Acute Abdomen: Clinical Context and Indications for Imaging

  • Philipe N. Khalil
Part of the Medical Radiology book series (MEDRAD)


The acute abdomen is characterized by the sudden onset of severe abdominal pain, which requires emergency medical or surgical consultation. It can be caused by diseases of any of the abdominal organs or organ systems, and, as such, the acute abdomen represents a physical condition rather than a disease. However, extra-abdominal disease may also lead cause an acute abdomen. A rapid and accurate diagnosis is essential because various potentially life-threatening processes may be the underlying causes of the physical complaints. Because of the wide spectrum of diseases that may cause an acute abdomen, the use of imaging techniques, in particular, multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI), is often warranted because of their ability to suggest alternative diagnoses if the suspected clinical diagnosis is unconfirmed by ultrasonography (US). Depending on the clinical pattern and basic diagnosis, the treatment of such injuries requires a balance between the quick availability, the possible diagnostic benefit of additional and potential radiation exposures by imaging, possible time delay. These circumstances are particularly relevant for patients with life-threatening illnesses, when MDCT should be immediately be performed, and for pregnant woman when dedicated MRI can be a diagnostic option. Thus, early use of MDCT has been shown to reduce the number of serious diagnoses that are missed. Advanced diagnostics that may be used to guide and treat both trauma and non-trauma patients include such techniques as endoscopy or selective angiography, e.g., for the treatment of gastrointestinal or visceral organ hemorrhage. Parenchymateous organ or hollow organ visceral bleeding, including perforations, is representative of classical, life-threatening diagnoses secured by MDCT. However, advanced testing in patients that require surgery for abdominal emergencies will result in a delay in the necessary treatments. The present chapter defines the clinical context of patients presenting with an acute abdomen and provides information’s on clinical pattern and diagnostic strategies.


Acute Pancreatitis Acute Appendicitis Acute Abdomen Clinical Pattern Acute Diverticulitis 
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  1. Aguirre DA, Santosa AC, Casola G, Sirlin CB (2005) Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 25:1501–1520PubMedCrossRefGoogle Scholar
  2. Ambrosetti P, Becker C, Terrier F (2002) Colonic diverticulitis: impact of imaging on surgical management–a prospective study of 542 patients. Eur Radiol 12:1145–1149PubMedCrossRefGoogle Scholar
  3. American College of Surgeons—Committee on Trauma (2004) Initial assessment and management. In: ATLS advanced trauma life support—program for doctors, 7th edn. American College of Surgeons, Chicago, IL, pp 11–29Google Scholar
  4. Andersson P, Söderholm JD (2009) Surgery in ulcerative colitis: indication and timing. Dig Dis 27:335–340PubMedCrossRefGoogle Scholar
  5. Angele MK, Khalil PN, Spelsberg F, Bruns CJ, Burges A, Jauch KW, Kleespies A (2011) Non-curable tumours of the female genital tract: therapeutic options in bowel stenosis and bleeding. Zentralbl Chir 136:237–243PubMedCrossRefGoogle Scholar
  6. Balthazar EJ (2002) Complications of acute pancreatitis: clinical and CT evaluation. Radiol Clin North Am 40:1211–1227PubMedCrossRefGoogle Scholar
  7. Boffard KD (2007) Surgical decision-making. In: Boffard KD (ed) Manual of definitive surgical trauma care, 2nd edn. Hodder Arnold, part of Hachette Livre, London, pp 47–64Google Scholar
  8. Bortoff GA, Chen MY, Ott DJ, Wolfman NT, Routh WD (2000) Gallbladder stones: imaging and intervention. Radiographics 20:751–766PubMedGoogle Scholar
  9. Cahir JG, Freeman AH, Courtney HM (2004) Multislice CT of the abdomen. Br J Radiol 77:64–73CrossRefGoogle Scholar
  10. de Dombal FT (1988) The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol Suppl 144:35–42PubMedGoogle Scholar
  11. Federle MP (2005) CT of the acute (emergency) abdomen. Eur Radiol 15(Suppl 4):D100–D104PubMedGoogle Scholar
  12. Furukawa A, Sakoda M, Yamasaki M, Kono N, Tanaka T, Nitta N, Kanasaki S, Imoto K, Takahashi M, Murata K, Sakamoto T, Tani T (2005) Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause. Abdom Imaging 30:524–534PubMedCrossRefGoogle Scholar
  13. Grafen FC, Neuhaus V, Schöb O, Turina M (2010) Management of acute small bowel obstruction from intestinal adhesions: indications for laparoscopic surgery in a community teaching hospital. Langenbecks Arch Surg 395:57–63PubMedCrossRefGoogle Scholar
  14. Gralnek IM, Barkun AN, Bardou M (2008) Management of acute bleeding from a peptic ulcer. N Engl J Med 359:928–937PubMedCrossRefGoogle Scholar
  15. Green JM (2008) When is the faster better? Operative timing in acute care surgery. Curr opin Crit Care 14:423–427PubMedCrossRefGoogle Scholar
  16. Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR (2010) Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 97:141–150PubMedCrossRefGoogle Scholar
  17. Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12:85–109PubMedGoogle Scholar
  18. Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW (2010) Clinical policy: critical issues in the evaluation and manage-ment of emergency department patients with suspected appendicitis. Ann Emerg Med 55:71–116 American College of Emergency PhysiciansPubMedCrossRefGoogle Scholar
  19. Jacobs DO (2007) Clinical practice. Diverticulitis. N Engl J Med 357:2057–2066PubMedCrossRefGoogle Scholar
  20. Jaeckle T, Stuber G, Hoffmann MH, Freund W, Schmitz BL, Aschoff AJ (2008) Acute gastrointestinal bleeding: value of MDCT. Abdom Imaging 33:285–293PubMedCrossRefGoogle Scholar
  21. Johansson M, Thune A, Nelvin L, Stiernstam M, Westman B, Lundell L (2005) Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis. Br J Surg 92:44–49PubMedCrossRefGoogle Scholar
  22. Khalil PN, Huber-Wagner S, Ladurner R, Kleespies A, Siebeck M, Mutschler W, Hallfeldt K, Kanz KG (2009) Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur J Med Res 14:231–239PubMedGoogle Scholar
  23. Khalil PN, Werner JC, Kleespies A (2010) Diagnostic of acute appendicitis in the emergency department. Notfall Rettungsmed 13:249–250CrossRefGoogle Scholar
  24. Khalil PN, Kleespies A, Angele MK, Thasler WE, Siebeck M, Bruns CJ, Mutschler W, Kanz KG (2011a) The formal requirements of algorithms and their implications in clinical medicine and quality management. Langenbecks Arch Surg 396:31–40PubMedCrossRefGoogle Scholar
  25. Khalil PN, Kleespies A, Angele MK, Bruns CJ, Siebeck M (2011b) Small bowel incarceration in recurrent perineal hernia after abdominoperineal resection. Int J Colorectal Dis 26:957–958PubMedCrossRefGoogle Scholar
  26. Kilpatrick CC, Monga M (2007) Approach to the acute abdomen in pregnancy. Obstet Gynecol Clin North Am 34:389–402PubMedCrossRefGoogle Scholar
  27. Kleespies A, Thasler WE, Schäfer C, Meimarakis G, Eichhorn ME, Bruns CJ, Jauch KW, Zügel N (2008) Acute pancreatitis: is there a need for surgery? Z Gastroenterol 46:790–798PubMedCrossRefGoogle Scholar
  28. Kool DR, Blickman JG (2007) Advanced Trauma Life Support. ABCDE from a radiological point of view. Emerg Radiol 14(3):135–141 Jul 2007PubMedCrossRefGoogle Scholar
  29. Laméris W, van Randen A, van Es HW, van Heesewijk JP, van Ramshorst B, Bouma WH, ten Hove W, van Leeuwen MS, van Keulen EM, Dijkgraaf MG, Bossuyt PM, Boermeester MA, Stoker J, MA OPTI (2009) Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 338:b2431PubMedCrossRefGoogle Scholar
  30. Larson DB, Johnson LW, Schnell BM, Salisbury SR, Forman HP (2011) National trends in CT use in the emergency department: 1995–2007. Radiology 258:164–173PubMedCrossRefGoogle Scholar
  31. Leschka S, Alkadhi H, Wildermuth S, Marincek B (2005) Multi-detector computed tomography of acute abdomen. Eur Radiol 15:2435–2447PubMedCrossRefGoogle Scholar
  32. Lim HK, Bae SH, Seo GS (1992) Diagnosis of acute appendicitis in pregnant women: value of sonography. AJR Am J Roentgenol 159:539–542PubMedGoogle Scholar
  33. Linsenmaier U, Wirth S, Reiser M, Körner M (2008) Diagnosis and classification of pancreatic and duodenal injuries in emergency radiology. Radiographics 28:1591–1602PubMedCrossRefGoogle Scholar
  34. Madoff DC, Denys A, Wallace MJ, Murthy R, Gupta S, Pillsbury EP, Ahrar K, Bessoud B, Hicks ME (2005) Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications. Radiographics 25(Suppl 1):S191–S211PubMedCrossRefGoogle Scholar
  35. Malfertheiner P, Chan FK, McColl KE (2009) Peptic ulcer disease. Lancet 374(9699):1449–1461PubMedCrossRefGoogle Scholar
  36. Martin MJ, Steele SR (2010) Twists and turns: a practical approach to volvulus and intussusception. Scand J Surg 99:93–102PubMedGoogle Scholar
  37. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Shackford SR, Champion HR, McAninch JW (1995) Organ injury scaling. Surg Clin North Am 75:293–303PubMedGoogle Scholar
  38. Myren J, Bouchier IA, Watkinson G, Softley A, Clamp SE, de Dombal FT (1988) The OMGE multinational inflammatory bowel disease survey 1976–1986. A further report on 3175 cases. Scand J Gastroenterol 144:11–19Google Scholar
  39. Oniscu GC, Parks RW, Garden OJ (2006) Classification of liver and pancreatic trauma. HPB (Oxford) 8:4–9CrossRefGoogle Scholar
  40. Pachter HL, Guth AA, Hofstetter SR, Spencer FC (1998) Changing patterns in the management of splenic trauma: the impact of nonoperative management. Ann Surg 227:708–717PubMedCrossRefGoogle Scholar
  41. Parks NA, Davis JW, Forman D, Lemaster D (2011) Observation for nonoperative management of blunt liver injuries: how long is long enough? J Trauma 70:626–629PubMedCrossRefGoogle Scholar
  42. Pringle JH (1908) Notes on the arrest of hepatic heorrhage due to trauma. Ann Surg 48:541–548PubMedCrossRefGoogle Scholar
  43. Renner P, Kienle K, Dahlke MH, Heiss P, Pfister K, Stroszczynski C, Piso P, Schlitt HJ (2011) Intestinal ischemia: current treatment concepts. Langenbecks Arch Surg 396:3–11PubMedCrossRefGoogle Scholar
  44. Rosen MP, Sands DZ, Longmaid HE 3rd, Reynolds KF, Wagner M, Raptopoulos V (2000) Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain. AJR Am J Roentgenol 174:1391–1396PubMedGoogle Scholar
  45. Rozycki GS, Tremblay L, Feliciano DV, Joseph R, DeDelva P, Salomone JP, Nicholas JM, Cava RA, Ansley JD, Ingram WL (2002) Three hundred consecutive emergent celiotomies in general surgery patients: influence of advanced diagnostic imaging techniques and procedures on diagnosis. Ann Surg 235:681–688PubMedCrossRefGoogle Scholar
  46. Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P, Navez B, Saad S, Neugebauer EA (2006) Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery. Surg Endosc 20:14–29PubMedCrossRefGoogle Scholar
  47. Schein M (2005a) The acute abdomen. In: Schein M, Rogers PN (eds) Schein’s common sense emergency abdominal surgery, 2nd edn. Springer, Berlin, pp 17–25CrossRefGoogle Scholar
  48. Schein M (2005b) Acute appendicitis. In: Schein M, Rogers PN (eds) Schein’s common sense emergency abdominal surgery, 2nd edn. Springer, Berlin, pp 245–254CrossRefGoogle Scholar
  49. Schick KS, Hüttl TP, Fertmann JM, Hornung HM, Jauch KW, Hoffmann JN (2008) A critical analysis of laparoscopic appendectomy: how experience with 1400 appendectomies allowed innovative treatment to become standard in a university hospital. World J Surg 32(7):1406–1413PubMedCrossRefGoogle Scholar
  50. Shakespear JS, Shaaban AM, Rezvani M (2010) CT findings of acute cholecystitis and its complications. AJR Am J Roentgenol 194:1523–1529PubMedCrossRefGoogle Scholar
  51. Shanley CJ, Weinberger JB (2008) Acute abdominal vascular emergencies. Med Clin North Am 92:627–647 ixPubMedCrossRefGoogle Scholar
  52. Silva AC, Pimenta M, Guimarães LS (2009) Small bowel obstruction: what to look for. Radiographics 29:423–439PubMedCrossRefGoogle Scholar
  53. Spencer SP, Power N, Reznek RH (2009) Multidetector computed tomography of the acute abdomen in the immunocompromised host: a pictorial review. Curr Probl Diagn Radiol 38:145–155PubMedCrossRefGoogle Scholar
  54. Stoker J, van Randen A, Laméris W, Boermeester MA (2009) Imaging patients with acute abdominal pain. Radiology 253:31–46PubMedCrossRefGoogle Scholar
  55. Szomstein S, Lo Menzo E, Simpfendorfer C, Zundel N, Rosenthal RJ (2006) Laparoscopic lysis of adhesions. World J Surg 30:535–540PubMedCrossRefGoogle Scholar
  56. Taourel P, Kessler N, Lesnik A, Pujol J, Morcos L, Bruel JM (2003) Helical CT of large bowel obstruction. Abdom Imaging 28:267–275PubMedCrossRefGoogle Scholar
  57. Trompetas V (2008) Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl 90:181–186PubMedCrossRefGoogle Scholar
  58. Wang YR, Richter JE, Dempsey DT (2010) Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Ann Surg 251:51–58PubMedCrossRefGoogle Scholar
  59. Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, Kim JC, Jeong SW, Park JG, Kang HK (2005) CT in blunt liver trauma. Radiographics 25:87–104PubMedCrossRefGoogle Scholar
  60. Zech CJ, Reiser MF (2010) Acute abdomen: an interdisciplinary challenge. Radiologe 50:208PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2011

Authors and Affiliations

  1. 1.Division of General and Visceral Surgery, Department of Surgery, Campus InnenstadtLudwig-Maximilians University (LMU)MunichGermany

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