Severe Abdominal Pain: Causes and When to Go to the ER

What to do right now

1. Call 911 or go to the ER if you have any emergency sign above.
2. Do not eat or drink until you are assessed, in case you need surgery or a scan. Small sips of water are usually fine if you are thirsty.
3. Do not take NSAIDs (ibuprofen, naproxen, aspirin), which can worsen bleeding or ulcers, or laxatives, which can harm a blocked bowel.
4. Note details: when it started, where it began and where it moved, what makes it worse, your last bowel movement, menstrual period, and medicines.
5. Do not drive yourself if the pain is severe.

Pain medicine does not hide the diagnosis. ER doctors give it early so you are comfortable while tests are done.

Causes of severe abdominal pain by location

The main causes explained

Appendicitis

Pain often starts as a vague ache around the belly button, then moves to the lower right over 12 to 24 hours and becomes sharp. Loss of appetite, nausea and low fever follow. Walking, coughing and bumps in the car hurt. It needs surgery or, in selected cases, antibiotics.

Gallbladder attack

Biliary colic is severe, steady pain under the right ribs or in the upper middle belly, often after a fatty meal, lasting 30 minutes to several hours. Fever and pain lasting longer than 6 hours suggest cholecystitis.

Kidney stones

Sudden, excruciating pain in the side or back that comes in waves and moves toward the groin. People cannot keep still. Blood in the urine and nausea are common.

Pancreatitis

Constant, severe upper belly pain that bores through to the back, worse after eating, with vomiting. The main causes are gallstones and alcohol.

Bowel obstruction

Cramping pain in waves, a swollen belly, vomiting and inability to pass gas or stool. Causes include adhesions from previous surgery, hernias and tumors. See bowel obstruction.

Perforation

A hole in the stomach or bowel, from an ulcer or diverticulitis, causes sudden, severe, constant pain that spreads across the belly, which becomes rigid. This is a surgical emergency.

Ruptured abdominal aortic aneurysm

Sudden severe belly or back pain with fainting, especially in older men who smoke. It is immediately life-threatening. See abdominal aortic aneurysm.

Mesenteric ischemia

Blocked blood flow to the bowel causes severe pain that seems out of proportion to a soft belly on examination. It occurs mainly in older adults with atrial fibrillation or vascular disease.

Causes in women

• Ectopic pregnancy: one-sided pain, vaginal bleeding and a positive pregnancy test; rupture causes collapse.
• Ovarian torsion: sudden severe one-sided pain with vomiting.
• Ruptured ovarian cyst: sudden pain, sometimes after sex or exercise.
• Pelvic inflammatory disease: lower belly pain, fever and abnormal discharge.

Causes outside the abdomen

Heart attack, pneumonia at the base of the lungs, testicular torsion, diabetic ketoacidosis, and shingles before the rash can all cause severe belly pain.

How severe abdominal pain is diagnosed

ER doctors will check your vital signs, examine your belly, and ask detailed questions. Tests often include:

• Blood tests: blood count, kidney and liver function, lipase (pancreatitis), lactate (ischemia), and a pregnancy test for anyone who could be pregnant.
• Urine test: for blood, infection and pregnancy.
• ECG: to rule out a heart attack in upper belly pain.
• Imaging: CT scan is the most useful test for most adults; ultrasound for gallbladder, pelvic and pregnancy-related problems and for children.

Treatment

Treatment depends on the cause: IV fluids, pain relief, anti-nausea medicine, antibiotics for infection, procedures to remove stones, and surgery for appendicitis, perforation, obstruction that does not settle, ectopic pregnancy or a ruptured aneurysm.

Frequently asked questions

When should I go to the ER for severe abdominal pain?

Go to the ER for sudden or severe pain, pain that keeps getting worse over hours, pain with fainting, fever, persistent vomiting, a rigid or swollen belly, blood in vomit or stool, chest pain, or pain during pregnancy. When in doubt, get checked.

What causes sudden severe abdominal pain?

Common causes are appendicitis, gallbladder attacks, kidney stones, pancreatitis, bowel obstruction and diverticulitis. Less common but dangerous causes include perforated ulcers, ectopic pregnancy, ovarian torsion, ruptured aortic aneurysm and blocked blood supply to the bowel.

Can gas cause severe abdominal pain?

Yes. Trapped gas can cause sharp, cramping pain that moves around and eases after passing gas or a bowel movement. Pain that is constant, localized, worsening, or comes with fever, vomiting or a swollen belly is not gas and needs assessment.

Should I take painkillers for severe stomach pain?

Avoid NSAIDs such as ibuprofen and aspirin, which can worsen ulcers and bleeding. Acetaminophen (paracetamol) at the label dose is safer while you seek help. Strong pain should be assessed rather than masked at home. ER doctors will give appropriate pain relief.

What is an acute abdomen?

An acute abdomen is sudden, severe abdominal pain that may need urgent treatment, sometimes surgery. It is a description, not a diagnosis. Causes range from appendicitis and perforation to obstruction, ectopic pregnancy and vascular emergencies.