What criteria should I use to determine whether a patient with acute abdominal pain requires urgent surgical referral?

Criteria for urgent surgical referral in patients with acute abdominal pain include:

• Signs of complicated acute diverticulitis: uncontrolled abdominal pain plus any of abdominal mass, peri-rectal fullness, abdominal rigidity and guarding (suggesting perforation or peritonitis), altered mental state, signs of sepsis (e.g., raised respiratory rate, low blood pressure, tachycardia), faecaluria or pneumaturia (suggesting fistula), absolute constipation with vomiting or distension (suggesting obstruction) require same-day hospital assessment and urgent referral NICE NG147.
• Suspected appendicitis with risk factors for complications: prompt hospital admission is recommended especially if there is suspicion of perforation, atypical presentation in pregnant women, older adults, or children, or if symptoms are worsening, to reduce morbidity and mortality NICE CKS.
• Presence of an abdominal or pelvic mass: especially if not obviously benign (e.g., not uterine fibroids), warrants urgent referral via suspected cancer pathway, as this may indicate malignancy requiring surgical assessment NICE NG12.
• Signs of peritonitis or bowel obstruction: such as abdominal rigidity, guarding, absolute constipation, vomiting, or abdominal distension, require urgent surgical evaluation NICE NG147.
• Systemic signs of sepsis: including altered mental state, hypotension, tachycardia, and low temperature in the context of abdominal pain, necessitate urgent referral NICE NG147.
• Other urgent indications: acute anal sphincter injury, suspected cauda equina syndrome, or acute stroke with abdominal symptoms require emergency referral NICE CKS.

In summary, urgent surgical referral is indicated when acute abdominal pain is accompanied by signs of complicated intra-abdominal pathology (e.g., perforation, abscess, obstruction), systemic sepsis, palpable masses suspicious for cancer, or when clinical suspicion of appendicitis or diverticulitis complications is high NICE CKS,NICE NG147,NICE NG12,NICE CKS.