The Acute Abdomen: Structured Diagnosis and Treatment

Abstract

Background: The acute abdomen is a life-threatening clinical entity that requires immediate diagnostic evaluation and appropriate treatment. 15-20% of emergency room patients with acute abdominal pain need interventional or surgical treatment.

Methods: This narrative review is based on publications retrieved by a PubMed search, current textbooks and guidelines, and the authors' personal experience.

Results: The acute abdomen presents with the sudden onset of maximally intense abdominal pain, sometimes with guarding, and often with impaired general well-being, ranging to manifestations of shock. Its more common causes, aside from nonspecific abdominal pain (30-41%), are acute appendicitis (8-30%), cholecystitis (9-11%), and ileus (4-5%). The diagnosis is established by the history and physical examination, laboratory tests, imaging studies, and, in some cases, exploratory laparoscopy. The acute abdomen is generally a surgical condition, but it often requires interdisciplinary, multimodal treatment and follow-up. It carries a 2% to 12% mortality, with the figure rising for every elapsed hour until specific treatment is provided.

Conclusion: Structured, quality-controlled, rapid, and targeted diagnosis and treatment markedly lower the morbidity and mortality of patients presenting with an acute abdomen.

Diagram

The desired time course of patient care from the moment of initial contact to the delivery of specific treatment. CT, computerized tomography; ER, emergency room; MRI, magnetic resonance imaging; qSOFA, quick sequential organ failure assessment (green arrows: start of therapeutic measures; red arrows: start of history-taking and diagnostic evaluation). The diagnostic evaluation overlaps with the treatment in a fluid process.

eFigure 1

Occlusive mesenteric ischemia a) Acute thrombotic occlusion of the mesenteric artery in the middle third. b) Bowel necrosis due to arterial occlusion, visible on CT as a lack of contrast enhancement in the affected portion of the bowel wall. c) Findings on surgical exploration.

eFigure 2

The management of covered perforated sigmoid diverticulitis with macroabscess (Classification of Diverticular Disease 2b) a) contrast-enhanced CT, coronal b) contrast-enhanced CT, axial c) CT fluoroscopy, axial (CT-guided drain placement with the Seldinger technique)