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Abdominal Pain in Older AdultsAka: Elderly with Acute Abdominal Pain

See Also
1. Acute Abdominal Pain
Epidemiology
1. Older adults present later in Acute Abdominal Pain
2. Older adults present with higher level of severity
  1. ER presentations requiring hospital admission: 50%
  2. ER presentations requiring surgery: 20-33%
  3. Surgical mortality: 2-13% (up to 34% if emergent)
Causes: Acute Abdominal Pain over age 55 years
1. See Acute Abdominal Pain Causes
2. Biliary disease (e.g. Cholecystitis): up to 33%
  1. Classic symptoms, signs often absent in older adults
    1. Nausea, Abdominal Pain and flank pain may be absent
    2. Leukocyte count and temperature may be normal
    3. Liver Function Tests may be normal
    4. Murphy's Sign less efficacious in older adults
  2. Complications of Acute Cholecystitis: >50% of elderly
    1. Risk for acute Ascending Cholangitis
3. Appendicitis (4-15%)
  1. Elderly often present late in course
    1. Generalized pain and peritoneal signs common
  2. Classic diagnostic criteria are often absent
    1. Fever is absent in a majority of patients
  3. Complications are common due to delay in presentation
    1. Increased Appendiceal gangrene risk
    2. Increased Appendiceal rupture risk
4. Peptic Ulcer Disease (16%)
  1. Causes: NSAIDs (most common), Helicobacter Pylori
  2. Abdominal Pain is often absent or non-specific
  3. Initial presentation after perforation is common
    1. Suggested by Leukocytosis and high Serum Amylase
    2. Perforation may be difficult to detect
      1. Free air may be absent on abdominal XRay
      2. Consider CT abdomen or ultrasound if suspected
5. Intestinal Obstruction (12%)
  1. Small Bowel Obstruction causes in older adults
    1. Adhesion from prior surgery (50-70%)
    2. Incarcerated Hernia (15-30%)
    3. Gallstone ileus (20% of SBO in the elderly)
      1. Air in biliary tree, Xray with ileal Gallstone
      2. High mortality in delayed diagnosis
  2. Large Bowel Obstruction causes
    1. Colon Cancer (most common)
    2. Diverticulitis
    3. Volvulus
6. Diverticulitis (6%)
7. Acute Pancreatitis
  1. Gallstone Pancreatitis accounts for 75% of cases
  2. Presentation is similar to younger patients
  3. Mortality is twice that of younger patients (20%)
8. Abdominal Aortic Aneurysm
9. Acute Mesenteric Ischemia
10. Other causes
  1. Abdominal causes
    1. Renal Colic or Nephrolithiasis
    2. Urinary Tract Infection or Pyelonephritis
    3. Constipation
    4. Abdominal muscle wall injury
  2. Extra-abdominal referred causes
    1. Inferior wall Myocardial Infarction
    2. Pulmonary Embolism
    3. Congestive Heart Failure
    4. Pneumonia
Prognosis
1. Mortality risks for Acute Abdominal Pain in elderly
  1. XRay demonstrates abdominal free air
  2. Leukocytosis with Left Shift (high Band Neutrophils)
  3. Age over 84 years old
Evaluation: Approach
1. See Abdominal Pain Evaluation
Evaluation: Pitfalls for Abdominal Pain in older patients
1. History may be difficult
  1. Altered Level of Consciousness or Dementia
  2. Hearing Impairment
2. Examination may underestimate severity of disease
  1. Fever is often absent (or only low-grade)
    1. Hypothermia often is clinical equivalent of fever
  2. Leukocytosis is often absent
  3. Tachycardia is often absent
  4. Local tenderness, guarding and rebound often absent
Evaluation: Predictors of older patients needing surgery
1. Hypotension
2. Bowel sounds abnormal
3. Leukocytosis
4. Abdominal imaging abnormalities
  1. Abdominal free air
  2. Dilated loops of bowel
  3. Bowel air-fluid levels
References

Surgery Book

Gastroenterology

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Abdominal Pain in Older AdultsAka: Elderly with Acute Abdominal Pain

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