Acute abdomen is one of the most common surgical emergencies encountered in clinical practice and refers to the sudden onset of severe abdominal pain requiring urgent evaluation and management. It represents a broad spectrum of surgical and medical conditions ranging from benign self-limiting disorders to life-threatening intra-abdominal catastrophes requiring immediate intervention. Acute abdominal pain accounts for nearly 5–10% of all emergency department visits worldwide and continues to constitute a major proportion of emergency surgical admissions.¹

The diagnosis of acute abdomen remains a significant challenge because of the diversity of etiologies and overlap in clinical presentations. Common causes include acute appendicitis, intestinal obstruction, perforation peritonitis, acute cholecystitis, pancreatitis, mesenteric ischemia, renal or ureteric colic, and gynecological emergencies.² Clinical manifestations vary according to age, sex, comorbid conditions, socioeconomic status, and geographical distribution. Delay in diagnosis and management may result in serious complications such as sepsis, perforation, peritonitis, prolonged hospitalization, and increased mortality.

A meticulous clinical evaluation remains the cornerstone in the diagnosis of acute abdomen. Detailed history regarding onset, duration, location, character, migration, and progression of pain, along with associated symptoms such as vomiting, fever, constipation, abdominal distension, urinary complaints, and anorexia, provides valuable diagnostic clues.^1,3 Physical examination including tenderness, guarding, rigidity, rebound tenderness, abdominal distension, bowel sounds, and hemodynamic status further helps in identifying patients requiring urgent surgical intervention. Although laboratory investigations and imaging modalities such as ultrasonography (USG), plain radiography, and computed tomography (CT) have significantly improved diagnostic accuracy, clinical judgment remains indispensable for early diagnosis and timely management.³

Several studies conducted in tertiary care centers have demonstrated that acute appendicitis is the most common cause of non-traumatic acute abdomen, followed by intestinal obstruction, perforation peritonitis, acute cholecystitis, and pancreatitis.^4,5 In developing countries, delayed presentation due to poor healthcare access, low socioeconomic status, and lack of awareness contributes substantially to morbidity and mortality associated with acute abdominal conditions. Peripheral tertiary care hospitals cater predominantly to rural and semi-urban populations and frequently serve as the first referral centers for surgical emergencies. Understanding the local etiological spectrum and clinical profile of acute abdomen in such settings is essential for early diagnosis, prompt intervention, and better resource allocation.

Despite the high burden of acute abdomen cases, limited literature is available regarding the spectrum of clinical presentation and management patterns in peripheral tertiary care institutions of North India, particularly in Jammu and Kashmir. Therefore, the present study titled “Spectrum of Clinical Profile of Acute Abdomen at a Peripheral Tertiary Care Hospital: An Observational Study” was conducted in the Department of General and Minimal Access Surgery, Government Medical College, Kathua, to evaluate the demographic characteristics, clinical presentation, etiological spectrum, investigations, and management outcomes among patients presenting with acute abdomen.

This hospital-based observational study was conducted in the Department of General and Minimal Access Surgery, Government Medical College, Kathua, over a period of 2 years. After obtaining approval from the Institutional Ethics Committee and written informed consent from the patients or their attendants, eligible patients were enrolled consecutively.

Sample size

               n =

where    p is the observed prevalence

               q = 100- p

               d is the margin of error

                is the ordinate of standard normal distribution at α% level of significance

Taking the prevalence of acute appendicitis among acute abdomen cases as 29% based on previous literature, with 95% confidence interval and 2.5% absolute precision, the minimum calculated sample size was 1265. Considering approximately 10% incomplete records and attrition, the final sample size was rounded to 1400 patients.

Recruitment criteria:

The study included all patients aged 18 years and above presenting with acute abdominal pain of less than 7 days duration and admitted with a diagnosis of acute abdomen under the Department of General and Minimal Access Surgery. Patients with abdominal trauma, pregnant women, patients with chronic abdominal pain without acute exacerbation, patients unwilling to participate, and those with incomplete clinical records were excluded from the study.

Data collection:

1. Detailed clinical history including age, sex, duration and site of pain, character of pain, associated symptoms such as vomiting, fever, constipation, abdominal distension, urinary complaints, and previous surgical history was recorded in a structured proforma.
2. General physical examination and detailed systemic examination were performed in all patients. Per abdominal examination included assessment for tenderness, guarding, rigidity, rebound tenderness, abdominal distension, palpable mass, bowel sounds, and signs of peritonitis. Vital parameters including pulse rate, blood pressure, respiratory rate, temperature, and oxygen saturation were documented at admission.
3. Relevant laboratory investigations including complete blood count (CBC), hemoglobin, renal function tests (RFT), liver function tests (LFT), serum electrolytes, blood sugar, serum amylase, serum lipase, and urine routine examination were performed in all patients as indicated clinically.
4. Radiological investigations included plain X-ray abdomen erect/supine view, chest X-ray, ultrasonography (USG) abdomen and pelvis, and contrast-enhanced computed tomography (CECT) abdomen in selected cases depending upon the provisional diagnosis and clinical condition of the patient.
5. Based on clinical examination and investigations, a provisional diagnosis was established. Patients were managed conservatively or surgically according to standard institutional protocols.
6. Operative findings were documented in patients undergoing surgery, while final diagnosis in conservatively managed patients was established on the basis of clinical improvement and radiological correlation.
7. Patients were followed throughout their hospital stay, and details regarding definitive diagnosis, type of management, operative procedures performed, postoperative complications, duration of hospital stay, and outcome were recorded and analyzed.

Statistical analysis: Data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) software version 25. Categorical variables were expressed as frequencies and percentages, whereas continuous variables were expressed as mean ± standard deviation (SD). Chi-square test or Fisher’s exact test was used for comparison of categorical variables, and Student’s t-test was applied for comparison of continuous variables wherever appropriate. A p-value of <0.05 was considered statistically significant.

were strictly maintained throughout the study.

Most patients belonged to the 31–50 years age group (41%) with male predominance (62%). Delayed presentation beyond 48 hours was observed in 35.7% patients. Leukocytosis was present in 64.3% cases, while generalized peritonitis was observed in 35.7% patients (table 1).

Table 1: Baseline Demographic and Clinical Characteristics of Patients

Abdominal pain was the universal presenting symptom. Acute appendicitis was the most common etiology (30%), followed by intestinal obstruction (22%) and perforation peritonitis (18%) as shown in table 2.

Table 2: Presenting Symptoms and Etiological Spectrum of Acute Abdomen (n = 1400)

Most patients (70%) required surgical intervention. Appendectomy was the most commonly performed surgical procedure (37.1%), followed by bowel resection and anastomosis (18.6%) as shown in table 3.

Table 3: Management Profile and Surgical Procedures (n = 1400)

Wound infection was the most common postoperative complication (14%). Overall mortality in the study was 3.9%. Most patients (76%) had hospital stay ≤7 days (table 4).

Table 4: Postoperative Complications and Clinical Outcomes (n = 1400)

Leukocytosis, generalized peritonitis, younger age, and delayed presentation were significantly associated with need for surgical intervention (p<0.001) as shown in table 5.

Table 5: Factors Associated with Surgical Intervention (n = 1400)

Delayed presentation, perforation peritonitis, advanced age, and leukocytosis were significant predictors of postoperative complications (p<0.001) as shown in table 6.

Table 6: Predictors of Postoperative Complications (n = 980)

Multivariate logistic regression analysis demonstrated that septicemia, mesenteric ischemia, delayed presentation, generalized peritonitis, ICU admission, and advanced age were independent predictors of mortality (table 7).

Table 7: Multivariate Logistic Regression Analysis for Mortality (n = 1400)

Acute abdomen remains one of the most frequently encountered surgical emergencies worldwide and continues to pose significant diagnostic and therapeutic challenges despite advances in imaging and perioperative care. Early identification of the underlying pathology and timely intervention are crucial for reducing morbidity and mortality. The present observational study conducted at the Department of General and Minimal Access Surgery, Government Medical College, Kathua, evaluated the clinical profile, etiological spectrum, management patterns, and outcomes among 1400 patients presenting with acute abdomen.

In the present study, the majority of patients belonged to the 31–50 years age group (41%), followed by the 18–30 years age group (28%). Similar findings were reported by Parab et al¹, who observed maximum incidence of acute abdomen among middle-aged adults. Singh et al³ also documented that most patients presenting with acute abdomen were between 31 and 50 years of age. The increased incidence in this age group may be attributed to higher prevalence of inflammatory and obstructive gastrointestinal diseases. Elderly patients constituted a smaller proportion in the present study but demonstrated significantly higher morbidity and mortality. Bala et al⁶ emphasized that advanced age is associated with delayed presentation, atypical symptoms, bowel ischemia, and poor physiological reserve, thereby contributing to adverse outcomes in acute abdominal emergencies.

A clear male predominance was observed in the present study, with males accounting for 62% of patients. Similar male predominance was reported by Singh et al³ and Prasad et al⁴ in their studies on acute abdomen. Bhatti et al⁵ also documented a predominance of male patients in surgical emergency admissions. The higher prevalence among males may be related to occupational stress, dietary factors, smoking, alcohol consumption, and delayed healthcare-seeking behavior. However, Shinde et al² reported relatively comparable gender distribution in their study population. Such differences may reflect regional demographic variations and differences in disease patterns.

Abdominal pain was the universal presenting complaint in the present study, occurring in 100% of patients. Vomiting or nausea was observed in 68% of cases, followed by abdominal distension (39%), constipation or obstipation (31%), and fever (29%). Similar symptom profiles were observed by Parab et al¹, who reported abdominal pain as the predominant presenting feature in all cases, with vomiting being the most common associated symptom. Shinde et al² similarly documented vomiting, abdominal distension, and fever among the common clinical presentations of acute abdomen. The predominance of these symptoms reflects the underlying inflammatory, obstructive, ischemic, or perforative intra-abdominal pathologies.

Leukocytosis was present in 64.3% of patients and showed significant association with requirement of surgical intervention and postoperative complications. Similar findings were observed by Prasad et al⁴, who demonstrated that elevated leukocyte count significantly correlated with operative management in patients with acute abdomen. Hardy et al⁷ also emphasized that leukocytosis remains an important inflammatory marker aiding diagnosis of surgical abdomen, especially when associated with peritoneal signs. Elevated total leukocyte count frequently reflects intra-abdominal infection, perforation, bowel ischemia, or systemic inflammatory response syndrome.

Generalized peritonitis was present in 35.7% of patients and was significantly associated with increased mortality and postoperative complications. Singh et al³ reported similar observations where perforation peritonitis and diffuse peritoneal contamination were major determinants of poor surgical outcome. Sartelli et al⁸ highlighted that generalized peritonitis is frequently associated with severe intra-abdominal sepsis, multiorgan dysfunction, and increased mortality if prompt source control is not achieved. Delayed diagnosis and inadequate resuscitation further worsen outcomes in such patients.

Acute appendicitis was identified as the most common etiology of acute abdomen in the present study, accounting for 30% of cases. Similar findings were documented by Bhatti et al⁵, who reported appendicitis in approximately 29% of acute abdomen patients. Singh et al¹ and Parab et al³ also identified acute appendicitis as the leading cause of non-traumatic acute abdomen. Di Saverio et al⁹, in the WSES Jerusalem guidelines, emphasized that acute appendicitis remains the most common emergency surgical condition worldwide and highlighted the importance of early diagnosis and prompt surgical management.8 The predominance of appendicitis in the present study may be related to the younger age distribution and improved diagnostic awareness among clinicians.

Intestinal obstruction constituted the second most common etiology (22%) in the present study. Similar incidence rates were reported by Singh et al³ and Bhatti et al⁵. Ten Broek et al¹⁰, in the Bologna guidelines, emphasized that postoperative adhesions remain the most common cause of intestinal obstruction worldwide, followed by obstructed hernias, malignancy, and volvulus. Delayed presentation of bowel obstruction significantly increases the risk of bowel ischemia, gangrene, perforation, and septic shock. In rural populations, delayed referral and poor access to specialized surgical care often contribute to disease progression before hospital admission.

Perforation peritonitis accounted for 18% of cases in the present study and was strongly associated with postoperative complications and mortality. Similar findings were reported by Singh et al³, who documented high mortality among patients with gastrointestinal perforation and diffuse peritonitis. Sartelli et al⁸ further stated that perforation peritonitis continues to remain one of the major causes of surgical sepsis in developing countries. Common etiologies include peptic ulcer disease, enteric fever, tuberculosis, ischemic bowel disease, and delayed intestinal obstruction. Inadequate sanitation, malnutrition, and delayed healthcare access contribute substantially to disease severity in low-resource settings.

Acute cholecystitis accounted for 12% of cases, while acute pancreatitis represented 9% of the etiological spectrum. Yokoe et al¹¹, in the Tokyo Guidelines 2018, emphasized that early diagnosis and severity assessment are essential for optimal management of acute cholecystitis. Most patients with acute cholecystitis in the present study were managed conservatively initially, followed by elective or interval cholecystectomy where indicated. Banks et al¹², in the revised Atlanta classification, recommended conservative management with supportive therapy as the cornerstone of treatment in uncomplicated acute pancreatitis. Similar management strategies were adopted in the present study, with surgical intervention reserved for complicated cases.

Mesenteric ischemia represented only 3% of cases but demonstrated the highest mortality in the present study. Bala et al⁶ emphasized that acute mesenteric ischemia remains one of the most lethal causes of acute abdomen because of delayed diagnosis and rapid progression to bowel necrosis. Nonspecific clinical presentation, late hospital presentation, and limited availability of advanced imaging modalities contribute significantly to mortality associated with mesenteric ischemia.

Most patients in the present study (70%) required surgical intervention, while 30% were managed conservatively. Comparable operative management rates were reported by Prasad et al³ and Singh et al⁴. The high surgical burden reflects the predominance of appendicitis, intestinal obstruction, and perforation peritonitis among emergency admissions. Early operative intervention in selected cases remains essential to reduce complications and mortality.

Appendectomy was the most commonly performed procedure (37.1%), followed by bowel resection and anastomosis (18.6%) and perforation closure (17.1%). Similar operative patterns were described by Singh et al³ in their observational study. Di Saverio et al⁹ also reported appendectomy as the most frequently performed emergency abdominal surgery worldwide. Emergency laparotomy continues to remain a lifesaving procedure in patients with perforation, bowel gangrene, and generalized peritonitis.

Wound infection was the most common postoperative complication in the present study, occurring in 14% of patients. Respiratory infection, septicemia, and anastomotic leak were other important complications. Similar findings were reported by Singh et al³, where surgical site infection constituted the majority of postoperative morbidity. Sartelli et al⁸ highlighted that contaminated emergency abdominal surgeries carry a substantially higher risk of postoperative infection because of bacterial contamination and systemic inflammatory response. Strict aseptic precautions, timely antibiotic administration, and optimized perioperative care are therefore essential in reducing postoperative complications.

The overall mortality rate in the present study was 3.9%. Mortality was significantly associated with delayed presentation, generalized peritonitis, septicemia, ICU admission, mesenteric ischemia, and advanced age. Similar predictors of mortality have been consistently reported in previous studies. Bala et al⁶ demonstrated that delayed diagnosis and bowel ischemia significantly increase mortality among acute abdomen patients. Hardy et al⁷ also emphasized that delayed recognition of surgical abdomen contributes substantially to poor outcomes. In the present study, patients presenting after 48 hours had significantly higher postoperative complications, prolonged hospital stay, and mortality. Rural healthcare limitations, transportation difficulties, socioeconomic constraints, and delayed referral patterns may account for late presentation in peripheral tertiary care settings.

Multivariate logistic regression analysis identified septicemia as the strongest independent predictor of mortality, followed by mesenteric ischemia, delayed presentation, generalized peritonitis, ICU admission, and advanced age. Similar findings were described by Sartelli et al⁸, who emphasized the importance of early sepsis recognition and prompt source control in reducing mortality associated with intra-abdominal infections. ICU admission often reflects severe systemic illness and multiorgan dysfunction requiring aggressive supportive care.

The present study highlights several important clinical implications. First, acute appendicitis continues to remain the leading cause of acute abdomen requiring emergency surgery. Second, delayed presentation remains a major contributor to adverse outcomes in rural populations. Third, simple clinical indicators such as leukocytosis, generalized peritonitis, and hemodynamic instability can help identify high-risk patients requiring urgent intervention. Finally, strengthening emergency surgical infrastructure, referral systems, imaging facilities, and critical care support at peripheral tertiary care hospitals may substantially improve patient outcomes.

The strengths of the present study include a large sample size and comprehensive evaluation of demographic, clinical, etiological, management, and outcome variables. However, the study also had certain limitations. Being a single-center observational study, the findings may not be universally generalizable. Long-term follow-up and quality-of-life assessment were not included. Nevertheless, the study provides valuable regional data regarding the spectrum and outcomes of acute abdomen in a peripheral tertiary care setting.

Acute abdomen remains one of the most common surgical emergencies encountered in peripheral tertiary care hospitals. Acute appendicitis was the most common etiology, followed by intestinal obstruction and perforation peritonitis. Male predominance and higher incidence among middle-aged adults were observed. Most patients required surgical intervention, with appendectomy being the most commonly performed procedure.

Delayed presentation, leukocytosis, generalized peritonitis, septicemia, mesenteric ischemia, and advanced age were significantly associated with postoperative complications and mortality. Early diagnosis, prompt resuscitation, timely surgical intervention, and improved perioperative care are essential for reducing morbidity and mortality associated with acute abdomen.

Strengthening emergency surgical services, improving referral systems, increasing public awareness regarding early healthcare seeking, and ensuring availability of diagnostic and critical care facilities at peripheral tertiary care centers can significantly improve outcomes in patients presenting with acute abdomen.

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