Document SFD-WI-CPG-001

Code:
SAINT FRANCIS DOCTORS’ Revision Rev. 00
No.:
HOSPITAL AND MEDICAL CENTER, INC. Date January 1, 2021
Effective:
Originating Department/Section/Committee: Page No. Page 1 of 5

Medical Services Division

Document Title:
Evaluation of Acute Abdominal Pain in Adult

I. DISEASE/CONDITION(S)
1. The term ‘acute abdominal pain’ is a synonym of ‘acute abdomen’ and
is defined as abdominal pain of a non-traumatic origin with a
maximum duration of 5 days. Approximately 10% of presentations at
the Emergency Room are because of acute abdominal pain.

2. It refers to intra-abdominal pathology, including extra-abdominal,

thoracic, and systematic pathology with an onset of less than 1 week
that may require urgent intervention such as surgery.

3. Acute abdominal pain can be caused by a variety of diseases ranging

from mild and self-limiting to life-threatening diseases. An early and
accurate diagnosis results in more accurate management and,
subsequently, leads to better outcomes. Acute abdominal pain can be
caused by a variety of underlying causes.

4. Causes for acute abdominal pain can be classified as urgent or non-

urgent. Urgent causes require immediate treatment (within 24 hours)
to prevent complications; whereas for on-urgent causes, immediate
treatment is not necessary.

5. The underlying cause for acute abdominal pain can be in the area of
many different specialties such as gynecology, surgery, internal
medicine, pediatrics, and urology. This leads to a large variation in the
choice of diagnostic modalities and treatment.

II. TARGET PATIENT POPULATION (INCLUSION CRITERIA)

1. All adult patients with acute abdominal pain.

III. CLINICAL SPECIALTY (INTENDED USERS)

1. ER. Family Medicine, OB-GYNE, General Surgeons, Internal
Medicine, and Urology.

IV. RECOMMENDATIONS
1. Introduction:
A. Abdominal pain is one of the most common reasons for
visiting the emergency room.

B. Acute abdomen can be a result of serious intra-abdominal

pathology necessitating emergency intervention.
 Document SFD-WI-CPG-001
Code:
SAINT FRANCIS DOCTORS’ Revision Rev. 00
No.:
HOSPITAL AND MEDICAL CENTER, INC. Date January 1, 2021
Effective:
Originating Department/Section/Committee: Page No. Page 2 of 5

Medical Services Division

Document Title:
Evaluation of Acute Abdominal Pain in Adult

C. Over 25% of abdominal pain cases are labeled as non-

specific or undifferentiated.

D. You should consider non-surgical causes of acute abdominal

pain.

2. Clinical Presentation (History and Examination): Workup for acute

abdominal pain includes patient’s history, physical examination
followed by laboratory and radiological studies.

A. History: Should focus on the details regarding the pain.

i. Pain: Onset: Sudden or Gradual.
a. Sudden: Perforated viscous, ruptured
abdominal aortic aneurysm.
b. Gradual: Inflammation like acute appendicitis or
acute cholecystitis.

ii. Character:
a. Burning: Peptic ulcer disease
b. Tearing: Aortic dissection
c. Colicky and intermittent: Obstruction:
Intestine/ureters/biliary tracts
d. Continuous and gradual: Inflammation,
ischemia

iii. Site (location) Radiation – Referral:

a. If pain referred to right subscapular – biliary
region
b. If pain referred to the back – Pancreatic in origin
c. If the pain radiates to the groin – Ureteric
d. If pain referred to right iliac fossa – Acute
appendicitis

iv. Aggravating/Alleviating Factors: Like food

movements, excretion, etc.

v. Associated Symptoms: Like nausea, vomiting,

constipation, abdominal distention, diarrhea, and
bleeding per rectum.
a. Pain followed by vomiting, mostly surgical
causes.
b. Pain, vomiting constipation, mostly obstruction
causes.
 Document SFD-WI-CPG-001
Code:
SAINT FRANCIS DOCTORS’ Revision Rev. 00
No.:
HOSPITAL AND MEDICAL CENTER, INC. Date January 1, 2021
Effective:
Originating Department/Section/Committee: Page No. Page 3 of 5

Medical Services Division

Document Title:
Evaluation of Acute Abdominal Pain in Adult

vi. Past Medical/Surgical History:

a. Abdominal surgery, diabetes mellitus, heart/lung
diseases.
b. Medications: Anticoagulants, NSAID
c. Social history, Gynecological history, and
Family history.

B. Physical Examination:
i. General Examination:
a. Overall appearance
i. If the patient is anxious, pale, sweaty →
vascular origin like AAA or mesenteric
ischemia.
ii. If the patient is lying still with the knee
flexed → peritonitis or pancreatitis.
b. Vital Signs: Pulse, temperature, blood pressure,
respiratory rate
c. Cardiac and lung examination in a patient with
upper abdominal pain.

ii. Abdominal Examination: Steps involved:

a. Inspection
b. Auscultation
c. Percussion
d. Palpation in that order of frequency.
e. Scars of previous surgery, abdominal distention,
visible peristalsis, swelling over hernia orifices,
rigidity, and tenderness, exaggerated or absent
intestinal sounds.

C. Laboratory Investigations: Lab studies are used to narrow

down the differential diagnosis.
i. CBC with differential leukocytosis with left shift →
inflammation or infection
ii. A normal WBC count does not rule out appendicitis.
iii. CRP
iv. Serum electrolytes
v. Blood Urea Nitrogen (BUN)
vi. Liver Function Tests (LFTs)
vii. Amylase and lipase measurements are recommended
in patients with epigastric pain
 Document SFD-WI-CPG-001
Code:
SAINT FRANCIS DOCTORS’ Revision Rev. 00
No.:
HOSPITAL AND MEDICAL CENTER, INC. Date January 1, 2021
Effective:
Originating Department/Section/Committee: Page No. Page 4 of 5

Medical Services Division

Document Title:
Evaluation of Acute Abdominal Pain in Adult

viii. Serum amylase – (Non-specific increase in many other

causes)
ix. Serum lipase – in acute pancreatitis
x. Urine Analysis
xi. HCG in all female of childbearing age.
xii. Blood grouping or cross-matching

D. Radiological Studies:
i. Plain Film
a. Perforated viscous: Air under diaphragm
b. Intestinal obstruction multiple fluid levels.
ii. Ultrasound Abdomen – Ultrasound is the imaging
study of choice for evaluating patients with acute right
upper quadrant pain.
a. Suspected hepatobiliary diseases like acute
cholecystitis
b. In pregnant women (pelvic or transvaginal
ultrasound)
iii. Computed Tomographic Scan – CT scan is an
imaging study of choice for evaluating patients with
acute right or left lower quadrant abdominal pain.
a. Acute appendicitis 96% sensitivity decrease
rate of negative appendectomy from 24% to 3%
b. Obese patients
iv. Magnetic Resonance Imaging (MRI)
a. Only in pregnant females with equivocal
ultrasound findings

E. Diagnostic Laparoscopy
i. If underlying etiology remains unclear despite clinical
evaluation and radiological imaging.
ii. Decrease negative laparotomy rate.
iii. Can be therapeutic at the same time.

F. Therapeutic Options:
i. Operative intervention: (See Algorithm)
a. Immediate/emergent
b. Urgent/within a few hours
ii. Patient stabilization if his/her condition permits.
iii. Specific treatment strategy for the acute abdomen is
largely dependent upon underlying etiology.
G. Special Patient Population: Needs special attention and
management.
 Document SFD-WI-CPG-001
Code:
SAINT FRANCIS DOCTORS’ Revision Rev. 00
No.:
HOSPITAL AND MEDICAL CENTER, INC. Date January 1, 2021
Effective:
Originating Department/Section/Committee: Page No. Page 5 of 5

Medical Services Division

Document Title:
Evaluation of Acute Abdominal Pain in Adult

i. Extremes of age
ii. Immunocompromised patients
iii. Critically ill patients
iv. Morbidly obese patients
v. Pregnant patients

H. Diagrams and Algorithm

V. QUALITY CONTROL
1. COMPLIANCE (USE) MEASURE
The patients > 14 years of age with acute abdominal pain to whom
these guidelines are applied.

2. EFFECTIVENESS (OUTCOME) MEASURE

Percentage of patients managed properly and discharged home safely
Patient’s experience
Absence of morbidities and mortalities

VI. REFERENCES
1. Evaluation of Acute Abdomen, BMJ Best Practice July 2021

2. Approach to Acute Abdominal pain: Practical Algorithms Advanced

Journal of Emergency Medicine 2020, 4(2):29

3. Systematic review of diagnostic pathways for patients presenting with

acute abdominal pain, International Journal for Quality Healthcare
Volume: 30(9), 2018

4. Practice Guidelines for Primary Care of Acute Abdomen 2015, Journal

hepato-biliary-pancreatic Society, 2016, 23 (3-36)

VII. APPENDICES
1. Management Algorithm of Epigastric Tenderness
2. Management Algorithm of Right Upper Quadrant Tenderness
3. Management Algorithm of Left Upper Quadrant Tenderness
4. Management Algorithm of Right Lower Quadrant Tenderness
5. Management Algorithm of Left Lower Quadrant Tenderness

Prepared by: Approved by:

DARRYL DALE ESPANCHO DR. DURES FE E. TAGAYUNA

System Document Controller, Administrative Department President