Medical Malpractice — Acute Abdomen/Surgical Abdomen

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“Acute abdomen” or “surgical abdomen” is medical shorthand for a patient who has acute abdominal pain. Acute abdomen is one of the most misdiagnosed conditions, often to disastrous results. Although acute abdominal pain can be hard to diagnosis, swift and accurate diagnosis is critical because delays can be serious and even fatal.

The challenges of acute abdomen are that there a number of organs located in the abdominal cavity (kidney, spleen, liver, stomach, intestines, gallbladder, pancreas, appendix, etc.), that pain isn’t always completely localized, and that a wide variety of conditions present with acute abdominal pain.

Not all situations of acute abdominal pain require surgery and it is up to a skilled doctor to quickly determine what is causing the pain and whether emergency surgery is required. Some of the conditions that present as acute abdomen (not all of which are serious or require surgery) include:

  1. Abdominal Aortic Aneurysm (AAA)
  2. Addison’s Disease
  3. Appendix
  4. Atrial Fibrilation (racing heart)
  5. Bile Duct Injury
  6. Bladder And Ureter Rupture or Blockage
  7. Blockage In The Intestine Or Bowel
  8. Cancer
  9. Diabetic ketoacidosis
  10. Diverticulitis
  11. Food Poisoning
  12. Gall Bladder
  13. Gastroenteritis
  14. Hernia
  15. Hypercalcemia
  16. Hyperthyroidisin
  17. Inflammatory Bowel Disease (IBD)
  18. Ischemic Bowel
  19. Kidney Stones (Nephrolithiasis)
  20. Lead poisoning
  21. Liver Rupture, Trauma, or Torsion
  22. Mesenteric Ischemia (lack of blood to the intestines)
  23. Myocardial Infarction (MI)/Heart Attack
  24. Pancreatitis
  25. Perforated Ulcer
  26. Peritonitis
  27. Pneumonia
  28. Poisoning
  29. Porphyria
  30. Prostate Abscess And Prostatitis
  31. Ruptured Spleen

Additional potential causes in women:

  1. Ectopic Pregnancy
  2. Endometriosis
  3. IUD Perforation or Migration
  4. Ovarian Cyst
  5. Pelvic inflammatory disease (PID)
  6. Tubo-ovarian abscesses
  7. Uterine Torsion, Prolapse, Dysplasia, Neoplasia

Suspicions for Adolescents:

  1. Acute Appendicitis
  2. Cholecystitis (acalculous)
  3. Pregnancy
  4. Ruptured Ovarian Cyst
  5. Testicular Torsion
  6. Worm Infestation

Common Causes of Acute Abdominal Pain in the Elderly:

  1. Appendicitis (increase gangrene risk and rupture risk)
  2. Biliary Colic or Cholecystitis
  3. Cancer
  4. Diverticulitis
  5. Incarcerated Hernia
  6. Intestinal Obstruction
  7. Perforated viscus
  8. Renal Colic or Nephrolithiasis

Infants and Children

Infants and young children present a particular challenge with acute abdomen, because they often can’t articulate the exact location of the problem or describe their symptoms and/or provide information such as onset. At the same time, a bdominal pain is one of the most frequent kinds of cases seen in pediatric emergency visits, and it is incumbent upon doctors to familiarize themselves with the protocols and differentiations to aid in making the critical determination as to whether emergency surgery is required. Critical factors such as whether the pain is constant or colicky, the site and radiation of pain, nausea, vomiting, bowel or urinary complaints, bleeding, fever, tenderness, rigidity, bowel sounds, pallor, and jaundice can all help to aid in the diagnosis. For infants and children the causes of surgical abdomen can include:

  1. Appendicitis
  2. Bladder Or Urinary Tract Infection
  3. Cholecystitis
  4. Congenital Abnormalities
  5. Esophageal Webs
  6. GI Perforation
  7. Hypoadrenocorticism (Addison’s Disease)
  8. Imperforate Anus, And E
  9. Incarcerated Inguinal Hernia
  10. Interocolitis
  11. Intestinal Obstruction From Atresia
  12. Intestinal Volvulus
  13. Intestinal Worm Infestation
  14. Intussuception
  15. Lead Poisoning
  16. Meckel’s Diverticulum
  17. Meconium Peritonitis
  18. NEC In Preterm Neonates
  19. Pancreatitis
  20. Poison
  21. Primary peritonitis
  22. Small Bowel Obstruction
  23. Stenosis (pressure on the nerves of the spinal chord)
  24. Torsion Of A Retained Testicle Or Uterus
  25. Trauma
  26. Volvulus Of A Gut With A Common Mesentery

The Challenge of Acute Abdomen

A brief overview of the many conditions that present with acute abdominal pain as their primary symptom makes it easy to appreciate the challenge doctors and emergency room personnel face when trying to diagnose acute abdomen and trying to determine which situations require immediate surgery.

However, the number of resources and volumes of information available about the signs, symptoms, and differential diagnosis protocols of acute abdomen make it a reasonable expectation that doctors be able to correctly diagnose this condition.

Wealth of Information

The good news is that the resources regarding acute abdomen are vast and minutely detailed. The volume of information is staggering and the details are more so. A quick glance at just the differential diagnosis guides include differentials such as the timing of the onset of pain, the duration of pain, whether vomiting is present and whether it appeared before, after or in conjunction with the onset of pain, which quadrant the pain seems localized in, how the abdomen responds to palpation (pressure or touch), likely suspicions by age group, what position the patient is lying in when the doctor walks into the room, localization or radiation of pain, recent trauma. A quick search on the world wide web will yield a sense of the vastness of the guidance available for diagnosing acute abdomen.

The Family Practice Notebook is just one small example. There are volumes of books dedicated just to timely diagnosis of acute abdomen, for example, Cope’s Early Diagnosis of the Acute Abdomen. One description of which states: “This book continues to be the outstanding guide to the difficult task of diagnosing and deciding how to manage acute abdominal pain, where decisions must be made quickly and mistakes can kill patients.” If this much information exists from a quick Internet search by a lay person, imagine the amount of detailed and technical information that exists for the medical professional! It’s hard to imagine a good excuse for ignorance or error.


In addition, to volumes of information, modern technology has provided an astonishing array of sophisticated diagnostic tests for all manner of acute abdominal conditions including: abdominal and/or pelvic ultrasound, abdominal CT scan, CBC (complete blood count); urinalysis, stool analysis, chest x-ray, leukocytosis , electrocardiogram , serum phosphate liver function test s, amylase arterial blood gas , left lateral decubitus x-ray, nasogastric tube abdominal x-ray (KUB) peripheral smear; serum amylase/lipase; b lood cultures, and stool examination.


If after a complete physical exam guided by differential diagnosis protocols, taking a complete patient history, and administering appropriate tests, results are still not definitive, there is always the option of calling in surgical consultation – calling in an expert.


In an article entitled Acute Abdominal Pain: What Not To Miss by MICHAEL BOHRN, MD, Associate Program Director and Clinical Assistant Professor, Emergency Medicine Residency, York Hospital/Pennsylvania State University, York, and BETTINA SIEWERT, MD, Assistant Professor, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass, they ask the following question: “How can you be sure not to miss the clues for abdominal catastrophes such as ectopic pregnancy, MI, abdominal aortic aneurysm, and ischemic bowel?”

And they answer this way: “Diagnosing acute abdominal pain is fraught with difficulty. Patients rarely present with classic histories and physicals. Childbearing women, the elderly, and children have a complex differential diagnosis. There are several abdominal disorders where a missed diagnosis can have deadly consequences. To overcome these diagnostic challenges, clinicians need to perform a careful history, a thorough evaluation of symptoms, a comprehensive physical examination, and use laboratory and radiologic tests judiciously.”


The most serious consequence of a missed acute abdomen diagnosis is death, but other consequences can also result, such as infection, hemorrhage, perforation, sepsis, gangrene and other serious and potentially deadly consequences.

Malpractice Issues

The malpractice issue raised by the misdiagnosis of acute abdomen is simply this: if volumes of information exist for differentiating the causes of acute abdomen, if the medical profession recognizes the challenge and has provided every possible resource for meeting that challenge, — is it not reasonable to expect medical professionals — especially those staffing our nation’s emergency rooms – to be eminently familiar with the differentials of acute abdomen, and to competently, correctly and swiftly diagnose acute abdomen despite the complications and challenges of doing so?

And if this answer to this question is Yes, then why does acute abdomen continue to be one of the most misdiagnosed conditions in medical emergencies? Is it not incumbent upon doctors and especially emergency room care givers to know educate themselves about this condition, and isn’t failure to do so a form of medical negligence?

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