Obstructive

· Bowel

· Biliary

· Ureteral

Cardiopulmonary

• ACS

• Pulmonary embolism

· Pneumonia

Figure 26-3. Acute abdominal pain diag nostic a l gorithm. AAA, abdominal aortic aneurysm; ACS, acute

coro nary syndrome; PID, pelvic i nflammatory d isease; TOA, tu ba-ovarian abscess.

processes (imminent diagnoses). If not found, a secondary search should begin for disease states requiring

identification before discharge (critical diagnoses).

Certain diagnoses should be automatically considered in

different age groups: AAA in the older adult, testicular

torsion in the adolescent male, and ectopic pregnancy in

females of reproductive age. As the most common surgical disease of the abdomen, appendicitis should always

be placed on the differential diagnosis regardless of age

(Figure 26-3 ).

TREATMENT

Resuscitation should be initiated in patients with hemodynamic instability without delay. Volume repletion should

begin with rapid infusion of isotonic crystalloid. In the

setting of massive hemorrhage, emergency release blood

(type O) can be transfused until typed and crossed blood

is available. In septic shock, a vasopressor should be

employed for persistent hypotension (mean arterial pressure [MAP) <65) after volume status has been optimized

or during volume resuscitation in the setting of severe

hemodynamic compromise (MAP <40-50 mmHg).

Antibiotics should be promptly administered in

patients with abdominal sepsis, peritonitis, or perforated

viscus. Specific diseases requiring antibiotic treatment

include appendicitis, cholecystitis, diverticulitis, pyelonephritis, and pelvic inflammatory disease.

Pain control can be tailored to the suspected disease

process. When gastritis/peptic ulcer disease (PUD) is suspected, a "GI cocktail" (typically a combination of Maalox,

viscous lidocaine, and Donnatal) may provide relief.

Ketorolac is useful in the setting of biliary colic and nephrolithiasis, but should be avoided in patients with PUD or

chronic kidney disease. Multiple randomized studies have

shown that narcotic pain medications do not interfere with

diagnostic ability. These agents should not be withheld in

patients with significant pain.

Consultation with the appropriate surgical service

should be emergently obtained for hemodynamic instability, suspected vascular catastrophe (ruptured AAA, ruptured ectopic, acute mesenteric occlusion), or abdominal

ACUTE ABDOMINAL PAIN

rigidity (ie, perforation). For patients with severe sepsis

secondary to an intra-abdominal abscess or obstruction of

the biliary tract, consultation with interventional radiology

can be pursued for percutaneous drainage.

DISPOSITION

..... Admission

Patients found to have a surgical disease, abdominal sepsis,

or intractable pain or vomiting regardless of the etiology

should be admitted to the hospital.

..... Discharge

Patients with resolution of symptoms without suspicion of

serious underlying pathology may be discharged. Follow-up

with a primary physician should be ensured, and the

patient should be instructed to return if there is progression

of symptoms.