Surgical Management Treatment Options

Abdominal Pain without Shock Surgical Management Treatment Options

The surgical management of patients with acute abdominal pain will depend on the specific pathology, but this is not always known. In general, there are two broad strategies.

Conservative management (wait and see)
Surgical intervention

Wait and see:

Allowing time to pass can be a helpful diagnostic aid. Nearly half of patients with acute abdominal pain receive no specific diagnosis but can be safely discharged if investigations are normal and symptoms settle. Many of these patients will be discharged directly from the ED with a wait and see strategy at home. Others will be admitted for closer monitoring and may be discharged by the surgical team at a later point, or the passage of time and the results of further investigations may allow for a definitive diagnosis to be made. The role of serial clinical examinations, best performed by the same senior surgeon, is central when it comes to monitoring these patients.

Further imaging:

Imaging options include ultrasound, CT and endoscopy. Decision making will be guided by the clinical presentation and suspected diagnosis.

Most patients with suspected acute surgical pathology will undergo imaging prior to surgical intervention (usually in the form of CT scanning) to help elucidate the nature of the pathology and guide the approach to surgery.

In other patients, where there is more diagnostic uncertainty, imaging may play a role in confirming or refuting certain suspected diagnoses. However, it is important to bear in mind that although CT is ‘non-invasive’, it is not without risk. As an example, it is estimated that a multiphase abdomen-pelvis CT scan performed in a 20-year-old female carries a 1/250 lifetime attributable risk of developing cancer as a direct result of the radiation exposure.[11] In younger patients in particular there should be a higher threshold to perform imaging that exposes to radiation.

Surgical options:

If a surgical condition is found then the patient may undergo a specific abdominal procedure, such as appendicectomy.
If a surgical cause is likely, but the nature remains unknown, then surgeons may undertake a diagnostic laparoscopy.
A diagnostic laparoscopy will give a cause for a patient’s abdominal pain in around 80% of cases. [12]
Surgeons will make the decision to operate by weighing up the risks and benefits of laparoscopy versus conservative treatment.
In critically unwell patients, or those too unstable to undergo laparoscopy, it may be appropriate to perform an exploratory laparotomy.

The following conditions indicate the need for operative intervention: