Acute abdominal pain, defined as pain of less than a week in duration, is a common complaint among elderly patients. Clinical diagnosis of abdominal pain in the elderly is complicated by many factors, including diminished immune function, vague symptoms, multiple comorbidities, and normal senescent anatomic alterations. Accurate diagnosis is imperative because morbidity and mortality are high in this patient population. Imaging plays an essential role in the diagnostic workup and management of elderly patients with acute abdominal pain. This article reviews common intra-abdominal senescent changes in the elderly and discusses appropriate protocol modifications that address comorbidities and optimize diagnostic quality. Various common and uncommon causes of acute abdominal pain in the elderly will be evaluated in the following categories: visceral, solid organ, and vascular pathology.