Acute Abdomen (Overview)
Pathway Home
Population Covered By The Guidance
This pathway provides guidance for imaging adult patients with non-traumatic acute abdominal pain. An approach is used based on categorization of symptoms with associated links to more specific pathways.
Date reviewed: January 2012
Date of next review: July 2023
Published: January 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page |
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|---|---|---|
| 1a |  |
Small Bowel Obstruction Image 1a (Plain radiograph, Supine view): Multiple dilated loops of small bowel. |
| 1b |  |
Image 1b (Plain radiograph, Erect view): Multiple dilated loops of small bowel with air-fluid levels and "string of pearls" sign indicating a mechanical small bowel obstruction. |
| 2a |  |
Incarcerated Small Bowel Hernia
Image 2a (Plain radiograph): Multiple dilated loops of small bowel in the upper abdomen. |
| 2b |  |
Image 2b (Plain radiograph): Lower abdominal film showing increased density in the right obturator foramen. |
| 2c |  |
Image 2c (Computed Tomography): Coronal view of the same patient demonstrating an incarcerated small bowel. Dilated proximal loops of small bowel enter a large right inguinal hernia. The distal small bowel loop exiting the hernia is collapsed. |
| 2d |  |
Image 2d (Computed Tomography): Axial view showing the dilated small bowel loop in the right inguinal hernia (arrow). |
| 3 |  |
Malignant Small Bowel Obstruction Image 3 (Small bowel enteroclysis): Small bowel obstruction due to a serosal metastasis (arrow). |
| 4 |  |
Gallstone Ileus Image 4 (Plain radiograph): Multiple loops of distended small bowel with air in the biliary tree (arrow). |
| 5 |  |
Gallstone Ileus
Image 5 (Computed Tomography): A large gallstone (arrow) is impacted in the small bowel causing mechanical obstruction. |
| 6 |  |
Pneumoperitoneum
Image 6 (Plain radiograph): Perforated bowel and pneumoperitoneum. The intraabdominal gas outlines the liver edge, gallbladder and falciform ligament. |
| 7 |  |
Pneumoperitoneum
Image 7 (Plain radiograph, Lateral decubitus): Perforated bowel with pneumoperitoneum. The intraabdominal gas outlines the liver edge and chest wall. |
| 8a |  |
Large Bowel Obstruction
Image 8a (Plain radiograph): Distension of the caecum, ascending and transverse colon. |
| 8b |  |
Image 8b (Computed Tomography): CT of the same patient showing marked caecal distension secondary to a constricting tumour (arrow). |
| 9a |  |
Colorectal Carcinoma
Image 9a: A right hemicolectomy showing a large, ulcerated and exophytic caecal adenocarcinoma. |
| 9b |  |
Image 9b (H&E, x2.5) and 9c (H&E, x10): Histological sections showing a moderately differentiated colorectal adenocarcinoma composed of malignant glands invading into the bowel wall (blue arrows). The glands are lined by cells showing marked nuclear atypia. Normal colonic mucosa is included for comparison (green arrow). |
| 9c |  |
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| 10 |  |
Caecal Volvulus Image 10 (Plain radiograph): Markedly distended loop of large bowel from a caecal volvulus. |
| 11 |  |
Sigmoid Volvulus Image 11 (Plain radiograph): Markedly dilated loop of large bowel. The dense white line between the limbs (arrow) points to the origin of the volvulus. |
| 12 |  |
Sigmoid Volvulus
Image 12 (Computed Tomography): Sigmoid volvulus with the classical "swirl" sign representing the twisted sigmoid mesentery (arrow). |
Teaching Points
Teaching Points
- An acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that requires immediate surgical or medical review
- Plain Film Radiography (PFR) has limited efficacy in an unselected population with acute abdominal pain, as it rarely alters clinical management
- Utilising PFR for the assessment of 'non-specific abdominal pain' is unlikely to yield a positive finding. Significantly, unrelated or incidental pathology can be identified and alter clinical management erroneously
- Evidence and consensus indications for plain film radiography in the investigation of 'non-traumatic acute abdominal pain' include
- Suspected bowel obstruction or ileus
- Suspected bowel perforation
- Ingested foreign body
- Severe abdominal pain/tenderness of unknown origin requiring opiate analgesia
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Anyanwu A, Moalypour S. Are abdominal radiographs still over-utilised in the assessment of acute abdominal pain? A district general hospital audit. J R Coll Surg Edin. 1998;43:267-70. (Level IV evidence)
- Morris-Stiff G, Stiff R, Morris-Stiff H. Abdominal radiograph requesting in the setting of acute abdominal pain: temporal trends and appropriateness of requesting. Ann R Coll Surg Eng. 2006;88:270-4. (Level IV evidence)
- Boleslawski E, Panis Y, Benoist S et al. Plain Abdominal radiography as a routine procedure for acute abdominal pain of the right lower quadrant: Prospective Evaluation. World J Surg. 1999;23:262-4. (Level II evidence). View the reference
- Stower M, Amar S, Mikulin J et al. Evaluation of the plain abdominal X-ray in the acute abdomen. J Royal Soc of Med. 1985;75:630-3. (Level II evidence). View the reference
- Campbell J, Gunn A. Plain abdominal radiographs and acute abdominal pain. Br J Surg. 1988;75:554-6. (Level IV evidence)
- Hayward M, Hayward C, Ennis W et al. A pilot evaluation of radiography of the acute abdomen. Clin Radiol. 1984;35:289-91. (Level IV evidence)
- Lacey G, Wignall B, Bradbrooke S et al. Rationalising abdominal radiography in the accident and Emergency Department. Clin Radiol. 1980;31:453-5. (Level III evidence)
- Eisenberg R, Heineken P, Hedgcock M et al. Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain. Ann Surg. 1983;197:464-9. (Level II evidence). View the reference
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
Radiation Risks of X-rays and Scans |
Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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