The patient with acute abdominal pain (not in shock)
Acute abdominal pain is pain of recent onset (typically <1 week) and ranges from self‑limiting, non‑specific pain to time‑critical surgical emergencies. A structured ED approach - focused history, serial examination, targeted investigations, timely analgesia, and clear escalation/referral decisions - reduces missed pathology and supports safe disposition.
Epidemiology (approximate)
- 40% non‑specific abdominal pain.
- 20% appendicitis.
- 20% gallstone‑related disease (biliary colic, cholecystitis, choledocholithiasis).
- 20% other causes (diverticulitis, pancreatitis, gastroenteritis, small bowel obstruction, renal colic, gynaecological causes, mesenteric ischaemia, hepatosplenic disease).
Pathophysiology - how pain type guides the history
- Visceral pain arises from stretch, distension or ischaemia of hollow organs and is typically vague, midline and poorly localised; it is often colicky when peristalsis is involved (early appendicitis is typically periumbilical).
- Parietal (somatic) pain results from peritoneal irritation and is sharp, well localised and worse on movement; it is associated with focal tenderness, guarding and rebound.
- Referred pain is perceived distant from the lesion (for example, shoulder tip pain from diaphragmatic irritation); a normal local exam at the site of perceived pain suggests referral.
Assessment - focused history
Aim to define onset, evolution and likely mechanism.