What is the treatment for severe abdominal pain and potential underlying conditions like appendicitis, diverticulitis, or sepsis?

Treatment of Severe Abdominal Pain and Potential Underlying Conditions

Severe abdominal pain from conditions like appendicitis, diverticulitis, or sepsis requires immediate intervention with appropriate diagnostic imaging, antimicrobial therapy, and surgical consultation for source control. 1

Initial Assessment and Management

• Rapid clinical evaluation is essential for diagnosing intra-abdominal infections (IAIs), which typically present with rapid-onset abdominal pain and signs of local and systemic inflammation (tenderness, fever, tachycardia, tachypnea) 1
• Immediate fluid resuscitation should be initiated when hypotension is identified in patients with septic shock, or when intra-abdominal infection is first suspected in patients without volume depletion 1
• Antimicrobial therapy should be started as soon as intra-abdominal infection is diagnosed or considered likely, with administration in the emergency department for patients without septic shock 1

Diagnostic Approach

• A step-up diagnostic approach should be used, beginning with clinical and laboratory examination and progressing to imaging examinations 1
• CT scan is the imaging modality of choice for adults not undergoing immediate laparotomy to determine the presence and source of intra-abdominal infection 1
• For female patients of childbearing potential, pregnancy testing should be performed prior to imaging, with ultrasound or MRI preferred during the first trimester 1
• In children, particularly those under 3 years, imaging should be performed when appendicitis diagnosis is uncertain, with ultrasound as a reasonable alternative to CT to avoid radiation exposure 1

Specific Treatment Approaches

Appendicitis

• Antimicrobial therapy should be administered to all patients diagnosed with appendicitis 1
• Appropriate antimicrobials should cover facultative and aerobic gram-negative organisms and anaerobes 1
• Operative intervention for acute, nonperforated appendicitis should be performed as soon as reasonably feasible, with both laparoscopic and open approaches being acceptable 1
• Nonoperative management may be considered for selected patients with acute, nonperforated appendicitis who show marked improvement prior to operation 1

Diverticulitis

• Acetaminophen is recommended as the primary analgesic for pain control in uncomplicated diverticulitis 2
• A clear liquid diet during the acute phase helps reduce pain by minimizing mechanical irritation of the inflamed colon 2
• Antibiotics should be used selectively rather than routinely, specifically for patients with comorbidities, frailty, or complicated diverticulitis (abscess, perforation, fistula) 2
• For persistent pain after acute episode resolution, low to modest doses of tricyclic antidepressants may be considered for visceral hypersensitivity 2

Intra-abdominal Abscess Management

• Patients with well-circumscribed periappendiceal abscesses can be managed with percutaneous drainage or operative drainage when necessary, with appendectomy generally deferred 1
• Non-drainable abscesses smaller than 3 cm without evidence of fistula and no steroid therapy may respond to antibiotic therapy alone, though with high recurrence rates 1
• Antibiotic therapy for abscesses should cover Gram-negative bacteria and anaerobes 1

Special Considerations

• Patient factors (advanced age, immunosuppression, malignancy, comorbidities) and disease factors significantly influence treatment outcomes and mortality risk 1
• Patients with an accumulated number of risk factors, including advanced age, high disease severity, and sepsis or septic shock, have a very high risk of death 1
• Preoperative treatments with immunomodulators associated with anti-TNF-α agents and steroids are risk factors for intra-abdominal sepsis in patients requiring emergency resectional surgery 1

Antimicrobial Therapy Guidelines

• For patients with septic shock, antibiotics should be administered as soon as possible 1
• Antimicrobial drug levels should be maintained during source control interventions, which may require additional administration just before the procedure 1
• In cases of superinfection or abscesses, prompt antimicrobial therapy against Gram-negative/aerobic and facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli is needed 1

Surgical Management

• Patients with perforated appendicitis should undergo urgent intervention for adequate source control 1
• Source control procedures are essential for managing intra-abdominal infections, with the primary objectives being control of the source of contamination and reduction of bacterial inoculum 1
• For patients with suspected appendicitis that cannot be confirmed or excluded by diagnostic imaging, careful follow-up is recommended, with possible hospitalization if the index of suspicion is high 1