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[page 193] [Italian Journal of Medicine 2015; 9:515] [page 193]
Introduction
Abdominal pain represents one of the most impor-
tant diagnostic challenges for any physician and its
correct interpretation and management require a
proper systematic approach and sometimes an urgent
action. Moreover the guidelines that can be referred
to for indications about the most adequate manage-
ment procedures are few and often focused only on ra-
diologic management. Therefore, we propose a review
of the literature on the diagnosis of abdominal pain,
which may contribute to improve the diagnosis and
treatment of this complex condition through a system-
atic review of the evidences available in this field.
Definition of the subject
Abdominal pain is classified as acute or chronic
based on an arbitrary cut-off of 12 weeks. To make a
differential diagnosis is very complex and requires an
accurate understanding of the medical history and a
comprehensive physical examination. Nonetheless the
cause remains unknown in 30% of cases.1,2
Abdominal pain: a synthesis of recommendations for its correct
management
Daniela Tirotta,1Annalisa Marchetti,2Mariangela Di Lillo,3Fulvio Pomero,4Roberta Re,5Michele Meschi,6
Domenico Montemurro,7Paola Gnerre,8Chiara Bozzano,9Micaela La Regina10
1Medicina Interna, Ospedale Cervesi, Cattolica (RN); 2Medicina d’Urgenza, Ospedali Riuniti, Ancona; 3Medicina di Ac-
cettazione e di Urgenza, Ospedali Riuniti, Marche Nord, Fano (PU); 4Dipartimento di Medicina Interna,
Ospedale S. Croce e Carle, Cuneo; 5Dipartimento di Medicina Interna, Ospedale Maggiore della Carità, Novara;
6Dipartimento di Medicina e Diagnostica, Ospedale Santa Maria, Parma; 7Dipartimento di Medicina Interna, Ospedale
S. Bortolo, Vicenza; 8UOC Medicina Interna, Ospedale San Paolo, Savona; 9UO Medicina Interna, Ospedale San Donato,
Arezzo; 10Medicina Interna, Ospedale Sant’Andrea, La Spezia, Italy
ABSTRACT
Abdominal pain represents one of the most important diagnostic challenges for any physician and its correct interpretation
and management require a proper systematic approach and sometimes an urgent action. Moreover the guidelines that can be re-
ferred to for indications about the most adequate management procedures are few and often focused only on radiologic mana-
gement. Consequently, the approach to abdominal pain is often empirical. Therefore, we propose a review of the literature on
the diagnosis of abdominal pain, which may contribute to improve the diagnosis and treatment of this complex condition through
a systematic review of the evidences available in this field. As to our methodology, we conducted an extensive search in the
main guideline databases (SIGN, ICSI, NICE, National Guideline Cleringhouse, CMA Infobase, NZ Guidelines Group, National
System Guidelines, Clinical Practice Guidelines Portal, eGuidelines), using as key words abdominal pain and abdominalgia.
The guidelines were assessed according to the 2010 Italian version of the AGREE (Appraisal of Guidelines, Research and Eval-
uation II) methodology. Afterwards we formulated our main recommendations associated with the corresponding levels of evi-
dence and focused our attention on some grey areas, which we investigated with further research using Medline and the main
systematic review databases (Cochrane database). The four main grey areas investigated were: hospital admission criteria, pro-
gnostic stratification, need for analgesic treatment and possibility of attributing abdominalgia to an abdominal pain syndrome.
We then formulated our consesus-based recommendations on the grey areas. Abdominal pain management remains a complex
issue for internists. As with other diagnostic challenges, it would be advisable to develop additional guidelines based on a multi-
disciplinary approach and not only focused on radiological management.
Correspondence: Daniela Tirotta, Medicina Interna, Ospedale
Cervesi di Cattolica (AUSL Romagna), via Beethoven 1,
47841 Cattolica (RN), Italy.
Tel.: +39.0541966291 - Fax: +39.0541966290.
E-mail: danitirotta@libero.it
Key words: Abdominal pain; management; hospital admission.
Conflict of interest: the authors declare no potential conflict
of interest.
See online Appendix for Summary.
Received for publication: 9 May 2014.
Revision received: 16 June 2014.
Accepted for publication: 25 June 2014.
This work is licensed under a Creative Commons Attribution
NonCommercial 3.0 License (CC BY-NC 3.0).
©Copyright D. Tirotta et al., 2015
Licensee PAGEPress, Italy
Italian Journal of Medicine 2015; 9:193-202
doi:10.4081/itjm.2015.515
Italian Journal of Medicine 2015; volume 9:193-202
Non-commercial use only
Epidemiology
Some observational studies have reported that
every year at least 1/3 of adults have an episode of ab-
dominal pain. The annual incidence of admissions to
Emergency Departments for this symptom is 44/1000,
whereas the hospital admission rate ranges between
18 and 42% depending on the studies.
An even more demanding challenge is managing
elderly patients: the admission rate of over 65s is as
high as 63%, 20-33% require urgent surgery, total
mortality is between 2 and 13%.3Diagnostic errors
can involve up to 70% of elderly patients.4,5
In 30% of cases a conclusive diagnosis cannot
even be made. The most common misdiagnosed cau-
ses are abdominal aneurysm, appendicitis, ectopic pre-
gnancy, diverticulitis, bowel perforation, mesenteric
ischemia and bowel obstruction.
Despite the causes for acute abdominal pain can be
>1000, about 80% of cases can be ascribed to acute ap-
pendicitis (26%), non specific abdominal pain (50%)
and acute cholecystitis (8%).6-10
Physiopathology of abdominal pain
The physiopathological mechanisms of abdominal
pain can be associated with peritoneal wall inflamma-
tion, obstruction of hollow bowels, vascular disorders
and abdominal wall alteration. On the contrary, extra-
abdominal referred pain, metabolic abdominal pain
and neurogenic abdominal pain share a different phy-
siopathology.
[page 194] [Italian Journal of Medicine 2015; 9:515]
Young FADOI internists: from evidence to clinical practice
Table 1. Abdominal pain by physiopathologic classes.
Pain of abdominal origin
Inflammation of the abdominal wall
Bacterial contamination (e.g., pelvic inflammatory disease, perforated appendix)
Chemical irritation (e.g., pancreatitis, perforated ulcer)
Mechanical obstruction of hollow bowels
Small and large intestine obstruction
Biliary tract obstruction
Ureter obstruction
Vascular diseases
Embolism or thrombosis
Vessel rupturing
Compression or torsion occlusion
Sickle-cell anemia
Changes in the abdominal wall
Mesenteric torsion/stretching
Muscle trauma/infections
Distension of visceral surfaces (e.g., kidney/liver capsule)
Referred extra-abdominal pain
Chest (e.g., pneumonia, coronary occlusion)
Spinal column (e.g., radiculitis due to artritis, Herpes zoster)
Genitals (e.g., testicular torsion)
Metabolic causes
Exogenous causes
Poisoning caused by lead and other substances
Black widow spider bite
Endogenous causes
Uremia
Diabetic ketoacidosis
Porphyria
Allergic factors (C1 esterase deficiency)
Neurogenic causes
Organic causes
Tabes dorsalis
Herpes zoster
Causalgia and other syndromes
Functional causes
Hematologic causes
Acute leukemia
Hemolitic anemia
Sickle-cell anemia
Henoch-Shönlein purpura
Modified from Tintinalli, 2004.1
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Differential diagnosis of abdominal pain
The differential dignosis of abdominal pain can be
based on physiopathologic categories (Table 1), type
of symptoms or site of pain.1
Methodology
Abdominal pain management:
collection of evidence
A search was made in the main databases using ab-
dominal pain or abdominalgia as keywords:
- Scottish Intercollegiate Guidelines Network (SIGN);
- Institute for Clinical System Improvement (ICSI);
- National Institute for Health and Clinical Excellence
(NICE) (NHS evidence);
- National Guideline Cleringhouse;
- Canadian Medical Association, CMA Infobase;
- New Zeland Guidelines Group;
- National Sistem Guidelines;
- Clinical Practice Guidelines Portal;
- eGuidelines.
The guidelines were assessed using the 2010 Ita-
lian version of the AGREE (Appraisal of Guidelines,
Research and Evaluation II) methodology.
We found and reviewed 7 guidelines (Table 2).11-18
Next, we extrapolated the main recommendations as-
sociated with the corresponding levels of evidence and
we conducted a methodological analysis.11
Grading levels of evidence
We referred to the evidence grading scheme deve-
loped within the framework of the Progetto Nazionale
Linee Guida (National Project Guideline), available
online at http://www.pnlg.it/doc/manuale: i) level I:
evidence from multiple clinical controlled trials and/or
systematic reviews of randomized studies; ii) level II:
evidence from a single randomized study with an ade-
quate design; iii) level III: evidence from non rando-
mized cohort studies or their meta-analysis; iv) level
IV: evidence from case-control retrospective studies
or their meta-analysis; v) level V: evidence from case
series with no control group; vi) level VI: evidence
from opinions of experts or expert committees as in-
dicated in the guidelines or consensus conferences.
We then focused our attention on the main 4 grey
areas we identified, and which we then investigated
with further research including also minor evidence:
studies from primary bibliographic databases and
other integrative reviews.
In particular, for hospital admission criteria, we
used the following research criteria: (“Abdominal
Pain”[Mesh]) AND “Hospitalization”[Mesh], Limits
Activated: Humans, English, French, Italian, All
Adult: 19+ years, years: 2000.
For prognostic stratification and management, we
adopted the following strategy published in Pubmed:
(“Abdominal Pain”[Mesh]) AND “Sensitivity and
Specificity”[Mesh]) AND “Diagnosis”[Mesh], also
(“likelihood ratio”[Mesh]) AND “Sensitivity and Spe-
cificity”[Mesh]) and AND “abdominal pain”[Mesh]),
Limits Activated: Humans, English, French, Italian,
All Adult: 19+ years, years:2000.
As to the need for analgesic treatment, we relied
on the Cochrane Database and Pubmed with mesh
analgesia AND abdominal pain.
Summary of abdominal pain guidelines
To create a more synthetic and systematic organi-
zation of recommendations extracted from the guide-
lines, we have divided them into four subchapters,
which correspond to four clinical syndromes: patients
with abdominal pain/acute non-specific abdominal
pain, patients with abdominal pain in one quadrant,
patient with abdominal pain and fever or suspected
[page 195] [Italian Journal of Medicine 2015; 9:515] [page 195]
Abdominal pain
Table 2. Evidence table.
Guidelines AGREE
Cartwright and Knudson, 200811 (38+75+39)/3=50.6
ACR, 200812 (56+67+75)/3=66
American College of Emergency Physicians, 201013 (59+57+56)/3=57.3
Society of American Gastrointestinal and Endoscopic Surgeons, 200714 (83+81+81)/3=81.6
ACR, 200815 (57+55+75)/3=62.3
ACR, 201016 (60+60+74)/3=64.6
ACR, 201016 (59+86+75)/3=73.3
National Collaborating Centre for Nursing and Supportive Care, 200817 (130+133+132)/3=131
World Gastroenterology Organisation, 200918 (60+67+74)/3=67
AGREE, Appraisal of Guidelines, Research and Evaluation II; ACR, American College of Radiology.
Non-commercial use only
acute appendicitis and, finally, patient with abdominal
pain secondary to suspected irritable bowel syndrome
(IBS) and, finally, patients with abdominal pain/acute
non specific abdominal pain.
Guidelines for this clinical picture: two guidelines
focus on patients with acute abdominal pain/diffuse
non specific abdominal pain.14,19
Recommended strategy: i) white blood cell count;
ii) prescription of abdominal ultrasound (US); iii) pre-
scription of abdominal computed tomography (CT)
with contrast agent (CA); iv) prescription of additional
imaging exams; v) diagnostic laparoscopy (DL).
Outcome: diagnosis.
Recommendations: i) the white blood cell count
confirms, but does not exclude, appendicitis even if it
is negative (level VI); ii) DL can be safely performed
in selected patients (level III), but it is not indicated
before non invasive procedures, despite it can be su-
perior to observation (level III). This procedure can be
considered for patients with acute abdominal pain of
unknown origin, after an appropriate clinical asses-
sment and imaging exams (VI).
Patients with abdominal pain in one quadrant
Guidelines for this clinical picture: four guidelines
provide recommendations for this symptom.15,16,19
Recommended strategy: i) request for amylase and
lipase tests; ii) prescription of abdominal US; iii) pre-
scription of abdominal CT with CA; iv) prescription
of additional imaging exams.
Outcome: diagnosis.
Recommendations: i) for the preliminary differential
diagnosis of epigastric pain, the pancreatic enzyme tests
are recommended (level VI); ii) for the preliminary dif-
ferential diagnosis of pain in the upper right quadrant,
abdominal US is recommended (level VI); iii) for the
differential diagnosis of pain in the lower quadrants, ab-
domen-pelvis CT is in general the most accurate
method. However for children, US is preferable. Also
for pregnant women, US is preferable and, if no diagno-
sis is obtained, abdominal nuclear magnetic resonance
(NMR) imaging should be prescribed (level VI); iv) for
the differential diagnoses of pain in the lower left qua-
drant, abdomen-pelvis CT is appropriate, but it is asso-
ciated with a high risk of radiation exposure. Other
techniques involve an intermediate appropriateness risk
with lower radiation doses. During pregnancy, indica-
tions are similar, but the most appropriate techniques are
US, also trans-rectal and trans-vaginal US, and, to a les-
ser extent, the barium enema (level VI).
Patient with abdominal pain and fever
or suspected acute appendicitis
Guidelines for this clinical picture: two guidelines
provide recommendations for these symptoms.13,16 Six
groups of patients are defined: i) adults with suspected
acute appendicitis; ii) children with suspected acute
appendicitis; iii) patients with acute abdominal pain
and fever after surgery; iv) patient with acute abdomi-
nal pain and fever with negative CT for abscesses in
the previous 7 days; v) patient with acute abdominal
pain and fever not operated; vi) pregnant patient.
Recommended strategy: i) use of clinical elements
(signs and symptoms); ii) use of abdomen-pelvis CT
with intra-venous or oral CA; iii) abdominal US; iv)
use of CT without CA; v) use of alternative techniques
(abdominal MR imaging with and without CA, abdo-
minal radiography with gastrografin, gallium and la-
belled leukocyte scintigraphy).
Outcome: diagnosis.
Recommendations: clinical elements (signs and
symptoms) are useful to stratify the patients and make
decisions on lab tests, imaging, management (di-
scharge, observation, surgical assessment) (level III).
The abdomen-pelvis CT scan confirms or excludes an
acute appendicitis and the CA enhances the sensitivity
of this tecnique (level III). Abdominal ultrasound con-
firms, but does not exclude an acute appendicitis and
is recommended in children and, as a preliminary exa-
mination, in adults (level III). Alternative imaging te-
chniques are less appropriate, but often pose fewer
risks associated with radiation exposure.
Patient with abdominal pain and hemodynamic
instability or severe abdominal distension
and a clear indication for laparotomy
One guideline provides recommendations for this
clinical picture.14
Recommended strategy: diagnostic laparotomy.
Recommendation: diagnostic laparotomy should
be avoided for the former clinical picture, while it has
a limited role for the latter (level VI).
Patient with abdominal pain secondary
to suspected irritable bowel syndrome
Two guidelines provide recommendations for this
clinical picture.17,19
Recommended strategy: i) examination and con-
firmation of the IBS; ii) investigation of red flags.
Recommendations: IBS must be suspected in case
of: abdominal pain or discomfort, change in bowel ha-
bits, bloating for at least 6 months16 (level III), abdomi-
nal pain/discomfort and chronicity, intermittent pain,
previous episodes, relief of pain with defecation, unu-
sual night time diffuse and localized pain18 (level VI).
IBS can be confirmed if: abdominal pain/di-
scomfort is relieved by defecation or is associated with
altered bowel frequency or altered stool consistency
accompanied by at least two of the following symp-
toms: straining, urgency, incomplete evacuation/abdo-
[page 196] [Italian Journal of Medicine 2015; 9:515]
Young FADOI internists: from evidence to clinical practice
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minal bloating/worsening by eating/mucus in the
stools16 (level I-III); on the basis of the Roma III cri-
teria: i) presence of symptoms for at least 6 month
before diagnosis; ii) recurrent abdominal pain or di-
scomfort for more than 3 days a month in the last 3
months; iii) at least 2 of the following features: clinical
improvement by defecation; association with a change
in bowel frequency or stool consistency18 (level I-III).
Patients should be examined to identify any red
flags: unexplained or unintentional weight loss, rectal
bleeding, family history of bowel or ovarian cancer,
change in bowel habits to more frequent stools persi-
sting for more than 6 weeks in a patient aged over 60
years; also: anemia, abdominal/rectal masses, inflam-
matory bowel disease17,18 (level I-III).
Main drawbacks of the assessed guidelines
These guidelines focus primarily on abdominal pain,
therefore they exclude other diseases associated with
other symptoms (such as a change in bowel habits or
melaena/hematemesis). Therefore abdominal pain as-
sociated with inflammatory bowel syndrome or anaemia
or a change in bowel habits should suggest a gastroen-
teric disease or an inflammatory bowel disease or, also,
a neoplastic etiology based on clinical criteria. However
this topic is outside the scope of this monograph.
Abdominal pain classified by quadrants is covered
by various guidelines issued by radiological societies
and can be a bias in terms of clinical methodology.
Grey areas
Four unanswered background questions have been
identified in the guidelines examined: i) Are there any
criteria to decide whether to keep at the hospital or di-
scharge a patient with acute abdominal pain? ii) For
the purpose of abdominal pain stratification what is
the value of the abdominal pain severity scores? iii)
Should the degree of pain be always assessed? Should
the analgesic therapy be always deferred initially? iv)
Are there any criteria to associate a patient with abdo-
minal pain to a specific abdominal syndrome?
Background question 1
Are there any criteria to decide whether to keep at
the hospital or discharge a patient with acute abdo-
minal pain?
Recommendation: the decision should be substan-
tially based on the clinical picture considering the
usual state of health of the patient, the identification
of any systemic involvement associated with the main
disease and the potential evolution of the category of
the suspected disorder (level VI). These variables
should lead to a preliminary assessment of the severity
and the presence of any potential indications of surgi-
cal abdomen (level VI).20-22
Despite in some case reports, the rate of inappro-
priate abdominal emergencies ranges from 5% to 82%,18
at present the flow of patients with abdominal pain is
not managed on a codified basis in emergency depart-
ments. In the literature some algorhytms are reported
that can be applied in hospitals. They are based on emer-
gency level, maximum waiting time before treatment
and most appropriate structures to treat these cases.
The primary goal is to define the severity of abdo-
minal pain: i) emergency (abdominal pain with gene-
ralized signs of severity, signs of shock). In this case,
the team should initiate resuscitation measures and
refer the patient to the surgery ward or the intensive
care unit; ii) urgency (abdominal pain with localized
signs of severity). In this case (evident local signs: oc-
clusive/peritoneal syndrome for suspected appendici-
tis, cholecystitis, sigmoiditis, strangulated hernia), the
team should agree on the necessary tests and exami-
nations to perform and the medical/surgical strategy
to implement; iii) relative urgency (no signs of seve-
rity). If the case is relatively urgent (abdominal pain
without local or generalized signs of severity), the
team should assess the following: i) Is the diagnosis
confirmed, suspected or unclear? ii) Should the patient
be admitted to hospital and why? iii) Which radio-
graphic examinations should be requested and when
(are they urgent or can they be deferred)?
The identification of an emergency should be based
on: clinical signs (signs of shock: tachycardia, hypoten-
sion, bleeding, confusion, respiratory distress, anuria);
biological signs (anaemia, dehydration, acidosis, kidney
failure). The diagnosis is sometimes evident and requi-
res immediate surgery, whereas on other occasions an
urgent abdominal CT scan may be required.
The main causes for an emergency are: i) ruptured
ectopic pregnacy or other cause of hemoperitoneum; ii)
ruptured aneurysm; iii) occlusion and peritonitis detec-
ted late or in fragile patients (children, elderly, immu-
nodepressed); iv) mesenteric ischemia or colic necrosis;
v) acute necrotizing-hemorrhagic pancreatitis.
These causes require prompt resuscitation measures
and often surgery, which correlates to the state of the
patient at time of admission, the decision-making speed
and the quality of the resuscitation procedure.
The second goal is to rule out a surgical abdomen,
which can be identified by a clinical examination in
70% of cases. Sometimes the clinical findings are not
specific, therefore either the patient is promptly admit-
ted to hospital and kept under observation or an US-CT
is performed to find more indications and refer him/her
to a medical department or to the surgical ward.
The following should be assessed in particular: wor-
sening of pain on palpation, a defensive reaction (peri-
toneal irritation), peritonism (sign of abdominal sepsis),
[page 197] [Italian Journal of Medicine 2015; 9:515] [page 197]
Abdominal pain
Non-commercial use only
more peritoneal signs (pain when breathing in and out
and coughing), no peristalsis or peristalsis with metallic
sounds. These signs are associated with hospital admis-
sion in 70% of the cases, if they are simultaneous.
Background question 2
For the purpose of abdominal pain stratification
what is the value of the abdominal pain severity scores?
Recommendation: scores are helpful to grade the
risk, however they cannot lead to a conclusive diagno-
sis (level I).23-34
In a recent health technology assessment36 the use
of a diagnostic tool seems useful to confirm the dia-
gnosis of acute appendicitis, but not to exclude it.
Among potentially helpful scores, we can name:
-Alvarado score: it can be used to assess pain in the
right iliac fossa [a score ≥7 has a positive predictive
value (PPV) of 84% for appendicitis and, in some stu-
dies, if ≥4, it suggests admission to hospital]. Further-
more, it can also be used outside hospital settings.
-APACHE score II, Ranson score: scores for acute
pancreatitis (Table 3).
Ranson score: early assessment system (mortality
of 0-3% if score <3, 11-15% if score ≥3, 40% if ≥6).
Although the system is still in use, a recent meta-
analysis has shown it has a poor predictive value.22
APACHE score II: originally it was used in the In-
tensive care Unit for critically-ill patients. At present it
is also used in acute pancreatitis. It has a good negative
predictive value (NPV) and a modest PPV for severe
acute pancreatitis. If the score is <8, mortality is below
4%; if it is >8, mortality is 11-18%. Drawbacks: it is
complex and does not differentiate necrotizing and in-
terstitial pancreatitis from sterile and infected necrosis.
Furthermore it has a PPV in the first 24 h [the predictive
value can be enhanced using the addition of a body mass
index score to APACHE II (known as APACHE O)].
- Ripasa score: it is used when acute appendicitis is su-
spected. Cut-off is 7.5, sensitivity (SE) is 88%, spe-
cificity (SP) is 67%, PPV is 93% and NPV is 53%.
Among other relevant factors we can include: i)
marked lymphopenia and neutropenia;23,24 ii) the
Roma III criteria and the Carnet’s sign for functional
etiology; iii) plasma lactates; iv) pain chronicity seems
to be associated with low education, female gender
and a history of abuse in young age.
Background question 3
Should the degree of pain be always assessed?
Should the analgesic therapy be always deferred ini-
tially?
In case of discharge from hospital, an analgesic
treatment can be prescribed and followed up in the
short term. In case of admission to hospital, analgesics
can be administered, while the patient is waiting in the
emergency department (sometimes for hours). Ac-
tually both a rehydration therapy (particularly in case
of sepsis) and an analgesic therapy are recommended
and don not seem to affect the management of the pa-
tient (level I).36-38
A recent Cochrane systematic review recommends
the use of opioid analgesics to control acute abdominal
pain, since they cannot affect the diagnosis, nor the se-
lection of treatment.39
Background question 4
Are there any criteria to associate a patient with
abdominal pain to a specific abdominal syndrome?
In the literature, just like in the clinical practice,
no structured approach to the differential diagnosis is
available. The clinical assessment should lead to the
identification of a specific syndrome on the basis of
the characterization of pain and the concomitant
symptoms (e.g., dull pain indicative of acute mesen-
teric ischemia, some types of bleedings and chemical
peritonitis; progressive pain associated with inflam-
mation, sepsis, distension of solid organs; colic pain
usually associated with occlusion of hollow organs),
vital signs (the most sensitive are heart rate, body tem-
perature, respiratory rate, blood pressure and urinary
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Young FADOI internists: from evidence to clinical practice
Table 3. Predictive severity scores in pancreatitis.
Time (h) SE (%) SP PPV NPV Accuracy
0
Clinical 44 95 65 87 84
Apache II 63 81 46 89 77
24
Clinical 59 96 75 90 88
Apache II >10 71 91 67 93 87
48
Clinical 66 95 76 92 89
Ranson >2 75 68 37 91 69
Apache II >9 75 92 71 93 88
SE, sensitivity; SP, specificity; PPV, positive predictive value; NPV, negative predictive value.
Non-commercial use only
output), assessment of the clinical picture (such as hi-
story of unoperated abdominal aneurysm, use of anti-
coagulants) (level VI).
Abdominal pain can be included in one of the fol-
lowing clinical syndromes: i) localized or diffuse pe-
ritonitic syndrome; ii) unspecific abdominal pain: pain
syndrome of non-gastric or medical origin, irritable
bowel disease; iii) vascular syndrome; iv) occlusal
syndrome.40
Peritonitic syndrome
The diagnosis of peritonitis is generally clinical,
although the onset is often insidious. Recommenda-
tions are based on consensus (level VI).41,42
Symptoms include: fever and shivering; abdomi-
nal pain or discomfort (70% of patients); unexplained
or rapidly progressive encephalopathy; diarrhea; asci-
tes unresponsive to diuretic therapy; ileus; nausea and
anorexia (that can precede pain) and vomiting (secon-
dary to organ pathology, such as peritoneum obstruc-
tion or inflammation). The patient appears to be very
unwell, temperature is often above 38°C, although se-
psis may also be accompanied by hypotermia. Subse-
quently the patient becomes oliguric and anuric until
shock develops.
Initially pain can be poorly localized (abdominal
wall), then it becomes more severe and localized (ab-
dominal wall) and can be exacerbated by coughing,
breathing in and out (SE 37%, SP 94%, PPV 70%,
NPV 79%).
Signs and symptoms can be misleading or concea-
led by: diabetes mellitus or other immunodepressed
conditions; advanced age; ascites (cirrhosis or neph-
rotic syndrome); peritoneal dialysis; steroid treatment.
Accurate management includes differentiation
between primary and secondary peritonitis.
Primary peritonitis is diffuse and/or is not associated
with a history of gastro-intestinal disease. In other cases
(localized or diffuse peritonitis with known gastro-in-
testinal disease), peritonitis is likely to be secondary.
In case of primary peritonitis, it is recommended to
perform a chemical and physical test and a culture of a
sample of ascitic tissue or from the peritoneal dialysis
and to initiate an antibiotic and support treatment to be
continued for 7 days. If the patient does not respond,
repeat the culture tests and remove the catheter.
The clinical history includes recent abdominal sur-
gery, previous episodes of peritonitis, travels, immuno-
suppressive therapy, comorbidity (chronic inflammatory
bowel disease, diverticolitis, peptic ulcer), which can
predispose to abdominal infections.
Non-specific abdominal pain
Non-specific abdominal pain is defined as a pain
of unknown origin at the time of admission to hospital
and requires surgery (in particular the patient has no
fever, no tachycardia and no abdominal tender-
ness).43,44 In general this is a self-limiting disorder (in
some more favorable cases the patient has no symp-
toms at 5 years in 77% of cases), which, however,
leads to 13-40% of admissions for surgery. In this
case, observation can be important. The patient should
be re-assessed within 24 h, because this might be an
unusual presentation of other acute diseases, such as
acute miocardial infarction and ischemic colitis.
Recent cases from etiological studies have shown
that 10% of patients have a neoplastic disease (in par-
ticular above 50 years of age). Sometimes it is caused
by gynecologic and urologic diseases, functional di-
seases, such as the irritable bowel syndrome (see gui-
delines previously examined); sometimes it is caused
by coeliac disease. Two disorders are often reported:
mild alcoholic pancreatitis, crisis secondary to sickle-
cell anemia.
Furthermore, a drug-related etiology should also
be considered: non-steroidal anti-inflammatory drugs,
erythromycin, other antibiotics (colitis due to clin-
damycin, cephalosporins, ampicillin, amoxicillin) and
sub-occlusion secondary to constipation.
Vascular abdominal syndrome
Vascular abdominal syndromes represent a severe
abdominal emergency, are typical of advanced age
and, although rare (1% of causes for acute abdominal
pain), they are associated with a high mortality rate
(10-90% of cases).45-49
The clinical picture in the early stages is unspecific
and similar to other abdominal syndromes (peritonitis,
occlusion). Pain can be acute, sudden (arterial embo-
lism or thrombosis) or slowly progressing (ischemia
by non occlusal causes or venous mesenteric throm-
bosis), associated with nausea, vomiting and change
in bowel habits.
Initially the physical examination is unspecific,
whereas at later stages (>6 h, necrotic evolution), the
patient develops typical signs of peritonitis, hemody-
namic instability and signs and symptoms of sepsis
with failure of multiple organs.
For an accurate and early diagnosis it is fundamen-
tal to identify the main risk factors when the medical
history is assessed.
Various pathogenic entities can be recognized with
the following characteristics: myocardial infarction/in-
testinal ischemia; aortic aneurysm rupturing or fissure,
abdominal aneurysm rupturing; abdominal blood ves-
sel thrombosis.
The main consensus-based recommendations for
a diagnosis of acute intestinal ischemia (level VI) in-
clude: i) significant risk factors: age >60 years; atrial
fibrillation or history of paroxymal atrial fibrillation,
recent myocardial infarction, heart failure, shock, pre-
vious arterial embolism; history of abdominal pain
[page 199] [Italian Journal of Medicine 2015; 9:515] [page 199]
Abdominal pain
Non-commercial use only
after eating and weight loss; abdominal pain inconsi-
stent with physical examination findings; nausea, vo-
miting; ii) suggestive test results, if associated with
significant risk factors: leukocytosis, increase of lac-
tate dehydrogenase and creatine phosphokinase, me-
tabolic acidosis.
In case of significant risk factors and hemodyna-
mic stability, angiography is recommeded with a si-
multaneous vasodilator infusion or papaverine infu-
sion in the superiror mesenteric artery, if readily
available; otherwise CT angiography is recommended.
If signs of peritonism and hemodynamic instability
are present, emergency exploratory laparotomy is re-
commended with resection of the necrotic intestinal
[page 200] [Italian Journal of Medicine 2015; 9:515]
Young FADOI internists: from evidence to clinical practice
Figure 1. Abdominal pain: diagnostic flow-chart.
Non-commercial use only
tract and revascularization (embolectomy, thrombec-
tomy and intra-arterial infusion of papaverine and va-
sodilators).
The following clinical factors are suggestive of
aortic aneurysm fissure or rupturing (the main progno-
stic factor is the size of the aneurysm): abdominal and
lumbar pain, shock, pulsating abdominal mass, syn-
chronous or asynchronous femoral pulses, risk factors
(smoking, family history, age>70 years, history of
atherosclerosis, female sex, diabetes, African race).
Among the diagnostic factors suggestive of a th-
rombosis of abdominal blood vessels, we highlight
(level VI): lower limb ischemia (no pulse, pallor, pa-
resthesia, pain), signs of mesenteric ischemia, signs of
spinal cord infarction.
The preliminary management of a patient with su-
spected aortic thrombosis requires an immediate CT an-
giography of the abdomen. In case of acute aortic
thrombosis, emergency laparotomy is required with
trombectomy or embolectomy or coronary artery by-
pass graft. In case of chronic or sub-acute occlusion, the
need for emergency surgery depends on the severity of
the clinical picture and the occlusion progression. The
strategy required most often in these cases is observa-
tion and anti-aggregating or anti-coagulating therapy.
Occlusal abdominal syndrome
The suspicion of an occlusal abdominal syndrome
is based on the clinical history of the patient and a
number of symptoms: abdominal pain, which is ini-
tially cramp-like and then becomes continuous; me-
teorism, tympanic abdomen, peristalsis with metallic
sounds, which, on the contrary are absent in paralytic
ileus. Vomiting is frequent in particular in upper oc-
clusions (small intestine); in distal occlusions, fecaloid
vomiting can be present.
The main recommendations are based on consen-
sus (level VI).50,51
Suggestive clinical history: previous abdominal
surgery, radiation therapy, bowel inflammatory disor-
ders, weight loss, constipation, pain in the upper ab-
dominal quadrant (biliary ileus).
An accurate preliminary management of abdominal
occlusal syndrome includes a differential diagnosis
between a mechanical obstruction and a paralytic ileus.
In case of mechanical ileus of unknown origin, an
abdominal CT scan with intravenous CA must be
performed immediately. In case of complications, such
as strangulation and intestinal ischemia, the patient
must be referred to the surgeon for emergency surgery.
If no indication for emergency surgery is present, a
conservative strategy must be implemented with sup-
port therapy (fluids), intestinal decompression (inser-
tion of naso-gastric tube and/or rectal tube) and
subsequent assessment; in case this clinical picture
persists, an exploratory laparotomy can be useful.
In case of a likely occlusion of the small intestine,
oral administration of CA (gastrografin) is required;
after 8 h bowel transit must be assessed in the colon
by abdominal radiography. If bowel transit is positive,
the patient must be kept under observation for 4-5
days. If no bowel transit is present, an exploratory la-
parotomy is indicated.
A summary of the management procedure propo-
sed is reported in Figure 1, whereas online Appendix
summarizes the proposed management procedure for
abdominal pain and the differential diagnosis factors.
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