From the Guidelines
Severe abdominal pain out of proportion to physical examination findings should be assumed to be a serious condition, such as acute mesenteric ischemia (AMI), until disproven. This is based on the most recent guidelines from the World Society of Emergency Surgery, which strongly recommend this approach, despite being based on low-quality evidence 1.
When evaluating abdominal pain, it is crucial to consider red flags that may indicate severe or life-threatening conditions. These include:
- Severe, sudden pain that feels different from usual discomfort
- Pain accompanied by fever
- Persistent vomiting or inability to keep fluids down
- Signs of dehydration
- Blood in vomit or stool
- Abdominal rigidity or severe tenderness to touch
- Pain that radiates to the back, chest, neck, or shoulders
- Abdominal distension or swelling
- Jaundice (yellowing of skin or eyes)
- Pain occurring during pregnancy
These symptoms may indicate serious conditions like appendicitis, intestinal obstruction, pancreatitis, ruptured organs, or internal bleeding that require urgent evaluation 1. Certain populations face higher risks, including elderly patients, immunocompromised individuals, and those with recent abdominal trauma or surgery. If experiencing these red flags, patients should seek emergency care immediately rather than attempting home remedies or waiting to see if symptoms resolve, as delays in treatment for conditions like appendicitis or intestinal perforation can lead to life-threatening complications.
From the Research
Red Flags for Abdominal Pain
Abdominal pain can be caused by a variety of gastrointestinal and nongastrointestinal disorders, and some conditions can be life-threatening if not diagnosed and treated promptly 2. The following are some red flags for abdominal pain:
- Sudden and severe pain
- Pain that worsens over time
- Pain that radiates to the back or shoulder
- Pain that is accompanied by vomiting, fever, or bleeding
- Pain that is exacerbated by movement or coughing
- Abdominal tenderness or guarding
- Rebound tenderness
Clinical Presentation of Acute Appendicitis
Acute appendicitis is one of the most common causes of acute abdominal pain in adults and children, with a lifetime risk of 8.6% in males and 6.7% in females 3. The clinical presentation of acute appendicitis typically includes:
- Vague periumbilical pain that migrates to the right lower quadrant
- Anorexia, nausea, and vomiting
- Low-grade fever
- Abdominal tenderness, especially in the right lower quadrant
- Rebound tenderness
Diagnosis and Management of Acute Appendicitis
The diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging 4. The Alvarado score, Pediatric Appendicitis Score, and Appendicitis Inflammatory Response score can help stratify patients as low, moderate, or high risk for acute appendicitis 3. Appendectomy via open laparotomy or laparoscopy is the standard treatment for acute appendicitis, but intravenous antibiotics may be considered first-line therapy in selected patients 4, 3.
Evaluation and Management of Acute Abdominal Pain
The evaluation and management of acute abdominal pain in the emergency department requires a thorough history, physical examination, and laboratory evaluation 5. Clinicians must consider multiple diagnoses, especially life-threatening conditions that require timely intervention to limit morbidity and mortality. Advances in diagnostics and management are impacting care pathways, and best-practice pathways are an important part of quality programs 6.