From the Guidelines
The initial management of a patient with acute abdomen involves a systematic approach beginning with rapid assessment and stabilization, prioritizing fluid resuscitation, pain control, and early surgical consultation if necessary, as supported by the most recent guidelines 1.
Initial Assessment and Stabilization
The first step in managing a patient with acute abdomen is to establish IV access with two large-bore catheters (18-gauge or larger) and initiate fluid resuscitation with crystalloids such as normal saline or lactated Ringer's at 1-2 L bolus for signs of hypovolemia. This is crucial in preventing shock and ensuring adequate perfusion of vital organs.
Laboratory Studies and Imaging
Obtain baseline laboratory studies including complete blood count, comprehensive metabolic panel, coagulation studies, urinalysis, and serum lactate. Imaging studies should be ordered based on the clinical presentation, with abdominal X-rays useful for bowel obstruction or perforation, ultrasound for biliary or gynecological pathology, and CT scan with IV contrast as the gold standard for most acute abdominal conditions, as recommended by recent guidelines 1.
Pain Control and Surgical Consultation
Pain control should be provided with titrated IV opioids such as morphine 2-4 mg or hydromorphone 0.5-1 mg, contrary to outdated concerns that analgesia masks physical findings. Surgical consultation should be obtained early if peritonitis, bowel obstruction, or vascular catastrophe is suspected. Broad-spectrum antibiotics (such as piperacillin-tazobactam 3.375g IV q6h or ceftriaxone 1g IV plus metronidazole 500mg IV q8h) should be administered if infection is suspected, as supported by guidelines 1.
Key Considerations
- Perform a focused history and physical examination, paying particular attention to the character, location, and radiation of pain, as well as associated symptoms.
- Maintain NPO status until a definitive diagnosis and treatment plan are established.
- Consider diagnostic laparoscopy if imaging is unhelpful, as it has a high accuracy rate in identifying the causative pathology of acute abdominal pain 1.
- Implement locally adapted guidelines to improve process of care variables and relevant clinical outcomes, as recommended by the Surgical Infection Society and the Infectious Diseases Society of America 1.
From the Research
Initial Presentation Maneuvers
The initial presentation maneuvers for a patient with acute abdomen include:
- A rapid cardiopulmonary assessment to ensure hemodynamic stability 2
- Focused history and examination to identify the cause of abdominal pain 2, 3
- Surgical consult to determine the need for surgical intervention 2, 3
- Radiologic examination, such as ultrasound or CT scan, to exclude life-threatening surgical conditions 2, 3, 4
Management
The management of acute abdomen involves:
- Pain relief and specific diagnosis 2, 3
- Rapid IV access and normal saline 20 ml/kg in the presence of shock/hypovolemia 2
- Adequate analgesia, with consideration of the impact on diagnostic accuracy 3
- Nothing per oral/IV fluids and Ryle's tube aspiration in sick patients 2
- Continuous monitoring and repeated physical examinations to assess the patient's condition 2, 5
Diagnostic Approach
The diagnostic approach to acute abdomen involves:
- A thorough and logical approach to the diagnosis of abdominal pain, considering the location of pain, age, and gender of the patient 4
- Use of ultrasonography (US) as the primary imaging technique, especially in young and female patients 4
- Selective use of CT imaging, considering the risks associated with radiation and costs 3, 4
- Consideration of diagnostic laparoscopy in patients without a specific diagnosis after appropriate imaging 3