain and selected examples

Quality of pain Selected examples of diseases

Dull, poorly Appendicitis Subtle, gradually worsening, vague periumbilical pain

localized, crampy, Subsequent migration to sharp, right lower quadrant pain
and midline (becomes parietal pain)
(visceral pain)
Nausea and vomiting follows onset of pain

Small bowel Periumbilical, crampy, paroxysmal pain

obstruction Associated with nausea, vomiting, obstipation, abdominal
distension

Distinct, sharp, Ovarian cyst Sudden onset of unilateral lower abdominal pain
and localized rupture Pain often begins during strenuous physical activity (eg,
(parietal pain) exercise or sexual intercourse)
May be accompanied by light vaginal bleeding

Diverticulitis Left lower quadrant (if sigmoid colon is involved) constant

pain that develops over several days
May have localized peritoneal signs (eg, localized guarding
and rebound tenderness)
Often accompanied by nausea, vomiting, and a change in
bowel habits

Pain that waxes Nephrolithiasis Severe, sudden-onset abdominal or flank pain

and wanes in Paroxysms of severe pain usually last 20 to 60 minutes
intensity (colicky
Radiates to the flank or groin
pain)
Associated with hematuria in most patients

Burning pain Gastroesophageal Burning sensation, commonly retrosternal and occurring in

reflux disease the postprandial period
May be associated with regurgitation (perception of flow of
refluxed gastric content into the mouth or hypopharynx)

Tearing pain Aortic dissection Acute-onset pain commonly in chest or back

Pain can extend into abdomen if abdominal aorta involved or
mesenteric vasculature is compromised

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Causes of abdominal pain by location

Right upper quadrant Left upper quadrant

Hepatitis Splenic abscess

Cholecystitis Splenic infarct

Cholangitis Gastritis

Biliary colic Gastric ulcer

Pancreatitis Pancreatitis

Budd-Chiari syndrome Left lower quadrant

Pneumonia/empyema pleurisy Diverticulitis
Subdiaphragmatic abscess Salpingitis
Right lower quadrant Ectopic pregnancy

Appendicitis Inguinal hernia

Salpingitis Nephrolithiasis

Ectopic pregnancy Irritable bowel syndrome

Inguinal hernia Inflammatory bowel disease

Nephrolithiasis Diffuse
Inflammatory bowel disease Gastroenteritis
Mesenteric adenitis (yersina) Mesenteric ischemia

Epigastric Metabolic (eg, DKA, porphyria)

Peptic ulcer disease Malaria

Gastroesophageal reflux disease Familial Mediterranean fever

Gastritis Bowel obstruction

Pancreatitis Peritonitis

Myocardial infarction Irritable bowel syndrome

Pericarditis

Ruptured aortic aneurysm

Periumbilical

Early appendicitis

Gastroenteritis

Bowel obstruction

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Ruptured aortic aneurysm

DKA: diabetic ketoacidosis.

Graphic 70233 Version 4.0

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Causes of acute pelvic pain in adult females by organ system

Reproductive tract Urinary tract

Gynecologic: Infectious Cystitis

Pelvic inflammatory disease
Pyelonephritis
Endometritis
Painful bladder syndrome
Salpingitis
Tubo-ovarian abscess Kidney stones

Urinary retention
Gynecologic: Noninfectious
Dysmenorrhea Malignancy (bladder cancer)
Ovarian cyst (ruptured or intact)
Vascular
Endometriosis
Uterine leiomyoma (fibroid): Degenerating Abdominal aortic aneurysm and dissection
or not Sickle cell disease crisis
Adenomyosis
Septic pelvic thrombophlebitis
Mittelschmerz (midcycle ovulatory pain)
Adnexal torsion (ovary and/or fallopian Ovarian vein thrombosis
tube) Pelvic congestion syndrome
Ovarian hyperstimulation syndrome
Musculoskeletal
Endosalpingiosis
Uterine perforation (in women who have Muscular strain or sprain
undergone a uterine procedure) Abdominal wall hematoma or infection
Asherman's syndrome
Hernia (inguinal or femoral)
Neoplasm
Pelvic fracture
Pregnancy-related
Myofascial pain
First trimester
Neurologic
Threatened abortion
Ectopic pregnancy, including heterotopic Herpes zoster
pregnancy
Anterior cutaneous nerve entrapment
Corpus luteum hematoma syndrome
Incomplete abortion
Abdominal epilepsy [5]
Septic abortion
Uterine impaction Abdominal migraine [6]

Second and third trimesters Psychiatric

Preterm labor Depression
Chorioamnionitis
Somatization disorder
Placental abruption
Narcotic seeking
Degenerating uterine leiomyoma (fibroid)

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Medical complications during pregnancy,

Sexual and interpersonal
such as appendicitis
Round ligament stretch Domestic violence

Postpartum Sexual abuse

Endometritis Other
Wound infection (cesarean section,
Familial Mediterranean Fever
laceration, or episiotomy repair)
Ovarian vein thrombosis or septic pelvic Porphyria [7]
thrombophlebitis Lead poisoning

Gastrointestinal TNF receptor-associated periodic syndrome (ie,

TRAPS)
Appendicitis

Irritable bowel syndrome

Diverticulitis

Inflammatory bowel disease

Fecal impaction or constipation

Gastroenteritis

Mesenteric lymphadenitis

Abdominopelvic adhesions

Perforated viscus

Bowel obstruction

Incarcerated or strangulated hernia

Ischemic bowel

Hirschsprung disease [1]

Intussusception [2]

Meckel's diverticulum [3]

Volvulus [4]

This table presents common etiologies but is not meant to be exhaustive.

TNF: tumor necrosis factor; TRAPS: tumor necrosis factor receptor-associated periodic syndrome.

References:
1. Qiu JF, Shi YJ, Hu L, et al. Adult Hirschsprung's disease: report of four cases. Int J Clin Exp Pathol 2013; 6:1624.
2. Lu T. Adult Intussusception. Perm J 2015; 19:79.
3. Dumper J, Mackenzie S, Mitchell P, et al. Complications of Meckel's diverticula in adults. Can J Surg 2006; 49:353.
4. Li X, Zhang J, Li B, et al. Diagnosis, treatment and prognosis of small bowel volvulus in adults: A monocentric summary of a
rare small intestinal obstruction. PLoS One 2017; 12:e0175866.

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5. Harshe DG, Harshe SN, Harshe GR, Harshe GG. Abdominal Epilepsy in an Adult: A Diagnosis Often Missed. J Clin Diagn Res
2016; 10:VD01.
6. Kunishi Y, Iwata Y, Ota M, et al. Abdominal Migraine in a Middle-aged Woman. Intern Med 2016; 55:2793.
7. Klobucic M, Sklebar D, Ivanac R, et al. Differential diagnosis of acute abdominal pain - acute intermittent porphyria. Med
Glas (Zenica) 2011; 8:298.

Adapted from: Lipsky AM, Hart D. Acute pelvic pain. In: Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th ed, Walls
RM, Hockberger RS, Gausche M, et al (Eds), Elsevier, Philadelphia 2018.

Graphic 120867 Version 2.0

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Patterns of referred abdominal pain

Pain from abdominal viscera often (but not always) localizes according to the structure's embryologic
origin, with foregut structures (mouth to proximal one-half of duodenum) presenting with upper
abdominal pain, midgut structures (distal one-half of duodenum to middle of the transverse colon)
presenting with periumbilical pain, and hind gut structures (remainder of colon and rectum, pelvic
genitourinary organs) presenting with lower abdominal pain. Radiation of pain may provide insight into
the diagnosis. As examples, pain from pancreatitis may radiate to the back, while pain from gallbladder
disease may radiate to the right shoulder or subscapular region.

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Selected extra-abdominal causes of acute abdominal pain

Cardiac Hematologic

Myocardial ischemia and infarction Sickle cell anemia

Myocarditis Hemolytic anemia
Endocarditis Henoch-Schönlein purpura
Heart failure Acute leukemia

Thoracic Toxins

Pneumonitis Hypersensitivity reactions: insect bites, reptile

Pleurodynia venoms
Pulmonary embolism and infarction Heavy metals and corrosives (eg, lead or iron)
Pneumothorax
Empyema
Esophagitis
Esophageal spasm
Esophageal rupture (Boerhaave's syndrome)

Neurologic Infections

Radiculitis: spinal cord or peripheral nerve Herpes zoster

tumors, degenerative arthritis of spine Osteomyelitis
Abdominal epilepsy Typhoid fever
Tabes dorsalis (tertiary syphilis)

Metabolic Miscellaneous

Uremia Muscular contusion, hematoma, or tumor

Diabetic ketoacidosis Opioid withdrawal
Porphyria Familial Mediterranean fever
Acute adrenal insufficiency Psychiatric disorders
Hyperlipidemia Heat stroke
Hyperparathyroidism
Hypercalcemia

Original table modified for this publication. Reproduced with permission from: Glasgow RE, Mulvihill SJ. Abdominal pain, including
the acute abdomen. In: Gastrointestinal and Liver Disease, Feldman M, Scharschmidt BF, Sleisenger MH (Eds), W.B. Saunders,
Philadelphia 1998. p.80. Copyright © 1998 W.B. Saunders.

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Symptoms associated with abdominal pain

Symptoms General notes Selected examples of diseases

Fever and chills Although generally Infectious mononucleosis – Most patients will
nonspecific, a fever have fever, while many will have splenic
suggests an infectious enlargement or mesenteric adenitis that can
or inflammatory manifest as abdominal pain.
process. It can occur Rocky Mountain spotted fever – In the early
with an intra-abdominal phase, most patients have nonspecific signs and
process or with a symptoms such as fever and can have
systemic infection or abdominal pain and nausea. The onset of
inflammatory process abdominal pain prior to the rash can lead to a
that can also cause misdiagnosis such as appendicitis, cholecystitis,
abdominal pain. and even bowel obstruction.

Nausea and vomiting Although these are Appendicitis

nonspecific symptoms, Diverticulitis
the order of appearance
Bowel obstruction
and quality of emesis
Gastroenteritis
may provide a clue to
the diagnosis. Gastritis

Vomiting that Peptic ulcer disease

starts after the
onset of pain is
more likely to have
a surgical process.
Bilious emesis
suggests
obstruction distal
to the duodenum.
Relatively benign
etiologies tend to
cause self-limited
vomiting.
Coffee-ground
emesis suggests
hematemesis.

Fatigue, weight loss, These constitutional Ovarian cancer – This can present with
anorexia symptoms are abdominal distension, dyspepsia, flatulence,
concerning for anorexia, pelvic pressure, back pain, rectal
malignancy or systemic fullness, or urinary symptoms.
illnesses. Colorectal cancer – This can present with
abdominal pain associated with changes in

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bowel habits, weight loss, and rectal bleeding.

Systemic lupus erythematosus – Up to 40% of
patients will have gastrointestinal
manifestations during their lifetime, which can
include dysphagia, diarrhea, peptic ulcer
disease, intestinal pseudo-obstruction, hepatitis
pancreatitis, mesenteric vasculitis with intestina
infarction, peritonitis, and ascites.
Hypercalcemia – This can present with vague
abdominal pain associated with anorexia,
nausea, vomiting, and constipation.

Diarrhea This is often associated Gastroenteritis

with an infectious cause Diverticulitis
but can also occur with
Mesenteric ischemia (may be bloody)
others.
Bowel obstruction
Inflammatory bowel disease (ie, Chron,
ulcerative colitis)

Obstipation or Obstipation (ie, inability Bowel obstruction.

constipation to pass flatus or stool), Constipation – This is a common cause of
especially associated abdominal pain but should be a diagnosis of
with increased belching exclusion in an emergency department patient.
and abdominal
Irritable bowel syndrome – This often presents
distension, is suggestive
with swings between diarrhea and constipation.
of a bowel obstruction.
This should be a diagnosis of exclusion that is
made in the outpatient setting (instead of the
emergency department) since this requires
persistent symptoms for 3 months to 1 year.

Dysuria, urinary These suggest a Urinary tract infection – This often presents with
urgency, urinary genitourinary cause of suprapubic discomfort associated with urinary
frequency, hematuria pain. symptoms.
Pyelonephritis – Fever (>38°C), flank pain,
costovertebral angle tenderness, and nausea or
vomiting suggest upper tract infection and
warrant more aggressive diagnostic and
therapeutic measures.
Nephrolithiasis – This causes flank pain and
hematuria but can also cause lower abdominal
pain if the stone is in the ureterovesical junction
Prostatitis.
Epididymitis.

Vaginal discharge, These suggest a Ectopic pregnancy – This characteristically

vaginal bleeding, gynecologic etiology of presents with pelvic pain, vaginal bleeding, and
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abnormal uterine abdominal pain. amenorrhea.

bleeding Pelvic inflammatory disease – This commonly
presents with bilateral lower abdominal pain
that often starts during or shortly after menses.
Pain that worsens during coitus or with jarring
movement may be the only symptom. Can also
cause abnormal uterine bleeding, new vaginal
discharge, urethritis, and fever. This is rarely
complicated by tubo-ovarian abscess or
perihepatitis (Fitz-Hugh-Curtis syndrome).
Endometriosis – This present with pelvic pain
that is often chronic and worse during menses
or ovulation, dysmenorrhea, and deep
dyspareunia.

Scrotal pain Scrotal pathology can Testicular torsion – This characteristically

cause lower abdominal presents with severe, sudden-onset pain
pain that does not following vigorous activity or testicular trauma.
always localize to the Inguinal hernia.
scrotum.

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Past medical/social history and medications that increase the risk of diseases
that cause abdominal or flank pain

Past history or medications Selected diseases with increased risk

Past medical history

Atherosclerosis Mesenteric ischemia

Peripheral vascular disease Abdominal aortic aneurysm

Atrial fibrillation Mesenteric ischemia

Heart failure

Diabetes mellitus Gastroparesis

Intra-abdominal infections
Constipation
Diabetic ketoacidosis

HIV Opportunistic infections (eg, cytomegalovirus,

Mycobacterium avium complex, cryptosporidium
Neoplasms (eg, Kaposi sarcoma, lymphoma)

Sickle cell disease Vaso-occlusive pain episode

Gallstones, cholecystitis
Acute hepatic or splenic sequestration
Renal papillary necrosis
Urinary tract infection, pyelonephritis

Primary (Addison disease) or secondary Adrenal crisis

adrenal insufficiency

Medications

Nonsteroidal antiinflammatory drugs Peptic ulcer disease

Antibiotics Clostridioides difficile colitis

Glucocorticoids (chronic therapy) Masking symptoms of serious pathology (eg, no

mounting fever or peritoneal signs)
Adrenal insufficiency
Gastritis, peptic ulcer disease
Hollow viscus perforation

Opioids Constipation
Withdrawal (causes abdominal cramping,
nausea)

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Anticoagulant or antiplatelet Rectus sheath hematoma

Retroperitoneal hematoma

HIV antiretroviral therapy Nephrolithiasis

Pancreatitis

Leukemia chemotherapy Neutropenic enterocolitis (typhlitis)

Social history

Alcohol use disorder Alcoholic ketoacidosis

Gastritis
Pancreatitis
Hepatitis
Cirrhosis (complicated by spontaneous bacterial
peritonitis)

Tobacco use Peptic ulcer disease

Abdominal aortic aneurysm
Bladder cancer (as well as other malignancies)

Cannabis Cannabis hyperemesis syndrome

New or multiple sexual partners Sexually transmitted infections

HIV: human immunodeficiency virus.

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Drugs associated with constipation

Analgesics

Anticholinergics
Antihistamines

Antispasmodics

Antidepressants

Antipsychotics

Cation-containing agents

Iron supplements

Aluminum (antacids, sucralfate)

Barium

Neurally active agents

Opiates

Antihypertensives

Ganglionic blockers

Vinca alkaloids

Calcium channel blockers

5HT3 antagonists

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Classification of shock

Septic Gram-positive (Pneumococcus, Staphylococcus, Streptococcus,

Enterococcus, Listeria)
Gram-negative (Klebsiella, Pseudomonas, Escherichia,
Haemophilus, Legionella, Neisseria, Moraxella, Rickettsia,
Francisella [tularemia])
Fungal (Candida, Aspergillus)
Viral (influenza, cytomegalovirus, Ebola, varicella)
Parasitic (Plasmodium, Ascaris, Babesia)
Mycobacterium (Mycobacterium tuberculosis, Mycobacterium
abscessus)

Nonseptic Inflammatory shock (systemic inflammatory response

Distributive syndrome): Burns, trauma, pancreatitis, postmyocardial
infarction, post-coronary bypass, post-cardiac arrest, viscus
perforation, amniotic fluid embolism, fat embolism, idiopathic
systemic capillary leak syndrome
Neurogenic shock: Traumatic brain injury, spinal cord injury
(quadriparesis with bradycardia or paraplegia with
tachycardia), neuraxial anesthesia
Anaphylactic shock: IgE-mediated (eg, foods, medications,
insect bites or stings), IgE-independent (eg, iron dextran),
nonimmumnologic (eg, exercise- or heat-induced), idiopathic
Other: Liver failure, transfusion reactions, vasoplegia (eg,
vasodilatory agents, cardiopulmonary bypass), toxic shock
syndrome, toxicologic (eg, heavy metals), beriberi

Cardiogenic Cardiomyopathic Myocardial infarction (involving >40% of the left ventricle or

with extensive ischemia)
Severe right ventricle infarction
Acute exacerbation of severe heart failure from dilated
cardiomyopathy
Stunned myocardium from prolonged ischemia (eg, cardiac
arrest, hypotension, cardiopulmonary bypass)
Stress-induced cardiomyopathy (eg, Takesubo
cardiomyopathy, sepsis)
Advanced septic shock
Myocarditis
Myocardial contusion
Drug-induced (eg, beta blockers)

Arrhythmogenic Tachyarrhythmia: Atrial tachycardias (fibrillation, flutter,

reentrant tachycardia), ventricular tachycardia and fibrillation
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Bradyarrhythmia: Complete heart block, Mobitz type II second

degree heart block

Mechanical Severe valvular insufficiency, acute valvular rupture (papillary

or chordae tendineae rupture, valvular abscess), critical
valvular stenosis, acute or severe ventricular septal wall defect
ruptured ventricular wall aneurysm, atrial myxoma

Hemorrhagic Trauma, gastrointestinal bleeding (eg, varices, peptic ulcer),

intraoperative and postoperative bleeding, retroperitoneal
bleeding (eg, ruptured aortic aneurysm), aortic-enteric fistula,
hemorrhagic pancreatitis, iatrogenic (eg, inadvertent biopsy o
arteriovenous malformation or left ventricle), tumor or
abscess erosion into major vessels, ruptured ectopic
pregnancy, postpartum hemorrhage, uterine or vaginal
hemorrhage (eg, infection, tumors, lacerations), spontaneous
Hypovolemic peritoneal hemorrhage from bleeding diathesis

Nonhemorrhagic Gastrointestinal losses (eg, diarrhea, vomiting, external

drainage), skin losses (eg, heat stroke, burns, dermatologic
conditions), renal losses (eg, excessive drug-induced or
osmotic diuresis, salt-wasting nephropathies,
hypoaldosteronism), third space losses into the extravascular
space or body cavities (eg, postoperative and trauma,
intestinal obstruction, crush injury, pancreatitis, cirrhosis)

Pulmonary Hemodynamically significant pulmonary embolus, severe

vascular pulmonary hypertension, severe or acute obstruction of the
pulmonic or tricuspid valve, venous air embolus

Mechanical Tension pneumothorax or hemothorax (eg, trauma,

Obstructive iatrogenic), pericardial tamponade, constrictive pericarditis,
restrictive cardiomyopathy, severe dynamic hyperinflation (eg
elevated intrinsic PEEP), left or right ventricular outflow tract
obstruction, abdominal compartment syndrome, aorto-caval
compression (eg, positioning, surgical retraction)

Endocrine (eg, adrenal insufficiency, thyrotoxicosis, myxedema

coma)
Metabolic (eg, acidosis, hypothermia)
Mixed/unknown
Other: Polytrauma with more than one shock category, acute
shock etiology with pre-existing cardiac disease, late
underresuscitated shock, miscellaneous poisonings

Aortic dissection causes shock when retrograde dissection results in cardiac tamponade, acute aortic
insufficiency, and myocardial infarction; please refer to the UpToDate topic text for details.

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IgE: immunoglobulin E; PEEP: positive end-expiratory pressure.

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Grey Turner sign

Grey Turner sign refers to flank ecchymoses that result from blood tracking subcutaneously from a
retroperitoneal or intraperitoneal source.

Reproduced from: Masha L, Bernard S. Grey Turner's sign suggesting retroperitoneal haemorrhage. Lancet 2014; 383:1920.
Illustration used with the permission of Elsevier Inc. All rights reserved.

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Female pelvic and abdominal hemoperitoneum

(A) Sagittal transvaginal view of pelvis shows no intrauterine pregnancy. There is a large amount of
complex fluid (F) and clot (C) surrounding the uterus (calipers). The ovaries were difficult to identify due
to the extent of hemorrhage and patient discomfort.

(B) Scanning of the upper abdomen showed fluid extending into Morrison's pouch. This patient was
unstable and went to the operating room. The hemoperitoneum was attributed to a ruptured
hemorrhagic corpus luteum.

Courtesy of Tejas S Mehta, MD, MPH.

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Ultrasound of an abdominal aortic aneurysm

The ultrasound examination of the abdominal aorta is shown in transverse projection (A) with Doppler
interrogation (B) and reveals an abdominal aortic aneurysm measuring 4.75 cms in maximum transverse
diameter. Turbulent flow in the aneurysm is reflected in the non-uniform heterogeneous Doppler
pattern.

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Yolk sac (transvaginal ultrasound)

Transvaginal sagittal image shows a clear yolk sac (arrow) within the sac, diagnostic of an intrauterine
pregnancy.

Courtesy of Tejas S Mehta, MD, MPH.

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Tubal pregnancy as adnexal mass

Two examples of ectopic pregnancy presenting as an extraovarian adnexal mass (arrows).

U: uterus; O: ovary.

Courtesy of Tejas S Mehta, MD, MPH.

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Acute cholecystitis with pericholecystic fluid seen on ultrasound

(A) Longitudinal view of the gallbladder showing small shadowing stones in the dependent part of the
gallbladder (arrow). The ultrasound also shows a thickened wall in both the longitudinal projection (small
arrowhead) and transverse projection (B).

(B) A small amount of pericholecystic fluid is noted (large arrowhead).

(C) The Doppler study shows an increase in blood flow to the wall (dashed arrow) reminiscent of the
hyperemia of an inflammatory process. These findings are consistent with acute calculous cholecystitis.

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Ultrasound image of acute calculous cholecystitis

There are two shadowing gallstones (S) lying dependently at the base of the distended gallbladder,
associated with diffuse thickening of the gallbladder wall (arrows). There is no definite fluid accumulation
in the gallbladder fossa. In the presence of a positive sonographic Murphy's sign, or appropriate clinical
setting, a diagnosis of acute calculous cholecystitis can be established.

Reproduced with permission from: Harwood-Nuss A, Wolfson AB, et al. The Clinical Practice of Emergency Medicine, 3rd Edition.
Lippincott Williams & Wilkins, Philadelphia 2001. Copyright © 2001 Lippincott Williams & Wilkins.

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Ultrasound demonstrating hydronephrosis

Longitudinal ultrasound of a hydronephrotic right lower quadrant kidney transplant showing dilatation of
the minor and major calyces.

Courtesy of Deborah A Baumgarten, MD, MPH.

Graphic 57935 Version 4.0

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Causes of potentially life-threatening abdominal catastrophe in the emergency

department patient with abdominal or flank pain

Etiology Clinical manifestations Risk factors, common causes, or

complications

Abdominal aortic Abdominal, back, or flank pain Risk factors include:

aneurysm Rupture typically produces acute, Tobacco use
severe pain and unstable Male sex
hypotension from exsanguinating Age greater than 60 years
hemorrhage
Hypertension
If a AAA ruptures into the
Family history of AAA
retroperitoneum and tamponades, a
Presence of other large vessel
patient can initially present
aneurysms
normotensive
Non-Hispanic White population
AAAs can cause hematuria and be
Peripheral vascular disease
misdiagnosed as renal colic [1,2]

Descending aortic Chest and/or upper back pain that Risk factors include:
dissection radiates to the abdomen Hypertension
Approximately one-third of patients Genetically mediated connective
with a descending dissection will tissue disorders (eg, Marfan
develop a malperfusion syndrome syndrome, Ehlers-Danlos
from the extension throughout the syndrome)
thoracoabdominal aortic branch Pre-existing aortic aneurysm,
vessels, causing splenic, kidney, or variant of aortic dissection,
bowel infarctions coarctation
Bicuspid aortic valve
Aortic instrumentation or surgery
Family history of aortic dissection
Turner syndrome
Vasculitis (eg, Takayasu, syphilitic)
Trauma
Pregnancy and delivery
Fluroquinolone use

Mesenteric Rapid onset of severe periumbilical Risk factors include any conditions
ischemia pain, often out of proportion to that:
findings on physical examination (ie, Reduce perfusion to the intestine
lack of tenderness or peritoneal (eg, low cardiac output)
signs) Predispose to mesenteric arterial
Bowel emptying, nausea, and embolism (eg, cardiac
vomiting arrhythmias, valvular disease)

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Blood in the stool and elevated serum Predispose to arterial thrombosis

lactate concentrations may not be (eg, atherosclerotic disease,
present initially abdominal trauma,
As bowel ischemia progresses, the hypercoagulable state, intra-
abdomen becomes grossly distended abdominal malignancy or
with peritoneal signs, a feculent odor infection)
to the breath may be appreciated, Predispose to venous thrombosis
bowel movements become bloody, Cause vasoconstriction
and shock develops

Hollow viscous Severe, sudden-onset, diffuse Risk factors and causes include:
perforation abdominal pain PUD
and/or peritonitis Involuntary guarding and/or rebound Any process that can result in
Fever frank bowel perforation leading to
Tachycardia, hypotension, signs of intraperitoneal dissemination of
shock pus and fecal material (eg, acute
appendicitis, diverticulitis)

Bowel Diffusely distended abdomen Can occur with acute bowel

strangulation Involuntary guarding and/or rebound obstruction, volvulus, or incarcerated
and/or intestinal hernia
Fever
gangrene Causes of small bowel obstruction
Tachycardia, hypotension, signs of
shock include:

Pain that progresses from crampy to Adhesions (50 to 70%)

constant and severe or localizes in Incarcerated hernias (15%)
the presence of other symptoms of Neoplasms (15%)
obstruction is concerning for Gallstone ileus (20% of cases
impending strangulation among older adult patients)
Crohn disease can cause fibrotic
strictures often leading to
repeated episodes of small bowel
obstruction
Risk factors for cecal volvulus include
adhesions, recent surgery, congenita
bands, and prolonged constipation
Risk factors for sigmoid volvulus
include excessive use of laxatives,
sedatives, anticholinergic
medications, ganglionic blocking
agents, and Parkinsonism
medications

Intra-abdominal Abdominal or flank pain Diverticulitis is the most common

abscess Abdominal tenderness cause
Fever Other common sites of abscess
formation include liver, kidney,
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genital tract, and psoas muscle

Biliary sepsis Acute cholecystitis – RUQ or Complications can include:

epigastric pain that typically occurs 1 Sepsis (from gangrenous
hour after fatty food ingestion cholecystitis or cholangitis)
Acute cholangitis (Charcot triad): Generalized peritonitis (from free
Fever gallbladder perforation into the
Abdominal pain peritoneum)
Jaundice (frequently absent) Abdominal wall crepitus (from
Severe (suppurative) cholangitis can emphysematous cholecystitis)
also include (Reynolds pentad): Bowel obstruction ("gallstone
Hypotension (this may be the only ileus" [mechanical obstruction
sign in older adults or those from passage of large gallstone])
taking glucocorticoids)
Mental status changes

Splenic rupture LUQ pain and tenderness Risk factors and causes include:
In the rare case of severe Blunt trauma
hemorrhage, can also cause Surgical or endoscopic
tachycardia, hypotension, and shock manipulation (eg, colonoscopy)
Infectious mononucleosis

Necrotizing Constant upper abdominal pain Approximately 15 to 25% of patients

pancreatitis Often with band-like radiation to the with acute pancreatitis develop
back necrosis of the pancreas or
peripancreatic tissue

Urinary sepsis A complicated UTI can present with Risk factors include:
(eg, obstructing sepsis, multiorgan system Urinary tract obstruction or
nephrolithiasis or dysfunction, shock, and/or acute abnormalities
pyelonephritis) kidney injury Recent urinary tract
instrumentation
Older age
Diabetes mellitus
Nephrolithiasis (a patient with
infected urine proximal to an
obstructing ureteral stone can
quickly become septic if not
drained)

Ectopic Female of childbearing age with the Risk factors include:

pregnancy characteristic triad: History of pelvic inflammatory
Amenorrhea disease
Abdominal/pelvic pain (severe, Previous tubal pregnancy
sudden onset) Endometriosis

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Vaginal bleeding (30% do not Indwelling intrauterine device

have this)
Hemodynamic instability can develop
if the structure (eg, fallopian tube) in
which the pregnancy is implanted
ruptures and hemorrhages

Placental An acute placental abruption Risk factors and causes include:

abruption and characteristically presents with: Maternal hypertension (most
other pregnancy Dark vaginal bleeding (the common cause)
complications amount of bleeding correlates Cocaine use
poorly with the severity of Alcohol consumption
separation)
Cigarette smoking
Abdominal pain
Trauma
Uterine contractions and
Advanced maternal age
tenderness
Acute DIC can develop from a
severe abruption (≥50% placental
separation) and is life-threatening
to both fetus and mother
Other life-threatening pregnancy-
related complications that cause
abdominal pain include:
Necrotic retained products of
conception leading to sepsis or
toxic shock syndrome
Complications of pregnancy
termination (including unsafe
abortion)
Uterine rupture

Spontaneous Patient with cirrhosis with any of the Usually, there is no apparent source
bacterial following: of infection
peritonitis Fever or hypothermia SBP occurs in up to one-fourth of
Abdominal pain patients admitted with cirrhosis and
Altered mental status ascites

Diarrhea
Ileus
Hypotension

Fournier Necrotizing fasciitis of the perineum Can occur as a result of a breach in

gangrene that begins abruptly with severe pain, the integrity of the gastrointestinal o
redness, edema, and induration and urethral mucosa
spreads rapidly to the anterior Risk factors include those for
necrotizing soft tissue infection (eg,

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abdominal wall and the gluteal diabetes, obesity,

muscles immunosuppression, malignancy,
The scrotum and penis can be alcohol misuse)
involved in males
The labia can be involved in females

Toxic megacolon Typically presents with at least 1 week Causes include:

of severe, bloody diarrhea followed Inflammatory bowel disease
by acute colonic dilatation Infectious colitis (eg, Clostridioides
Often associated with fever, difficile, cytomegalovirus colitis)
hypotension, confusion, and toxic Methotrexate therapy
appearance
Malignancy (eg, Kaposi sarcoma)

Toxic shock Characteristic manifestations are Risk factors include:

syndrome fever, rash, hypotension, and Use of high-absorbancy tampons
multiorgan dysfunction Retained tampons
Commonly include abdominal pain, Wound infections
nausea, vomiting, and diarrhea
Burns

Ruptured Sudden-onset abdominal or pelvic Risk factors include:

hemorrhagic pain Current, known cyst
ovarian cyst Shock is uncommon Conditions that predispose to cys
These are rarely life-threatening since formation (eg, ovulation
most hemorrhagic cysts stop induction, prior history of ovarian
bleeding spontaneously cysts)
Vaginal intercourse

AAA: abdominal aortic aneurysm; PUD: peptic ulcer disease; SBP: spontaneous bacterial peritonitis; RUQ:
right upper quadrant; LUQ: left upper quadrant; UTI: urinary tract infection; DIC: disseminated
intravascular coagulation.

References:
1. Marston WA, Ahlquist R, Johnson G Jr, Meyer AA. Misdiagnosis of ruptured abdominal aortic aneurysms. J Vasc Surg 1992;
16:17.
2. Fernando SM, Tran A, Cheng W, et al. Accuracy of presenting symptoms, physical examination, and imaging for diagnosis of
ruptured abdominal aortic aneurysm: Systematic review and meta-analysis. Acad Emerg Med 2022; 29:486.

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Approach to abdominal pain in non-pregnant patients in the emergency

department

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20:48 5/12/24 Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department - UpToDate

ED: emergency department; IV: intravenous; CBC: complete blood count; LFTs: liver function tests; IVC:
inferior vena cava; CXR: chest radiograph; ECG: electrocardiogram; AAA: abdominal aortic aneurysm; CT:
computed tomography; ICU: intensive care unit; ACS: acute coronary syndrome; PUD: peptic ulcer
disease; UTI: urinary tract infection; PID: pelvic inflammatory disease; RUQ: right upper quadrant; TAH-
BSO: total abdominal hysterectomy with bilateral salpingo-oophorectomy; HIV: human
immunodeficiency virus.

* Peritoneal signs include rigidity, involuntary muscle guarding, severe or rebound tenderness, and pain
with coughing or shaking stretcher.

¶ Stress-dose glucocorticoids (eg, hydrocortisone) should be administered if adrenal insufficiency is

suspected (eg, chronic glucocorticoid therapy, history of primary adrenal insufficiency).

Δ For example, pain that resolves with reduction of incarcerated hernia.

◊ Concerning signs, symptoms, and history for acute vascular process include pain out of proportion to
exam, sudden onset of pain, associated syncope, new onset or prior history of atrial fibrillation, and prior
history of atherosclerotic vascular disease or hypertension.

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§ Signs and symptoms suggesting obstruction include vomiting, increased belching, obstipation, and
abdominal distension.

¥ Signs and symptoms of UTI include dysuria, urinary urgency/frequency, and pyuria. Signs and
symptoms of cervicitis/PID include lower abdominal pain, abnormal uterine bleeding, vaginal discharge,
cervical motion and/or adnexal tenderness, and vaginal/endocervical discharge.

‡ Either point-of-care or radiology-performed depending on available equipment and expertise with

specific study.

† Signs and symptoms suggesting a gynecologic cause include sudden onset of maximal intensity of
pain, lower abdominal/pelvic location of pain, associated vaginal discharge or bleeding, and adnexal or
cervical motion tenderness.

** High-risk features include previous bariatric surgery, active malignancy, taking glucocorticoids or
immunosuppressives, organ transplant recipient, sickle cell disease, HIV. Refer to related UpToDate
content for further discussion.

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20:48 5/12/24 Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department - UpToDate

Approach to abdominal pain in pregnant patients with hemodynamic

instability or peritonitis in the emergency department*

Most patients with pregnancy-related bleeding who are RhD negative should receive anti-D immune
globulin. Refer to UpToDate content on RhD alloimmunization prevention in pregnant and postpartum
patients.

IV: intravenous; FHR: fetal heart rate; OB-GYN: obstetrics and gynecology; CXR: chest radiograph; ECG:
electrocardiogram; CT: computed tomography; MRI: magnetic resonance imaging; HELLP: hemolysis,
elevated liver enzymes, and low platelets; CBC: complete blood count; hCG: human chorionic
gonadotropin; IUP: intrauterine pregnancy; IVC: inferior vena cava.

* Use this algorithm for a pregnant patient with peritoneal signs (eg, rigidity, involuntary muscle
guarding, severe or rebound tenderness, pain with coughing or shaking stretcher), shock/hemodynamic
instability, or toxic appearance.

¶ Laboratory tests include CBC, basic metabolic panel, lactate, liver enzymes, lipase, urinalysis, type and
cross, coagulation studies, and quantitative hCG (if IUP has not been documented).

Δ Ultrasound should evaluate for:

Intrauterine pregnancy
Adnexal mass or pelvic mass

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Peritoneal free fluid

Gallstones/cholecystitis
Nephrolithiasis/hydronephrosis
Pericardial effusion/tamponade
IVC diameter and collapse (as indicator of fluid status)

◊ Digital vaginal examination should not be performed in a patient with vaginal bleeding after 20 weeks
of gestation unless placenta previa has been excluded by ultrasound examination.

§ Antimicrobial choice is empiric and should be tailored to each individual. Reasonable options include
vancomycin and either piperacillin-tazobactam, meropenem, cefepime and metronidazole, or gentamicin
and metronidazole. Refer to UpToDate content on the evaluation and management of suspected sepsis
and septic shock in adults for examples of other empiric strategies and dosing.

¥ The choice of imaging study or studies is best made jointly by the clinical (medical, surgical, obstetric)
providers and the radiologist, who can sometimes modify the technique to minimize fetal risk without
significantly compromising the information needed for maternal diagnostic evaluation and
management. Refer to UpToDate content on diagnostic imaging in pregnant patients.

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Empiric antibiotic regimens for high-risk community-acquired intra-abdominal

infections in adults

Dose

Single-agent regimen

Imipenem-cilastatin 500 mg IV every 6 hours

Meropenem 1 g IV every 8 hours

Doripenem 500 mg IV every 8 hours

Piperacillin-tazobactam 4.5 g IV every 6 hours

Combination regimen with metronidazole

ONE of the following:

Cefepime 2 g IV every 8 hours

OR

Ceftazidime 2 g IV every 8 hours

PLUS:

Metronidazole 500 mg IV or orally every 8 hours

High-risk community-acquired intra-abdominal infections are those that are severe or in patients at high
risk for adverse outcomes or antimicrobial resistance. These include patients with recent travel to areas
of the world with high rates of antibiotics-resistant organisms, known colonization with such organisms,
advanced age, immunocompromising conditions, or other major medical comorbidities. Refer to the
UpToDate topic on the antimicrobial treatment of intra-abdominal infections for further discussion of
these risk factors.

For empiric therapy of high-risk community-acquired intra-abdominal infections, we cover streptococci,

Enterobacteriaceae resistant to third-generation cephalosporins, Pseudomonas aeruginosa, and
anaerobes. Empiric antifungal therapy is usually not warranted but is reasonable for critically ill patients
with an upper gastrointestinal source.

Local rates of resistance should inform antibiotic selection (ie, agents for which there is >10% resistance
among Enterobacteriaceae should be avoided). If the patient is at risk for infection with an extended-
spectrum beta-lactamase (ESBL)-producing organism (eg, known colonization or prior infection with an
ESBL-producing organism), a carbapenem should be chosen. When beta-lactams or carbapenems are
chosen for patients who are critically ill or are at high risk of infection with drug-resistant pathogens, we
favor a prolonged infusion dosing strategy. Refer to other UpToDate content on prolonged infusions of
beta-lactam antibiotics.

The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot
use other beta-lactams or carbapenems (eg, because of severe reactions).

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The antibiotic doses listed are for adult patients with normal renal function. The duration of antibiotic
therapy depends on the specific infection and whether the presumptive source of infection has been
controlled; refer to other UpToDate content for details.

IV: intravenous.

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Empiric antibiotic regimens for health care-associated intra-abdominal

infections in adults

Dose

Single-agent regimen

Imipenem-cilastatin 500 mg IV every 6 hours

Meropenem 1 g IV every 8 hours

Doripenem 500 mg IV every 8 hours

Piperacillin-tazobactam 4.5 g IV every 6 hours

Combination regimen

ONE of the following:

Cefepime 2 g IV every 8 hours

OR

Ceftazidime 2 g IV every 8 hours

PLUS:

Metronidazole 500 mg IV or orally every 8 hours

PLUS ONE of the following (in some cases*):

Ampicillin 2 g IV every 4 hours

OR

Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours

For empiric therapy of health care-associated intra-abdominal infections, we cover streptococci,

enterococci, Enterobacteriaceae that are resistant to third-generation cephalosporins and
fluoroquinolones, Pseudomonas aeruginosa, and anaerobes. We include coverage against methicillin-
resistant Staphylococcus aureus (MRSA) with vancomycin in those who are known to be colonized, those
with prior treatment failure, and those with significant prior antibiotic exposure. Empiric antifungal
coverage is appropriate for patients at risk for infection with Candida spp, including those with upper
gastrointestinal perforations, recurrent bowel perforations, surgically treated pancreatitis, heavy
colonization with Candida spp, and/or yeast identified on Gram stain of samples from infected peritoneal
fluid or tissue. Refer to other UpToDate content on treatment of invasive candidiasis.

If the patient is at risk for infection with an extended-spectrum beta-lactamase (ESBL)-producing

organism (eg, known colonization or prior infection with an ESBL-producing organism), a carbapenem
should be chosen. For patients who are known to be colonized with highly resistant gram-negative
bacteria, the addition of an aminoglycoside, polymyxin, or novel beta-lactam combination (ceftolozane-
tazobactam or ceftazidime-avibactam) to an empiric regimen may be warranted. In such cases,
consultation with an expert in infectious diseases is advised.

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When beta-lactams or carbapenems are chosen for patients who are critically ill or are at high risk of
infection with drug-resistant pathogens, we favor a prolonged infusion dosing strategy. Refer to other
UpToDate content on prolonged infusions of beta-lactam antibiotics.

The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot
use other beta-lactams or carbapenems (eg, because of severe reactions).

The antibiotic doses listed are for adult patients with normal kidney function. The duration of antibiotic
therapy depends on the specific infection and whether the presumptive source of infection has been
controlled; refer to other UpToDate content for details.

IV: intravenous.

* We add ampicillin or vancomycin to a cephalosporin-based regimen to provide enterococcal coverage,

particularly in those with postoperative infection, prior use of antibiotics that select for Enterococcus,
immunocompromising condition, valvular heart disease, or prosthetic intravascular materials. Coverage
against vancomycin-resistant enterococci (VRE) is generally not recommended, although it is reasonable
in patients who have a history of VRE colonization or in liver transplant recipients who have an infection
of hepatobiliary source.

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Empiric antimicrobial agent selection for acute complicated urinary tract

infection in nonpregnant adults

Patient
Risk for MDR? * Empiric regimens Comments
population

Hospitalized with: N/A In regions where community The rationale for broad
Critical illness prevalence of ESBL-producing coverage is the high risk o
warranting organisms is high or adverse outcomes with
intensive care uncertain: insufficient antimicrobial
(eg, severe An antipseudomonal therapy.
sepsis) or carbapenem: When broad-spectrum
Urinary tract Imipenem 500 mg IV regimens are used
obstruction every 6 hours empirically, it is important
infused over 3 hours to tailor the regimen if
or culture and susceptibility
Meropenem 1 g IV testing indicate that a
every 8 hours narrower agent would be
infused over 3 hours active.
plus
Vancomycin 15 to 20
mg/kg IV every 8 to 12
hours with or without a
loading dose

In regions where community

prevalence of ESBL-producing
organisms is low:
Select a regimen based
on individual MDR risk,
as listed for "Other
hospitalized patients"

Other hospitalized No Ceftriaxone 1 g IV once Concern for particular

patients daily pathogens (eg, because of
Alternatives: prior isolates) should further
inform antibiotic selection:
Levofloxacin 750 mg IV
or orally daily If Enterococcus is
suspected (eg, based on
Ciprofloxacin 400 mg
prior isolates),
IV twice daily
piperacillin-tazobactam
Ciprofloxacin 500 mg
is active against this and
orally twice daily
gram-negatve
Ciprofloxacin
pathogens.
extended-release 1000

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mg orally once daily If drug-resistant gram-

positive organisms are
suspected, vancomycin
(for MRSA) or linezolid o
daptomycin (for VRE)
should be added to the
gram-negative agent
(eg, ceftriaxone).
If Pseudomonas is
suspected, piperacillin-
tazobactam, cefepime,
or a fluoroquinolone are
appropriate options.

Yes Piperacillin-tazobactam If VRE or MRSA are

3.375 g IV every 6 hours or suspected (eg, based on
Cefepime 2 g IV every 12 prior isolates), vancomycin
hours (not for ESBL risk) or (for MRSA) or daptomycin
An antipseudomonal or linezolid (for VRE) is
carbapenem (if recent added.
ESBL isolate):
Imipenem 500 mg IV
every 6 hours infused
over 3 hours or
Meropenem 1 g IV
every 8 hours infused
over 3 hours

Outpatients No, and no For patients with low risk of If the community
concerns with fluoroquinolone prevalence of
fluoroquinolones resistance/toxicity: fluoroquinolone resistance
(eg, at low risk for Ciprofloxacin 500 mg in Escherichia coli is known
adverse effects) orally twice daily for 5 to to be >10%, give one dose
7 days or of a long-acting parentera
Ciprofloxacin extended- agent prior to the
release 1000 mg orally fluoroquinolone:
once daily for 5 to 7 days Ceftriaxone 1 g IV or
or IM once
Levofloxacin 750 mg Ertapenem 1 g IV or IM
orally once daily for 5 to once
7 days Gentamicin 5 mg/kg IV
or IM once
Tobramycin 5 mg/kg IV
or IM once

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No, but with For patients who cannot use a In outpatients who are
concerns with fluoroquinolone: systemically ill or are at
fluoroquinolones One dose of a long- risk for more severe
(eg, at risk for acting parenteral agent: illness, we favor
adverse effects) Ceftriaxone 1 g IV or continuing the parenteral
IM once or agent until culture and
Ertapenem 1 g IV or susceptibility testing
IM once or results can guide selection
of an appropriate oral
Gentamicin 5 mg/kg
agent.
IV or IM once or
Tobramycin 5 mg/kg
IV or IM once
Followed by one of the
following:
TMP-SMX one
double-strength
tablet orally twice
daily for 7 to 10 days
or
Amoxicillin-
clavulanate 875 mg
orally twice daily for
7 to 10 days or
Cefpodoxime 200
mg orally twice daily
for 7 to 10 days or
Cefadroxil 1 g orally
twice daily for 7 to
10 days

Yes Ertapenem 1g IV or IM If the patient cannot take

once a fluoroquinolone or has
Followed by: high risk for
Ciprofloxacin 500 mg fluoroquinolone resistance
orally twice daily for 5 (fluoroquinolone-resistant
to 7 days or isolate or fluoroquinolone
use in prior three months)
Ciprofloxacin
extended-release 1000 Ertapenem 1 g IV or IM
mg orally once daily once daily until
for 5 to 7 days or cultures and
susceptibility testing
Levofloxacin 750 mg
return
orally daily for 5 to 7
days

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These antibiotic regimens represent our approach to empiric treatment for acute complicated UTI in
nonpregnant individuals. Once culture and susceptibility testing results are available, the regimen should
be tailored to those results. If feasible, an antibiotic with a narrow spectrum of activity should be chosen
to complete the antibiotic course. Refer to other UpToDate content for discussion of UTI during
pregnancy.

IM: intramuscular; IV: intravenous; MDR: multidrug resistance; MRSA: methicillin-resistant Staphylococcus
aureus; TMP-SMX: trimethoprim-sulfamethoxazole; UTI: urinary tract infection; VRE: vancomycin-resistant
Enterococcus.

* Risk factors for MDR gram-negative UTIs include any one of the following in the prior three months:
An MDR, gram-negative urinary isolate, including a fluoroquinolone-resistant Pseudomonas urinary
isolate
Inpatient stay at a health care facility (eg, hospital, nursing home, long-term acute care facility)
Use of a fluoroquinolone, TMP-SMX, or broad-spectrum beta-lactam (eg, third- or later-generation
cephalosporin)
Travel to parts of the world with high rates of MDR organisms

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Empiric antimicrobial selection for acute complicated urinary tract infection in

nonpregnant adults in the inpatient setting

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This algorithm reflects our approach to the selection of empiric antimicrobial therapy for nonpregnant
patients hospitalized (or expected to be hospitalized) with an acute complicated UTI. Ultimately, the
selection of antimicrobial therapy should be individualized based on severity of illness, individual and
community risk factors for resistant pathogens, and specific host factors. Refer to other UpToDate
content for discussion of UTI during pregnancy.
The decision to hospitalize a patient is usually clear in the setting of critical illness or sepsis.
Otherwise, general indications for inpatient management include persistently high fever (eg,
>101°F/>38.4°C) or pain, marked debility, inability to maintain oral hydration or take oral medications,
suspected urinary tract obstruction, and concerns regarding adherence to therapy. If outpatient
management is anticipated following therapy in the emergency department, refer to other UpToDate
content on antimicrobial therapy selection for the outpatient setting.
In addition to antimicrobial therapy, the possibility of urinary obstruction should be considered and
managed, if identified. Patients who have anatomical or functional urinary tract abnormalities
(including neurogenic bladder, indwelling bladder catheters, nephrostomy tubes, ureteral stents) may
warrant additional management, such as more frequent catheterization to improve urinary flow,
exchange of a catheter, and/or urologic or gynecologic consultation.
Doses listed are for patients with normal renal function and may require adjustment in the setting of
renal impairment.

ESBL: extended-spectrum beta-lactamase; FQ: fluoroquinolone; IV: intravenous; MDR: multi-drug

resistant; MRSA: methicillin-resistant Staphylococcus aureus; PO: oral; TMP-SMX: trimethoprim
sulfamethoxazole; UTI: urinary tract infection; VRE: vancomycin-resistant enterococci.

* We consider individuals who have pyuria with only cystitis symptoms to have acute simple cystitis and
manage them differently. Fever or systemic symptoms suggest that infection has extended beyond the
bladder and is a complicated UTI. The possibility of prostatitis should also be considered in males with
urinary and systemic symptoms. The temperature threshold used to determine whether to treat a patient
as simple cystitis versus complicated UTI is not well defined and should take into account baseline
temperature, other potential contributors to an elevated temperature, and the risk of poor outcomes
should empiric antimicrobial therapy be inappropriate.

¶ Features that should raise suspicion for urinary tract obstruction include a decline in the renal function
below baseline, a decline in urine output, or colicky abdominal pain suggestive of nephrolithiasis.

Δ This includes a single antimicrobial dose given for prophylaxis prior to prostate procedures.

◊ Advanced cephalosporin or carbapenem combinations with beta-lactamase inhibitors and the

advanced aminoglycoside plazomicin also have activity against some ESBL-producing and, in some cases,
MDR Pseudomonas aeruginosa isolates and are effective for acute complicated UTI; however, these should

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only be used in select cases of highly resistant infections. If carbapenem resistance is suspected based on
prior susceptibility testing results, an infectious diseases consult should be obtained.

§ The choice among these agents depends on susceptibility of prior urinary isolates, patient
circumstances (allergy or expected tolerability, history of recent antimicrobial use), local community
resistance prevalence (if known), drug toxicity and interactions, availability, and cost. If drug-resistant
gram-positive organisms are suspected because of previous urinary isolates or other risk factors,
vancomycin (for MRSA) or linezolid or daptomycin (for VRE) should be added.

¥ Concern for particular pathogens (eg, because of prior urinary isolates) should further inform antibiotic
selection. If Enterococcus species are suspected, piperacillin-tazobactam has activity against these
organisms in addition to typical gram-negative pathogens. If drug-resistant gram-positive organisms are
suspected, vancomycin (for MRSA) or linezolid or daptomycin (for VRE) should be added to the gram-
negative agent. If there is a risk of P. aeruginosa, piperacillin-tazobactam, cefepime, or a fluoroquinolone
is an appropriate option.

‡ A longer duration of therapy may be warranted in patients who have a nidus of infection that cannot be
removed. Patients who have worsening symptoms following initiation of antimicrobials, persistent
symptoms after 48 to 72 hours of appropriate antimicrobial therapy, or recurrent symptoms within a few
weeks of treatment should have additional evaluation including abdominal/pelvic imaging, if not already
performed) for factors that might be compromising clinical response.

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Chest radiograph of intraperitoneal free air

This plain PA radiograph of the chest taken with the patient upright reveals a small amount of free air
under the right hemidiaphragm confirming the diagnosis of a perforated abdominal viscus. The lucent,
crescent-shaped free air is noted between the arrows. The dome of the liver (arrow) and the soft tissue
shadow of the right hemidiaphragm (arrowhead) border the free air.

PA: posterior-anterior.

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Free air and air-fluid level on x-ray

An A-P x-ray (A) shows free air under the diaphragm, a well-defined liver edge (dashed arrow), but no
obvious free fluid. A lateral examination (B) shows an air fluid level (arrowhead) that was not obvious on
the A-P examination. The free air above (arrow) outlines the liver edge with greater clarity (dashed
arrow).

A-P: anteroposterior.

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Free air lateral x-ray

A lateral examination (A) shows a small amount of air under the right hemidiaphragm (arrow) and a small
amount of air under the left hemidiaphragm (arrowhead). Image B is a magnified view and highlights the
small amount of air under the right hemidiaphragm (arrow) and a small amount of air under the left
hemidiaphragm (arrowhead).

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Decubitus x-ray of intraperitoneal free air

The plain film examination of the abdomen in decubitus position reveals a large amount of free air
collecting in the right flank, clearly outlining the bowel wall (open arrows). When air is present on both
sides of the bowel, the wall is outlined with clear distinction because of the contrast differences created
on both sides. This is called Rigler's sign and is pathognomonic for free air in the peritoneal cavity. The
yellow arrows show air-fluid levels in distended bowel.

Reproduced with permission from: Daffner RH. Clinical Radiology: The Essentials, 3rd Edition. Philadelphia: Lippincott Williams &
Wilkins, 2007. Copyright © 2007 Lippincott Williams & Wilkins.

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Ruptured abdominal aortic aneurysm

The CT scan of the abdomen shows an acute rupture of a 5 cm infrarenal abdominal aortic aneurysm.
The high density acute blood obliterates the periaortic fat plane (arrow in A). The blood dissects into the
retroperitoneum and obliterates the fat plane around the IVC (arrowhead) and the right psoas muscle in
the posterior pararenal space (dashed arrow). The high density acute blood is better appreciated with
narrowed windows (arrow in B). The full extent of the bleed is demonstrated by the maroon overlay in
image C. The aneurysm is overlaid in bright red and the compressed IVC in blue.

CT: computed tomography; IVC: inferior vena cava.

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Approach to abdominal pain in hemodynamically stable pregnant patients

without peritonitis in the emergency department*

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Most patients with pregnancy-related bleeding who are RhD negative should receive anti-D immune
globulin. Refer to UpToDate content on RhD alloimmunization prevention in pregnant and postpartum
patients.

HCG: human chorionic gonadotropin; IUP: intrauterine pregnancy; OB-GYN: obstetrics and gynecology;
CT: computed tomography; MRI: magnetic resonance imaging; HELLP: hemolysis, elevated liver enzymes,
and low platelets; CBC: complete blood count.

* Use this algorithm for a pregnant patient without peritoneal signs, shock/hemodynamic instability, or
toxic appearance.

¶ Ultrasound indications are based on gestational age, previous documented IUP, and location of pain.
Should evaluate for peritoneal free fluid and for the following:
If <20 weeks gestation, undocumented IUP, and lower abdominal pain: evaluate for IUP
If lower abdominal pain: also evaluate for peritoneal free fluid, adnexal/pelvic mass or torsion, and
appendicitis
If flank or right upper quadrant pain: evaluate for nephrolithiasis/hydronephrosis and
gallstones/cholecystitis
If >20 weeks gestation, can evaluate for all of the above and abruption and uterine rupture

Δ Digital vaginal examination should not be performed in a patient with vaginal bleeding after 20 weeks
of gestation unless placenta previa has been excluded by ultrasound examination.

◊ Laboratory tests may include CBC, basic metabolic panel, lactate, liver enzymes, lipase, urinalysis, type
and cross, and coagulation studies.

§ Suspect ectopic pregnancy if no IUP visualized and quantitative HCG is greater than discriminatory zone
for HCG. Refer to UpToDate content on the approach to the patient with pregnancy of unknown location.

¥ The choice of imaging study or studies is best made jointly by the clinical (medical, surgical, obstetric)
providers and the radiologist, who can sometimes modify the technique to minimize fetal risk without
significantly compromising the information needed for maternal diagnostic evaluation and
management. Refer to UpToDate content on diagnostic imaging in pregnancy.

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Upright abdominal x-ray of small bowel obstruction

This plain, upright abdominal radiograph shows dilated loops of small bowel with air-fluid levels
consistent with a diagnosis of small bowel obstruction.

Courtesy of Richard A Hodin, MD.

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Small bowel obstruction on x-ray of the abdomen

A supine examination of the abdomen (A) shows a dilated loop of small bowel on the left side of the
abdomen (arrow). The upright examination (B) shows an air fluid level in the stomach (arrow) and in the
small bowel (arrowhead).

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Small bowel obstruction CT

Small bowel obstruction seen on CT scan showing dilated, fluid-filled loops of small bowel.

CT: computed tomography.

Courtesy of Richard A Hodin, MD.

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Small bowel obstruction CT (coronal images)

Small bowel obstruction seen by CT scan (coronal images) showing dilated, fluid-filled loops of small
intestine.

CT: computed tomography.

Courtesy of Richard A Hodin, MD.

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Causes of right upper quadrant (RUQ) abdominal pain

RUQ Clinical features Comments

Biliary

Biliary colic Intense, dull discomfort located Patients are generally well-
in the RUQ or epigastrium. appearing.
Associated with nausea,
vomiting, and diaphoresis.
Generally lasts at least 30
minutes, plateauing within one
hour. Benign abdominal
examination.

Acute cholecystitis Prolonged (>4 to 6 hours) RUQ or

epigastric pain, fever. Patients
will have abdominal guarding
and Murphy's sign.

Acute cholangitis Fever, jaundice, RUQ pain. May have atypical presentation in
older adults or
immunosuppressed patients.

Sphincter of Oddi dysfunction RUQ pain similar to other biliary Biliary type pain without other
pain. apparent causes.

Hepatic

Acute hepatitis RUQ pain with fatigue, malaise, Variety of etiologies include
nausea, vomiting, and anorexia. hepatitis A, alcohol, and drug-
Patients may also have jaundice, induced.
dark urine, and light-colored
stools.

Perihepatitis (Fitz-Hugh-Curtis RUQ pain with a pleuritic Aminotransferases are usually

syndrome) component, pain is sometimes normal or only slightly elevated.
referred to the right shoulder.

Liver abscess Fever and abdominal pain are the Risk factors include diabetes,
most common symptoms. underlying hepatobiliary or
pancreatic disease, or liver
transplant.

Budd-Chiari syndrome Symptoms include fever, Variety of causes.

abdominal pain, abdominal
distention (from ascites), lower
extremity edema, jaundice,
gastrointestinal bleeding, and/or
hepatic encephalopathy.

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Portal vein thrombosis Symptoms include abdominal Clinical manifestations depend

pain, dyspepsia, or on extent of obstruction and
gastrointestinal bleeding. speed of development. Most
commonly associated with
cirrhosis.

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Causes of epigastric abdominal pain

Epigastric Clinical features Comments

Acute myocardial infarction May be associated with shortness Consider particularly in patients
of breath and exertional with risk factors for coronary
symptoms. artery disease.

Acute pancreatitis Acute-onset, persistent upper

abdominal pain radiating to the
back.

Chronic pancreatitis Epigastric pain radiating to the Associated with pancreatic

back. insufficiency.

Peptic ulcer disease Epigastric pain or discomfort is Occasionally, discomfort localizes

the most prominent symptom. to one side.

Gastroesophageal reflux disease Associated with heartburn,

regurgitation, and dysphagia.

Gastritis/gastropathy Abdominal discomfort/pain, Variety of etiologies including

heartburn, nausea, vomiting, and alcohol and nonsteroidal
hematemesis. antiinflammatory drugs (NSAIDs)

Functional dyspepsia The presence of one or more of Patients have no evidence of

the following: postprandial structural disease.
fullness, early satiation,
epigastric pain, or burning.

Gastroparesis Nausea, vomiting, abdominal Most causes are idiopathic,

pain, early satiety, postprandial diabetic, or postsurgical.
fullness, and bloating.

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Causes of flank pain in an adult with a normal genitourinary examination

Common causes

Nephrolithiasis

Pyelonephritis

Herpes zoster

Rib fracture

Muscle strain

Lower lobe pneumonia

Less frequent causes

Obstructive uropathy (from processes such as urothelial/bladder carcinoma, thrombi, tumors, or

retroperitoneal fibrosis)

Perinephric abscess

Abdominal aortic aneurysm (AAA)

Pulmonary embolism

Malignancy (eg, renal cell carcinoma)

Renal infarction (from renal artery thrombosis, embolism, or dissection)

Renal vein thrombosis

Renal papillary necrosis

Loin pain-hematuria syndrome

Renal laceration/hemorrhage (due to trauma)

Retroperitoneal hemorrhage, abscess, or mass

Psoas abscess

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Ultrasound of kidney/ureteral stone

Longitudinal (A) and transverse (B) ultrasound images of the right kidney showing an echogenic stone
(arrowheads) with posterior acoustic shadowing (dashed arrows). One year later the patient presented
with right flank pain and microscopic hematuria (C, D). There is now moderate hydronephrosis, and the
stone has migrated into the proximal right ureter (arrowhead) with posterior acoustic shadowing (dashed
arrow).

Courtesy of Deborah A Baumgarten, MD, MPH.

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Hydronephrosis and hydroureter

Longitudinal ultrasound image of the right kidney (A) showing hydronephrosis. Multiple longitudinal
images (B-E) following the dilated right ureter to the point of obstruction, a cluster of echogenic distal
ureteral stones with shadowing (arrows).

DIST: distal; KID: kidney; LONG: longitudinal; MID: midline; RT: right; PROX: proximal.

Courtesy of Deborah A Baumgarten, MD, MPH.

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CT of a ureteral stone

Ureterolithiasis with obstruction. Image of the abdomen from a CT with intravenous contrast shows a
stone (arrow) in the proximal left ureter with slight delayed enhancement and mild hydronephrosis of the
left kidney. The right kidney is normal with high density contrast excretion in the right ureter
(arrowhead).

CT: computed tomography.

Courtesy of Jonathan Kruskal, MD.

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Ureteral obstruction

Sequential transverse images from a noncontrast CT scan. Panel A shows hydronephrosis in the lower
pole of the right kidney and a dilated ureter (arrow). The stone obstructing the ureter is visible (arrow) in
Panel B.

Courtesy of Deborah A Baumgarten, MD, MPH.

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Potential causes of acute pelvic pain in nonpregnant adult women by age grou

Less common
Patient category Common diagnoses Rare diagnoses
diagnoses

Reproductive age (not Dysmenorrhea Adenomyosis Asherman's syndrome

pregnant) Endometriosis or Ovarian torsion (months
endometrioma, Endometritis postprocedure or
including ruptured (postprocedure) delivery)
Ovarian cyst, Leiomyoma Endosalpingiosis
including ruptured (degenerating) Neoplasm/malignancy
Pelvic inflammatory Mittelschmerz including gynecologic,
disease, including gastrointestinal, and
Sickle cell crisis in
salpingitis or tubo- urologic
menstruating
ovarian abscess women with sickle Ovarian vein
cell disease thrombosis, including
septic pelvic
Urinary retention
thrombophlebitis
(related to
medications or Pelvic congestion
underlying syndrome
conditions, such as Torsion of subserosal
surgery) fibroid
Uterine perforation
(typically after uterine
procedure or
intrauterine device
insertion)

Reproductive age Ectopic pregnancy Ovarian torsion Heterotopic pregnanc

(undergoing fertility Ovarian follicular
treatment) cyst
Ovarian
hyperstimulation
syndrome

Reproductive age Wound infection Abdominal wall Anterior cutaneous

(postpartum or Endometritis hematoma, nerve entrapment
postprocedure) infection, seroma, syndrome
dehiscence Ovarian vein
Ureteral obstruction thrombosis
Septic pelvic
thrombophlebitis

Postmenopausal Malignancy Ischemic colitis Endometriosis

women (gynecologic,
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gastrointestinal, or Pelvic inflammatory

urologic) disease, tubo-ovarian
abscess

All groups Appendicitis Bowel obstruction Abdominal epilepsy

Diverticulitis Fecal impaction or Abdominal migraine
Gastroenteritis constipation Abdominal aortic
Inflammatory bowel Inguinal or femoral aneurysm
disease hernia Bladder cancer
Irritable bowel Interstitial Depression (while
syndrome cystitis/painful depression is
Musculoskeletal bladder common, it is
pelvic pain Muscular strain or uncommonly a cause
Urinary tract sprain of acute pelvic pain)
infection (cystitis, Pelvic adhesive Domestic violence
pyelonephritis) disease Fracture of pelvis or
Urolithiasis (postoperative hip
scarring) Familial
Perforated viscus Mediterranean Fever
Perirectal abscess Herpes Zoster
Postoperative pelvic Hirschsprung disease
abscess Incarcerated or
Urethral strangulated hernia
diverticulum Intussusception
Ureteral obstruction Lead poisoning
Urinary retention Malingering
Meckel's diverticulum
Mesenteric adenitis
Narcotic seeking
Ovarian torsion
Ovarian vein
thrombosis
Pelvic congestion
syndrome
Porphyria
Septic pelvic
thrombophlebitis
Sexual abuse
Sickle cell crisis
Somatization disorder
TRAPS
Uterine rupture
Volvulus

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Vulvar varicosities
Wandering spleen

TRAPS: tumor necrosis factor receptor-associated periodic syndrome.

Adapted from: Bhavsar AK, Gelner EJ, Shorma T. Common Questions About the Evaluation of Acute Pelvic Pain. Am Fam Physician
2016; 93:41.

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Pelvic causes of abdominal pain in women

Pelvic causes of
abdominal pain Lateralization Clinical features Comments
in women

Ectopic Either side or Vaginal bleeding with abdominal pain, typically Patients can
pregnancy diffuse six to eight weeks after last menstrual period. present with
abdominal pain life-
threatening
hemorrhage
if ruptured.

Pelvic Lateralization Characterized by the acute onset of lower Wide

inflammatory uncommon abdominal or pelvic pain, pelvic organ spectrum of
disease tenderness, and evidence of inflammation of clinical
the genital tract. Often associated with cervical presentations
discharge.

Ovarian torsion Localized to one Acute onset of moderate-to-severe pelvic pain, Generally not
side often with nausea and possibly vomiting, in a associated
woman with an adnexal mass. with vaginal
discharge.

Ruptured Localized to one Sudden-onset unilateral lower abdominal pain. Generally not
ovarian cyst side The classic presentation is sudden onset of associated
severe focal lower quadrant pain following with vaginal
sexual intercourse. discharge.

Endometriosis Associated with dysmenorrhea, pelvic pain, Patients may

dyspareunia, and/or infertility, but other present with
symptoms may also be present (eg, bowel or one symptom
bladder symptoms). or a
combination
of symptoms.

Acute Most often preceded by pelvic inflammatory Diagnostic

endometritis disease. criteria the
same as
pelvic
inflammatory
disease.

Chronic Present with abnormal uterine bleeding, which

endometritis may consist of intermenstrual bleeding,
spotting, postcoital bleeding, menorrhagia, or
amenorrhea. Vague, crampy lower abdominal

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pain accompanies the bleeding or may occur

alone.

Leiomyomas Symptoms related to bulk or infrequently

(fibroids) acute pain from degeneration or torsion of
pedunculate tumor. Pain may be associated
with a low-grade fever, uterine tenderness on
palpation, elevated white blood cell count, or
peritoneal signs.

Ovarian Abdominal distention/discomfort, Women

hyperstimulation nausea/vomiting, and diarrhea. More severe undergoing
cases can have severe abdominal pain, ascites, fertility
intractable nausea, and vomiting. treatment.

Ovarian cancer Abdominal or pelvic pain. May have associated

symptoms of bloating, urinary urgency or
frequency, or difficulty eating/feeling full
quickly.

Ovulatory pain Occurs mid-cycle, coinciding with timing of May be right-

(Mittelsmerz) ovulation. or left-sided,
depending on
site of
ovulation
during that
cycle.

Pregnancy and related complications*

* Refer to the UpToDate topics on abdominal pain.

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Causes of lower abdominal pain

Lower abdomen Localization Clinical features Comments

Appendicitis Generally right lower Periumbilical pain Occasional patients

quadrant initially that radiates to present with epigastric
the right lower or generalized
quadrant. Associated abdominal pain.
with anorexia, nausea,
and vomiting.

Diverticulitis Generally left lower Pain usually constant Clinical presentation

quadrant, although and present for several depends on severity of
right-sided symptoms days prior to underlying
are not uncommon presentation. May have inflammatory process
associated nausea and and whether or not
vomiting. complications are
present.

Nephrolithiasis Either Pain most common Cause symptoms as

symptom, varies from stone passes from rena
mild to severe. Generally pelvis to ureter.
flank pain, but may have
back or abdominal pain.

Pyelonephritis Either Associated with dysuria,

frequency, urgency,
hematuria, fever, chills,
flank pain, and
costovertebral angle
tenderness.

Acute urinary retention Suprapubic Present with lower

abdominal pain and
discomfort; inability to
urinate.

Cystitis Suprapubic Associated with dysuria,

frequency, urgency, and
hematuria.

Infectious colitis Either Diarrhea as the Patients with

predominant symptom, Clostridioides difficile
but may also have infection can present
associated abdominal with an acute abdomen
pain, which may be and peritoneal signs in
severe. the setting of
perforation and
fulminant colitis.
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Testicular torsion Can begin in lower Often associated with Usually in boys or
abdomen, localizing to nausea and vomiting. adolescents.
side ipsilateral to testicle

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Causes of diffuse abdominal pain

Diffuse/poorly
Clinical features Comments
characterized

Bowel obstruction Most common symptoms are nausea, Multiple etiologies.

vomiting, crampy abdominal pain, and
obstipation.

Distended, tympanic abdomen with

high-pitched or absent bowel sounds.

Perforation of the Severe abdominal pain, particularly Can present acutely or in an indolent
gastrointestinal following procedures. manner, particularly in
tract immunosuppressed patients.

Acute mesenteric Acute and severe onset of diffuse and May occur from either arterial or venous
ischemia persistent abdominal pain, often disease. Patients with aortic dissection
described as pain out of proportion to can have abdominal pain related to
examination. mesenteric ischemia.

Chronic Abdominal pain after eating ("intestinal May occur from either arterial or venous
mesenteric angina"), weight loss, nausea, vomiting, disease.
ischemia and diarrhea.

Inflammatory Associated with bloody diarrhea, May have symptoms for years before
bowel disease urgency, tenesmus, bowel incontinence, diagnosis. Associated extraintestinal
(ulcerative weight loss, and fevers. manifestations (eg, arthritis, uveitis).
colitis/Crohn
disease)

Viral Diarrhea accompanied by nausea,

gastroenteritis vomiting, and abdominal pain.

Spontaneous Fever, abdominal pain, and/or altered Most often in cirrhotic patients with
bacterial mental status. advanced liver disease and ascites.
peritonitis

Dialysis-related Abdominal pain and cloudy peritoneal Only in peritoneal dialysis patients.
peritonitis effluent. Other symptoms and signs
include fever, nausea, diarrhea,
abdominal tenderness, and rebound
tenderness.

Colorectal cancer Variable presentation, including

obstruction and perforation.

Other malignancy Vary depending on malignancy.

Celiac disease Abdominal pain in addition to including

diarrhea with bulky, foul-smelling,

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floating stools due to steatorrhea and

flatulence.

Ketoacidosis Diffuse abdominal pain and nausea and

vomiting.

Adrenal Diffuse abdominal pain and nausea and Patients with adrenal crisis may present
insufficiency vomiting. with shock and hypotension.

Foodborne illness Mixture of nausea, vomiting, fever,

abdominal pain and diarrhea.

Irritable bowel Chronic abdominal pain with altered

syndrome bowel habits.

Constipation Associated with a variety of neurologic

and metabolic disorders, obstruction
lesions of the gastrointestinal tract,
endocrine disorders, psychiatric
disorders, and side effect of medications

Diverticulosis May have symptoms of abdominal pain Often an asymptomatic and incidental
and constipation. finding on colonoscopy or
sigmoidoscopy.

Lactose Associated with abdominal pain,

intolerance bloating, flatulence, and diarrhea.
Abdominal pain may be cramping in
nature.

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Causes of left upper quadrant (LUQ) abdominal pain

LUQ Clinical features Comments

Splenomegaly Pain or discomfort in LUQ, left Multiple etiologies.

shoulder pain, and/or early
satiety.

Splenic infarct Severe LUQ pain. Atypical presentations common.

Associated with a variety of
underlying conditions (eg,
hypercoagulable state, atrial
fibrillation, and splenomegaly).

Splenic abscess Associated with fever and LUQ Uncommon. May also be
tenderness. associated with splenic infarction

Splenic rupture May complain of LUQ, left chest Most often associated with
wall, or left shoulder pain that is trauma.
worse with inspiration.

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Modified Alvarado score for diagnosis of appendicitis

Feature Points

Migratory right lower quadrant pain 1

Anorexia 1

Nausea or vomiting 1

Tenderness in the right lower quadrant 2

Rebound tenderness in the right lower quadrant 1

Fever >37.5°C (>99.5°F) 1

Leukocytosis of white blood cell count >10 × 10 9 /liter 2

Total 9

Score of 0 to 3 indicates appendicitis is unlikely and other diagnoses should be pursued. Score of ≥4
indicates that the patient should be further evaluated for appendicitis.

C: centigrade; F: Fahrenheit.

Modified from: Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15:557.

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Less common causes of abdominal pain

Abdominal aortic aneurysm

Abdominal compartment syndrome

Abdominal migraine

Acute hepatic porphyrias (eg, acute intermittent porphyria)

Angioedema (either hereditary or angiotensin-converting enzyme [ACE] inhibitor-related)

Celiac artery compression syndrome

Chronic abdominal wall pain

Colonic pseudo-obstruction (acute or chronic)

Eosinophilic gastroenteritis

Epiploic appendagitis

Familial Mediterranean fever

Helminthic infections

Herpes zoster

Hypercalcemia

Hypothyroidism

Lead poisoning

Meckel's diverticulum

Narcotic bowel syndrome

Paroxysmal nocturnal hemoglobinuria

Pseudoappendicitis

Pulmonary etiologies

Rectus sheath hematoma

Renal infarction

Rib pain

Sclerosing mesenteritis

Somatization

Thoracic duct-venous junction obstruction

Wandering spleen

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