Evidence-based guideline for evaluation and management of surgical and non-surgical abdominal emergencies including appendicitis, cholecystitis, pancreatitis, bowel obstruction, and mesenteric ischemia.
A comprehensive, evidence-based clinical guideline for the systematic evaluation and management of acute abdominal emergencies in adult and pediatric patients. This resource synthesizes recommendations from the major international emergency surgery societies, gastroenterology professional organizations, hepatobiliary consensus panels, colorectal surgery working groups, and vascular surgery expert committees into a single integrated reference for emergency physicians, general surgeons, gastroenterologists, and advanced practice providers who manage patients presenting with acute abdominal pain.1 2 3 4 5 6 7 8 9 10
Acute abdominal pain accounts for approximately 5% to 10% of all emergency department (ED) visits and remains one of the most challenging clinical presentations in emergency medicine. The differential diagnosis is broad, spanning surgical emergencies requiring immediate intervention (perforated viscus, mesenteric ischemia, ruptured abdominal aortic aneurysm) to conditions amenable to medical management (uncomplicated diverticulitis, mild pancreatitis). Failure to identify time-sensitive surgical pathology carries significant morbidity and mortality. This guideline provides a structured, evidence-based approach to the diagnosis, risk stratification, and management of the most common and most dangerous causes of the acute abdomen.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | Systematic Approach to Acute Abdominal Pain & Appendicitis | History and physical exam pearls; pain location differential diagnosis table; laboratory evaluation (CBC, BMP, lipase, LFTs, lactate, UA, betahCG); imaging strategy (CT, US, plain films, MRI); Alvarado score; AIR score; CT vs US sensitivity/specificity; complicated vs uncomplicated appendicitis; antibiotic-only management; CODA trial evidence; pediatric and pregnant considerations |
| Part 2 | Acute Cholecystitis, Cholangitis & Acute Pancreatitis | Tokyo Guidelines severity grading (Grade I/II/III); US findings; HIDA scan indications; management by severity grade; early cholecystectomy; percutaneous cholecystostomy; choledocholithiasis and cholangitis; ERCP indications; Revised Atlanta Classification; BISAP score; Ranson criteria; CTSI/Balthazar score; fluid resuscitation; nutrition; necrotizing pancreatitis management; biliary pancreatitis |
| Part 3 | Small Bowel Obstruction, Large Bowel Obstruction & Diverticulitis | Adhesive SBO diagnosis and CT findings; conservative management; water-soluble contrast challenge (Gastrografin); surgical indications; strangulation signs; sigmoid and cecal volvulus; Ogilvie syndrome; neostigmine; Hinchey classification; uncomplicated diverticulitis management; DIABOLO trial; complicated diverticulitis; abscess drainage; Hartmann procedure vs primary anastomosis |
| Part 4 | Perforated Peptic Ulcer, Mesenteric Ischemia, Vascular Emergencies & Special Populations | Boey score; omental patch repair; CT findings of pneumoperitoneum; mesenteric ischemia types (arterial embolism, arterial thrombosis, venous thrombosis, NOMI); CTA diagnosis; lactate significance; anticoagulation and revascularization; AAA rupture management; EVAR vs open repair; ectopic pregnancy; discriminatory zone; methotrexate criteria; pediatric emergencies (intussusception, pyloric stenosis, Meckel diverticulum); elderly; immunocompromised; pregnant patients |
Di Saverio S, Podda M, De Simone B, et al. “Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines.” World J Emerg Surg. 2020;15(1):27. DOI: 10.1186/s13017-020-00306-3 ↩︎
Yokoe M, Hata J, Takada T, et al. “Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis.” J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. DOI: 10.1002/jhbp.515 ↩︎
Banks PA, Bollen TL, Dervenis C, et al. “Classification of acute pancreatitis — 2012: revision of the Atlanta classification and definitions by international consensus.” Gut. 2013;62(1):102-111. DOI: 10.1136/gutjnl-2012-302779 ↩︎
Ten Broek RPG, Krielen P, Di Saverio S, et al. “Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the World Society of Emergency Surgery ASBO working group.” World J Emerg Surg. 2018;13:24. DOI: 10.1186/s13017-018-0185-2 ↩︎
Sartelli M, Weber DG, Kluger Y, et al. “2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.” World J Emerg Surg. 2020;15(1):32. DOI: 10.1186/s13017-020-00313-4 ↩︎
Bala M, Kashuk J, Moore EE, et al. “Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery.” World J Emerg Surg. 2017;12:38. DOI: 10.1186/s13017-017-0150-5 ↩︎
Tarasconi A, Coccolini F, Biffl WL, et al. “Perforated and bleeding peptic ulcer: WSES guidelines.” World J Emerg Surg. 2020;15:3. DOI: 10.1186/s13017-019-0283-9 ↩︎
Crockett SD, Wani S, Gardner TB, et al. “American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis.” Gastroenterology. 2018;154(4):1096-1101. DOI: 10.1053/j.gastro.2018.01.032 ↩︎
Hall JF, Roberts PL, Ricciardi R, et al. “Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence?” Dis Colon Rectum. 2011;54(3):283-288. DOI: 10.1007/DCR.0b013e3182028576 ↩︎
Chaikof EL, Dalman RL, Eskandari MK, et al. “The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.” J Vasc Surg. 2018;67(1):2-77.e2. DOI: 10.1016/j.jvs.2017.10.044 ↩︎
Comprehensive guide to perforated peptic ulcer with Boey score, mesenteric ischemia types and management, ruptured AAA emergency management, ectopic pregnancy evaluation and treatment, and special populations including pediatric, elderly, immunocompromised, and pregnant patients.
Comprehensive guide to adhesive small bowel obstruction with CT findings, conservative management, water-soluble contrast challenge, and surgical indications; large bowel obstruction including volvulus and Ogilvie syndrome; and diverticulitis with Hinchey classification, DIABOLO trial evidence, and surgical decision-making.
Comprehensive guide to acute cholecystitis with Tokyo Guidelines severity grading, cholangitis management, ERCP indications, and acute pancreatitis with Revised Atlanta Classification, BISAP score, Ranson criteria, CTSI/Balthazar score, fluid resuscitation, nutrition, and necrotizing pancreatitis management.
Structured approach to acute abdominal pain evaluation including history, physical exam, differential diagnosis by pain location, laboratory and imaging strategy, and comprehensive appendicitis management with Alvarado score, AIR score, and CODA trial evidence.