Author:

RosauraFernández

Signs and Symptoms

• Sudden severe abdominal pain typically:
  • Initially local
  • Often rapidly becoming diffuse due to peritonitis
  • Consider persistent local pain due to abscess/phlegm on formation
• Rigidity
• Guarding
• Rebound tenderness
• Absent bowel sounds
• Abdominal distention
• SIRS/sepsis/septic shock
• Consider delayed presentations of common etiologies

Essential Workup

Upright CXR:

• Best demonstrates pneumoperitoneum
• When in upright position for 5-10 min, may detect as little as 1-2 mL of free air under diaphragm

Diagnostic Tests & Interpretation

Differential Diagnosis

• Pneumomediastinum with peritoneal extension
• Appendicitis/diverticulitis/cholecystitis/pancreatitis
• Pneumonia
• DKA
• Intra-abdominal abscess
• Peptic ulcer disease
• Myocardial infarction
• Obstruction
• PID/TOA
• Ovarian torsion
• Ectopic pregnancy

Prehospital

Initiate IV fluids for patients with history of vomiting or abnormal vital signs

Initial Stabilization/Therapy

• Identify those with SIRS/sepsis/septic shock
• Use aggressive supportive measures to correct hypoxia, hypotension, and hypoperfusion
• Aggressive fluid resuscitation using crystalloid fluids
• Early and adequate broad-spectrum antibiotics or surgery or both
• Consider vasopressors if fluids not tolerated or not sufficient to maintain physiologic stability
• Consider intubation and mechanical ventilation as needed

ED Treatment/Procedures

• Nasogastric tube
• Foley catheter
• Administer broad-spectrum antibiotic coverage for gram-positive cocci, gram-negative Enterobacteriaceae and obligate anaerobes:
  • Penicillin-β-lactamase inhibitor
  • Cephalosporin-based regimen
  • Antianaerobic agent
  • Monobactam agent
  • Carbapenem agent
  • Antienterococcal and antistaphylococcal agents
• For high-risk adult or pediatric patient (>1 mo of age) administer piperacillin-tazobactam
• For patients with allergy to β-lactamase inhibitor, consider following triple regimen:
  • Aztreonam 1-2 g IV q8h (peds ≥9 mo: 30 mg/kg IV q6-8h)
  • Vancomycin 10-20 mg/kg IV q12h (peds: 10 mg/kg IV q6h)
  • Metronidazole 1 g IV (peds: 22-40 mg/kg/d IV divided q8h)
• Immediate surgical consultation for operative intervention

Medication

• Penicillin-β-lactamase inhibitor:
  • Piperacillin-tazobactam 3.375-4.5 g IV q6h (peds: 240-300 mg/kg/day IV divided q6-8h)
• Carbapenem:
  • Imipenem-cilastatin 0.5-1 g IV q6-8h (peds:15-25 mg/kg IV q6h)
  • Meropenem 1-2 g IV q8h (peds: 30-120 mg/kg/d IV divided q8h)
• Cephalosporin-based regimen with antianaeorobic agent:
  • Cefepime 1-2 g IV q12h (peds <40 kg: 50 mg/kg IV q12h) plus metronidazole 1 g IV then 0.5 g IV q6-8h
• Allergy to β-lactamase inhibitor regimen:
  • Aztreonam 1-2 g IV q8h (peds ≥9 mo: 30 mg/kg IV q6-8h)
  • Vancomycin 10-20 mg/kg IV q12h (peds: 10 mg/kg IV q6h)
  • Metronidazole 1 g IV (peds: 22-40 mg/kg/d IV divided q8h)
• Morphine sulfate: 2-4 mg (peds: 0.1 mg/kg) IV q2-3h

Disposition

Follow-up Recommendations

Postoperative surgery follow-up

• GansSL, StokerJ, BoermeesterMA. Plain abdominal radiography in acute abdominal pain; past, present, and future . Int J Gen Med. 2012;5:525-533.
• JonesAE, PuskarichMA. The Surviving Sepsis Campaign guidelines for 2012: Update for emergency medicine physicians . Ann Emerg Med. 2014;63:35-47.
• LangellJT, MulvihillSJ. Gastrointestinal perforation and the acute abdomen . Med Clin North Am. 2008;92:599-625.
• MazuskiJE, TessierJM, MayAK, et al. The surgical infection society revised guidelines on the management of intra-abdominal infection . Surg Infect. 2017;18(1):1-76.
• RhodesA, EvansLE, AlhazzaniW, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septick shock . Crit Care Med. 2017;45(3):486-552.
• SpanglerR, Van PhamT, KhoujahD, et al. Abdominal emergencies in the geriatric patient . Int J Emerg Med. 2014;7:43.

See Also (Topic, Algorithm, Electronic Media Element)

Abdominal Pain

ICD9

• 533.50 Chronic or unspecified peptic ulcer of unspecified site with perforation, without mention of obstruction

• 562.11 Diverticulitis of colon (without mention of hemorrhage)

• 868.00 Injury to other intra-abdominal organs without mention of open wound into cavity, unspecified intra-abdominal organ

• 540.0Acute appendicitis with generalized peritonitis

• 567.9 Unspecified peritonitis

• 863.29 Other injury to small intestine, without mention of open wound into cavity

• 868.10 Injury to other intra-abdominal organs with open wound into cavity, unspecified intra-abdominal organ

ICD10

• K27.5 Chronic or unsp peptic ulcer, site unsp, with perforation

• K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding

• S36.99XA Other injury of unspecified intra-abdominal organ, initial encounter

• K35.2 Acute appendicitis with generalized peritonitis

• K65.9 Peritonitis, unspecified

• S36.498A Other injury of other part of small intestine, init encntr

SNOMED

• 49011004 Internal injury of abdominal organs (disorder)

• 88169003 Peptic ulcer with perforation (disorder)

• 76953007 Diverticulitis of colon with perforation (disorder)

• 286967008 Acute perforated appendicitis

• 20784007 Internal injury of abdominal organs with open wound into cavity (disorder)

• 282061008 Rupture of jejunum (disorder)

• 48661000 Peritonitis (disorder)