Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Evaluation of the adult with abdominal pain in the emergency department

John L Kendall, MD, FACEP
Maria E Moreira, MD
Section Editor
Robert S Hockberger, MD, FACEP
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Abdominal pain continues to pose diagnostic challenges for emergency clinicians. In many cases, the differential diagnosis is wide, ranging from benign to life-threatening conditions. Causes include medical, surgical, intraabdominal, and extraabdominal ailments. Associated symptoms often lack specificity and atypical presentations of common diseases are frequent, further complicating matters.

The elderly, the immunocompromised, and women of childbearing age pose special diagnostic challenges. Elderly and diabetic patients often have vague, nonspecific complaints and atypical presentations of potentially life-threatening conditions leading to time consuming workups [1,2]. The immunocompromised patient may suffer from a wide range of ailments, including unusual and therapy-related conditions. Pregnancy leads to physiologic and anatomic changes affecting the presentation of common diseases. (See "Approach to acute abdominal pain in pregnant and postpartum women".)

This topic review will discuss how to assess the adult patient presenting to the emergency department (ED) with abdominal pain, and provide a synopsis of important diagnoses to consider. Detailed discussions of specific diagnoses are found separately.


Abdominal pain comprises 5 to 10 percent of emergency department (ED) visits [3-6]. Despite sophisticated diagnostic modalities, undifferentiated abdominal pain remains the diagnosis for approximately 25 percent of patients discharged from the ED and between 35 and 41 percent for those admitted to the hospital [4,7-9]. Approximately 80 percent of patients discharged with undifferentiated abdominal pain improve or become pain-free within two weeks of presentation [9].

Older patients with abdominal pain have a six- to eightfold increase in mortality compared to younger patients [1,10]. The elderly (ie, patients over 65 years of age) account for 20 percent of ED visits, of which 3 to 4 percent are for abdominal pain [1,10,11]. About one-half to two-thirds of these patients requires hospitalization, while one-third requires surgical intervention [2,5,12-14]. Some studies suggest the elderly sustain increased mortality when their diagnosis is not determined in the ED [15].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 06, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hustey FM, Meldon SW, Banet GA, et al. The use of abdominal computed tomography in older ED patients with acute abdominal pain. Am J Emerg Med 2005; 23:259.
  2. Cooper GS, Shlaes DM, Salata RA. Intraabdominal infection: differences in presentation and outcome between younger patients and the elderly. Clin Infect Dis 1994; 19:146.
  3. Brewer BJ, Golden GT, Hitch DC, et al. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg 1976; 131:219.
  4. Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995; 13:301.
  5. Sanson TG, O'Keefe KP. Evaluation of abdominal pain in the elderly. Emerg Med Clin North Am 1996; 14:615.
  6. Kamin RA, Nowicki TA, Courtney DS, Powers RD. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am 2003; 21:61.
  7. Irvin TT. Abdominal pain: a surgical audit of 1190 emergency admissions. Br J Surg 1989; 76:1121.
  8. Jess P, Bjerregaard B, Brynitz S, et al. Prognosis of acute nonspecific abdominal pain. A prospective study. Am J Surg 1982; 144:338.
  9. Lukens TW, Emerman C, Effron D. The natural history and clinical findings in undifferentiated abdominal pain. Ann Emerg Med 1993; 22:690.
  10. Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. J Gerontol A Biol Sci Med Sci 2005; 60:1071.
  11. Kizer KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med 1998; 16:357.
  12. Marco CA, Schoenfeld CN, Keyl PM, et al. Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes. Acad Emerg Med 1998; 5:1163.
  13. de Dombal FT. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol Suppl 1988; 144:35.
  14. Bugliosi TF, Meloy TD, Vukov LF. Acute abdominal pain in the elderly. Ann Emerg Med 1990; 19:1383.
  15. Fenyö G. Acute abdominal disease in the elderly: experience from two series in Stockholm. Am J Surg 1982; 143:751.
  16. Barone JE, Gingold BS, Arvanitis ML, Nealon TF Jr. Abdominal pain in patients with acquired immune deficiency syndrome. Ann Surg 1986; 204:619.
  17. Yoshida D, Caruso JM. Abdominal pain in the HIV infected patient. J Emerg Med 2002; 23:111.
  18. Marston WA, Ahlquist R, Johnson G Jr, Meyer AA. Misdiagnosis of ruptured abdominal aortic aneurysms. J Vasc Surg 1992; 16:17.
  19. Sinha P, Kuruba N. Ante-partum haemorrhage: an update. J Obstet Gynaecol 2008; 28:377.
  20. Luber SD, Fischer DR, Venkat A. Care of the bariatric surgery patient in the emergency department. J Emerg Med 2008; 34:13.
  21. Ellison SR, Ellison SD. Bariatric surgery: a review of the available procedures and complications for the emergency physician. J Emerg Med 2008; 34:21.
  22. Edwards ED, Jacob BP, Gagner M, Pomp A. Presentation and management of common post-weight loss surgery problems in the emergency department. Ann Emerg Med 2006; 47:160.
  23. Potts DE, Sahn SA. Abdominal manifestations of pulmonary embolism. JAMA 1976; 235:2835.
  24. Styrud J, Eriksson S, Segelman J, Granström L. Diagnostic accuracy in 2,351 patients undergoing appendicectomy for suspected acute appendicitis: A retrospective study 1986-1993. Dig Surg 1999; 16:39.
  25. de Dombal FT. Acute abdominal pain in the elderly. J Clin Gastroenterol 1994; 19:331.
  26. Parker LJ, Vukov LF, Wollan PC. Emergency department evaluation of geriatric patients with acute cholecystitis. Acad Emerg Med 1997; 4:51.
  27. Baris D, Karagas MR, Verrill C, et al. A case-control study of smoking and bladder cancer risk: emergent patterns over time. J Natl Cancer Inst 2009; 101:1553.
  28. McNamara R, Dean AJ. Approach to acute abdominal pain. Emerg Med Clin North Am 2011; 29:159.
  29. Kelso LA, Kugelmas M. Nontraumatic abdominal pain. AACN Clin Issues 1997; 8:437.
  30. Yamamoto W, Kono H, Maekawa M, Fukui T. The relationship between abdominal pain regions and specific diseases: an epidemiologic approach to clinical practice. J Epidemiol 1997; 7:27.
  31. Staniland JR, Ditchburn J, De Dombal FT. Clinical presentation of acute abdomen: study of 600 patients. Br Med J 1972; 3:393.
  32. Purcell TB. Nonsurgical and extraperitoneal causes of abdominal pain. Emerg Med Clin North Am 1989; 7:721.
  33. Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emerg Med Clin North Am 2003; 21:937.
  34. Kresovich-Wendler K, Levitt MA, Yearly L. An evaluation of clinical predictors to determine need for rectal temperature measurement in the emergency department. Am J Emerg Med 1989; 7:391.
  35. Eskelinen M, Ikonen J, Lipponen P. Contributions of history-taking, physical examination, and computer assistance to diagnosis of acute small-bowel obstruction. A prospective study of 1333 patients with acute abdominal pain. Scand J Gastroenterol 1994; 29:715.
  36. Liddington MI, Thomson WH. Rebound tenderness test. Br J Surg 1991; 78:795.
  37. Bemelman WA, Kievit J. [Pysical examination--rebound tenderness]. Ned Tijdschr Geneeskd 1999; 143:300.
  38. Bennett DH, Tambeur LJ, Campbell WB. Use of coughing test to diagnose peritonitis. BMJ 1994; 308:1336.
  39. Markle GB 4th. A simple test for intraperitoneal inflammation. Am J Surg 1973; 125:721.
  40. Thomson H, Francis DM. Abdominal-wall tenderness: A useful sign in the acute abdomen. Lancet 1977; 2:1053.
  41. Singer AJ, Brandt LJ. Pathophysiology of the gastrointestinal tract during pregnancy. Am J Gastroenterol 1991; 86:1695.
  42. Adedeji OA, McAdam WA. Murphy's sign, acute cholecystitis and elderly people. J R Coll Surg Edinb 1996; 41:88.
  43. Quaas J, Lanigan M, Newman D, et al. Utility of the digital rectal examination in the evaluation of undifferentiated abdominal pain. Am J Emerg Med 2009; 27:1125.
  44. Manimaran N, Galland RB. Significance of routine digital rectal examination in adults presenting with abdominal pain. Ann R Coll Surg Engl 2004; 86:292.
  45. Wroblewski M, Mikulowski P. Peritonitis in geriatric inpatients. Age Ageing 1991; 20:90.
  46. Sivanesaratnam V. The acute abdomen and the obstetrician. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14:89.
  47. Graff L, Radford MJ, Werne C. Probability of appendicitis before and after observation. Ann Emerg Med 1991; 20:503.
  48. Nagurney JT, Brown DF, Chang Y, et al. Use of diagnostic testing in the emergency department for patients presenting with non-traumatic abdominal pain. J Emerg Med 2003; 25:363.
  49. Ramoska EA, Sacchetti AD, Nepp M. Reliability of patient history in determining the possibility of pregnancy. Ann Emerg Med 1989; 18:48.
  50. Silver BE, Patterson JW, Kulick M, et al. Effect of CBC results on ED management of women with lower abdominal pain. Am J Emerg Med 1995; 13:304.
  51. Elangovan S. Clinical and laboratory findings in acute appendicitis in the elderly. J Am Board Fam Pract 1996; 9:75.
  52. Calder JD, Gajraj H. Recent advances in the diagnosis and treatment of acute appendicitis. Br J Hosp Med 1995; 54:129.
  53. Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg 1984; 200:567.
  54. Paajanen H, Tainio H, Laato M. A chance of misdiagnosis between acute appendicitis and renal colic. Scand J Urol Nephrol 1996; 30:363.
  55. Puskar D, Bedalov G, Fridrih S, et al. Urinalysis, ultrasound analysis, and renal dynamic scintigraphy in acute appendicitis. Urology 1995; 45:108.
  56. Pomper SR, Fiorillo MA, Anderson CW, Kopatsis A. Hematuria associated with ruptured abdominal aortic aneurysms. Int Surg 1995; 80:261.
  57. Eisenberg RL, Heineken P, Hedgcock MW, et al. Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain. Ann Surg 1983; 197:464.
  58. Kellow ZS, MacInnes M, Kurzencwyg D, et al. The role of abdominal radiography in the evaluation of the nontrauma emergency patient. Radiology 2008; 248:887.
  59. Billittier AJ, Abrams BJ, Brunetto A. Radiographic imaging modalities for the patient in the emergency department with abdominal complaints. Emerg Med Clin North Am 1996; 14:789.
  60. Markowitz SK, Ziter FM Jr. The lateral chest film and pneumoperitoneum. Ann Emerg Med 1986; 15:425.
  61. Mindelzun RE, Jeffrey RB. Unenhanced helical CT for evaluating acute abdominal pain: a little more cost, a lot more information. Radiology 1997; 205:43.
  62. Maglinte DD, Reyes BL, Harmon BH, et al. Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol 1996; 167:1451.
  63. Ritz JP, Runkel N, Berger G, Buhr HJ. [Prognostic factors in mesenteric infarct]. Zentralbl Chir 1997; 122:332.
  64. Laméris W, van Randen A, van Es HW, et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009; 338:b2431.
  65. Jang T, Chauhan V, Cundiff C, Kaji AH. Assessment of emergency physician-performed ultrasound in evaluating nonspecific abdominal pain. Am J Emerg Med 2014; 32:457.
  66. Stoker J, van Randen A, Laméris W, Boermeester MA. Imaging patients with acute abdominal pain. Radiology 2009; 253:31.
  67. Siewert B, Raptopoulos V, Mueller MF, et al. Impact of CT on diagnosis and management of acute abdomen in patients initially treated without surgery. AJR Am J Roentgenol 1997; 168:173.
  68. MacKersie AB, Lane MJ, Gerhardt RT, et al. Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. Radiology 2005; 237:114.
  69. Nagurney JT, Brown DF, Novelline RA, et al. Plain abdominal radiographs and abdominal CT scans for nontraumatic abdominal pain--added value? Am J Emerg Med 1999; 17:668.
  70. Lee SY, Coughlin B, Wolfe JM, et al. Prospective comparison of helical CT of the abdomen and pelvis without and with oral contrast in assessing acute abdominal pain in adult Emergency Department patients. Emerg Radiol 2006; 12:150.
  71. Payor A, Jois P, Wilson J, et al. Efficacy of Noncontrast Computed Tomography of the Abdomen and Pelvis for Evaluating Nontraumatic Acute Abdominal Pain in the Emergency Department. J Emerg Med 2015; 49:886.
  72. Dewitte A, Biais M, Coquin J, et al. [Diagnosis and management of acute mesenteric ischemia]. Ann Fr Anesth Reanim 2011; 30:410.
  73. McSweeney SE, O'Donoghue PM, Jhaveri K. Current and emerging techniques in gastrointestinal imaging. J Postgrad Med 2010; 56:109.
  74. Espinoza R, Balbontín P, Feuerhake S, Piñera C. [Acute abdomen in the elderly]. Rev Med Chil 2004; 132:1505.
  75. Gürleyik G, Gürleyik E, Unalmişer S. Abdominal surgical emergency in the elderly. Turk J Gastroenterol 2002; 13:47.
  76. Rothrock SG, Green SM, Dobson M, et al. Misdiagnosis of appendicitis in nonpregnant women of childbearing age. J Emerg Med 1995; 13:1.
  77. Webster DP, Schneider CN, Cheche S, et al. Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age. Am J Emerg Med 1993; 11:569.
  78. Morishita K, Gushimiyagi M, Hashiguchi M, et al. Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age. Am J Emerg Med 2007; 25:152.
  79. John R, Johnson JK, Kukreja S, et al. Domestic violence: prevalence and association with gynaecological symptoms. BJOG 2004; 111:1128.
  80. Olson L, Anctil C, Fullerton L, et al. Increasing emergency physician recognition of domestic violence. Ann Emerg Med 1996; 27:741.
  81. Cope Z. Early Diagnosis of the Acute Abdomen, 2nd, Oxford, London 1921.
  82. Thomas SH, Silen W, Cheema F, et al. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg 2003; 196:18.
  83. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996; 3:1086.
  84. Gallagher EJ, Esses D, Lee C, et al. Randomized clinical trial of morphine in acute abdominal pain. Ann Emerg Med 2006; 48:150.
  85. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA 2006; 296:1764.
  86. Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev 2011; :CD005660.
  87. Birnbaum A, Schechter C, Tufaro V, et al. Efficacy of patient-controlled analgesia for patients with acute abdominal pain in the emergency department: a randomized trial. Acad Emerg Med 2012; 19:370.
  88. Smith JE, Rockett M, Creanor S, et al. PAin SoluTions In the Emergency Setting (PASTIES)--patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial. BMJ 2015; 350:h3147.
  89. Motov S, Rockoff B, Cohen V, et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2015; 66:222.
  90. Graff L, Russell J, Seashore J, et al. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med 2000; 7:1244.
  91. Sandhu GS, Redmond AD, Prescott MV. Non-specific abdominal pain: a safe diagnosis? J R Coll Surg Edinb 1995; 40:109.
  92. Gatzen C, Paterson-Brown S, Touquet R, Dudley HA. Management of acute abdominal pain: decision making in the accident and emergency department. J R Coll Surg Edinb 1991; 36:121.
  93. Gunnarsson OS, Birgisson G, Oddsdottir M, Gudbjartsson T. [One year follow-up of patients discharged from the emergency department with non-specific abdominal pain]. Laeknabladid 2011; 97:231.