The evolving role of MRI in abdominopelvic emergencies: from problem-solving to first-line imaging

Acute abdominopelvic pain requires rapid imaging triage, traditionally dominated by computed tomography (CT) and ultrasound (US). However, advances in magnetic resonance imaging (MRI), including accelerated acquisition, motion-robust sequences, and non-contrast protocols, have expanded its role beyond a problem-solving tool toward selective first-line imaging in specific clinical scenarios. This review provides a decision-based framework for MRI utilization in nontraumatic abdominopelvic emergencies, integrating current evidence on diagnostic performance, workflow considerations, and clinical impact. MRI offers clear advantages in radiation-sensitive populations (pregnant and pediatric patients), in biliary obstruction, and for characterizing pancreatic complications, while remaining complementary in most other emergency settings. We highlight high-yield indications where MRI may replace or precede CT, supported by comparative data, and provide practical, rapid MRI protocols (< 15 min) adaptable to emergency workflows. Importantly, we present a balanced discussion of real-world constraints, including availability, cost, scan time, and patient tolerance, that currently limit universal adoption. MRI should therefore be viewed not as a universal replacement for CT, but as a targeted, high-value imaging strategy in selected emergency scenarios where it improves diagnostic confidence, avoids ionizing radiation, and influences management.