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The term acute abdomen refers to abdominal pain that is acute in onset and associated with signs and symptoms that point to intraabdominal pathology requiring urgent evaluation and treatment. Abdominal pain is a very common chief complaint; distinguishing the etiology of the pain and determining the need for surgical intervention requires a thorough history and physical examination combined with judicious use of lab testing and imaging.

History

A careful history is an important component of elucidating the etiology of acute abdominal pain. Specific components of the history include the onset and duration of pain, provocative and palliative factors, the quality of the pain, its location, the presence of radiation or referred pain, any associated symptoms, and a thorough menstrual history in women.

Onset and duration

Pain that is sudden in onset suggests perforation or rupture such as a perforated peptic ulcer, ruptured abdominal aortic aneurysm, or ruptured ectopic pregnancy. Any mechanism that suddenly floods the peritoneal cavity with an irritant fluid such as blood, pus, or gastrointestinal contents will cause acute peritonitis with a sudden onset. Pain that is rapid in onset and accelerating in course may be caused by colic (for example, nephrolithiasis, cholelithiasis, or small bowel obstruction), inflammatory causes (appendicitis, pancreatitis, or diverticulitis), or ischemia (mesenteric ischemia, strangulated bowel, or volvulus). Pain that is gradual in onset and increases may be due to apppendicitis, cholecystitis, nonstrangulated bowel obstruction, urinary retention, or ectopic pregnancy.

Location

Acute epigastric pain is consistent with early acute appendicitis, peptic ulcer (either perforated or nonperforated), acute pancreatitis, mesenteric ischemia, or dissecting aortic aneurysm. Right upper quadrant (RUQ) pain can be caused by cholecystitis, cholithiasis, acute hepatitis, right renal colic, or right pyelonephritis. Acute left upper quadrant (LUQ) pain may result from splenic infarction, splenic rupture (secondary to trauma), left sided pyelonephritis, or left sided renal colic. Right lower quadrant (RLQ) pain is common in later stages of acute appendicitis (ruptured or nonruptured) as well as perforated duodenal ulcer. Left lower quadrant (LLQ) pain is typical in colonic diverticulitis.