What are the common causes of sharp abdominal pain?

Common Causes of Sharp Abdominal Pain

The most common causes of sharp abdominal pain include appendicitis (8-30% of cases), acute cholecystitis (9-11%), small bowel obstruction (4-5%), and nonspecific abdominal pain (30-41%), with the differential diagnosis requiring urgent differentiation of life-threatening conditions from benign etiologies. 1, 2

Most Common Etiologies by Frequency

High-Frequency Causes

• Nonspecific abdominal pain accounts for approximately one-third of emergency department presentations and often remains undiagnosed 1
• Acute appendicitis represents 8-30% of cases presenting with acute abdominal pain 1, 2
• Acute cholecystitis causes 9-11% of acute abdominal pain presentations 2
• Small bowel obstruction accounts for 4-5% of cases, with adhesions from prior surgery responsible for 55-75% of these obstructions 3, 2
• Pancreatitis is among the most common documented pathologies in the "other" category 1
• Renal colic (nephrolithiasis) frequently presents with sharp, severe abdominal pain 1
• Diverticulitis is a common cause requiring imaging confirmation 1

Gastrointestinal Causes

• Perforated peptic ulcer presents with sudden-onset sharp pain and requires urgent surgical evaluation 1
• Bowel obstruction or infarction can cause severe sharp pain with distension 1
• Gastrointestinal perforation from any cause produces acute peritonitis 1
• Irritable bowel syndrome can cause sharp abdominal pain, though nocturnal symptoms warrant further investigation 4
• Inflammatory bowel disease (Crohn's disease, ulcerative colitis) causes sharp pain during flares, affecting 50-70% of IBD patients during active disease 4

Life-Threatening Causes Requiring Immediate Recognition

Vascular Emergencies

• Mesenteric ischemia presents with severe pain out of proportion to physical examination findings and carries 30-90% mortality if not rapidly diagnosed 1, 4

  • Arterial embolism accounts for 40-50% of acute mesenteric ischemia cases 1
  • Acute mesenteric artery thrombosis causes 20-30% of cases 1
  • Nonocclusive mesenteric ischemia represents 25% of cases 1
  • Mesenteric venous thrombosis accounts for 5-15% 1

• Abdominal aortic aneurysm rupture causes severe abdominal and back pain with >50% mortality even with prompt intervention 4

• Aortic dissection involving the abdominal aorta produces severe, abrupt-onset pain 4

Other Critical Conditions

• Ectopic pregnancy in women of reproductive age 5
• Acute myocardial infarction can present with epigastric pain 5
• Splenic rupture from trauma or spontaneous causes 5

Organ System-Specific Causes

Hepatobiliary

• Acute cholecystitis and cholelithiasis are common causes of right upper quadrant sharp pain 1

Pulmonary

• Pneumonia (particularly lower lobe) can present with referred abdominal pain 1

Oncologic

• Cancer (various intra-abdominal malignancies) accounts for a significant portion of acute presentations 1
• Colorectal cancer is the most common cause of large bowel obstruction (60% of cases) 3
• Carcinomatosis peritoneal can cause obstruction and pain 3

Infectious/Inflammatory

• Abscesses anywhere in the abdomen can cause localized sharp pain 1
• Fever with abdominal pain raises suspicion for intra-abdominal infection requiring urgent imaging 1

Critical Diagnostic Approach

CT abdomen and pelvis with IV contrast is the preferred initial imaging for nonlocalized acute abdominal pain with fever or concerning features, as it changes management in 51% of patients and admission decisions in 25%. 1, 4

Imaging Selection by Clinical Scenario

• CT angiography is the gold standard for suspected mesenteric ischemia and aortic pathologies 4
• Ultrasonography is preferred for right upper quadrant pain to evaluate biliary disease 4, 6
• Plain radiography has limited utility (25% of mesenteric ischemia cases have normal films) and should only screen for perforation or obstruction 1

High-Risk Populations Requiring Lower Threshold for Imaging

• Elderly patients may have normal laboratory values despite serious infection and require earlier imaging 1
• Neutropenic patients have masked signs of sepsis with high mortality rates 1
• Postoperative patients presenting with acute pain require urgent evaluation 1
• Immunocompromised patients warrant expedited diagnostic workup 1

Common Pitfalls to Avoid

• Do not rely on laboratory tests alone in elderly patients, as they may be normal despite serious pathology 1
• Pain out of proportion to examination should immediately raise suspicion for mesenteric ischemia, which requires emergent intervention 1
• Delayed diagnosis of mesenteric ischemia increases mortality with every elapsed hour 2
• Atypical presentations are common in elderly patients and women, who may have genitourinary causes 6