Abdominal emergencies in the elderly requiring emergent surgery pose a significant challenge to the emergency physician. Because of concomitant illness, these patients generally have a substantial operative risk. Further, the symptoms and signs in these patients are frequently milder and less specific than in younger adults with the same conditions. Therefore, the emergency physician must develop a high index of suspicion for these conditions and must seek early surgical consultation, even if a definitive diagnosis has not been established. In other words, in many cases consultation must be sought on the basis of the emergency physician's clinical suspicion rather than on "hard" data. Emergency physicians must pay particular attention to associated extra-abdominal disease, which must be diagnosed and stabilized to minimize the risk of emergent surgery. Only aggressive assessment, expeditious resuscitation, and team work with the surgical consultants can minimize the high mortality rate associated with these acute abdominal surgical emergencies.