The New England Journal of MedicineAcute Abdomen in the Modern Era

Modernizing Acute Abdomen Diagnosis: Balancing Traditional Methods with Advanced Imaging

The diagnosis and management of acute abdominal pain have evolved significantly since Vincent Zachary Cope’s seminal 1921 treatise, “Early Diagnosis of the Acute Abdomen.” Although Cope emphasized the primacy of history-taking and physical examination, modern approaches integrate these fundamental skills with advanced imaging techniques, analgesic use, and prompt surgical consultation. This review examines current best practices in evaluating acute abdominal pain, highlighting the importance of balancing traditional clinical acumen with technological advancements to improve patient outcomes.

Key Points:

• Acute abdominal pain accounts for 5-10% of all emergency department visits.
• Main pathophysiological conditions leading to surgical interventions include gastrointestinal obstruction, hemorrhage, ischemia, and viscus perforation.
• The need for emergency general surgery is an independent risk factor for postoperative complications and death.
• Administering analgesics during initial assessment does not significantly alter diagnosis or treatment plans.
• Studies support the safety and effectiveness of analgesia in adults presenting with abdominal pain.
• Contrast-enhanced CT angiography of the abdomen and pelvis is the primary imaging technique for assessing acute abdominal pain in non-pregnant adults.
• CT angiography increases diagnostic certainty, reduces hospital admission rates, and leads to more timely surgical interventions.
• Unenhanced CT scans are approximately 30% less accurate than contrast-enhanced CT angiography.
• Delays in care should be avoided while waiting for image interpretation.
• Ultrasonography is preferred for diagnosing acute biliary disease and appendicitis, especially in pregnant patients.
• Point-of-care ultrasonography has potential for a wide range of abdominal pain disorders but is operator-dependent.
• The ACR Choosing Wisely campaign aims to reduce unnecessary imaging through evidence-based criteria.
• Older adults may present with unreliable history, vague symptoms, and diminished physiological reserve, making contrast-enhanced CT angiography particularly beneficial.
• Prompt surgical consultation is crucial to avoid complications and death.
• Disparities exist in timely surgical consultation, with Black Medicare patients having lower odds of receiving consultations.
• Cognitive biases, such as attribution bias, confirmation bias, and anchoring bias, can lead to missed diagnoses.
• Six strategies in decision-making include pattern recognition, ruling out worst-case scenarios, exhaustive method, hypothetical deductive method, heuristics, and studying diagnostic errors.
• The Ishikawa fishbone diagram depicts a cause-and-effect approach for achieving timely evaluation and diagnosis of acute abdominal pain.

HCN Medical Memo
Although advanced imaging techniques have revolutionized the diagnosis of acute abdominal pain, physicians must not overlook the enduring value of thorough history-taking and physical examination. Balancing traditional clinical skills with modern technology, while being mindful of cognitive biases, is essential for accurate and timely diagnosis in acute abdomen cases.

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