Surgery Book

Gastroenterology

  • Abdominal Pain in Older Adults

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Abdominal Pain in Older Adults

Aka: Abdominal Pain in Older Adults, Elderly with Acute Abdominal Pain, Acute Abdomen in the Elderly, Intra-Abdominal Infection in Older Patients
  1. See Also
    1. Acute Abdominal Pain
    2. Abdominal Pain Evaluation
    3. Acute Abdominal Pain Causes
  2. 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: 50-60%
      2. ER presentations requiring surgery: 20-33%
      3. Surgical mortality: 2-13% (up to 34% if emergent)
  3. 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 represent 10% of appendectomies
      2. Elderly often present late in course
        1. Generalized pain and peritoneal signs common by the time elderly present
        2. Presentation at 3 days in 20% and at 7 days in 8% of elderly patients
        3. Mortality approaches 20%
      3. Classic diagnostic criteria are often absent
        1. Fever, Nausea, Vomiting, anorexia, abdominal gaurding are each present in only 50% of patients
        2. Classic Periumbilical Pain migrating to right lower quadrant is present in only 40% of elderly with Appendicitis
        3. Leukocytosis is absent in 40% of patients
        4. Urinalysis may show Hematuria or pyuria leading to missed diagnosis
        5. Missed diagnosis is common with 20-25% of elderly being sent home on their initial Appendicitis presentation
      4. 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
  4. Labs
    1. Complete Blood Count
      1. Leukocyte count is often normal despite peritonitis
    2. Comprehensive metabolic panel
    3. Blood Cultures
    4. Lipase
    5. Lactic Acid
    6. Urinalysis
      1. Urinalysis may show Hematuria or pyuria in Appendicitis
  5. Imaging
    1. Upright Chest XRay (or left lateral decubitus xray)
      1. Evaluate for abdominal free air
    2. CT Abdomen and Pelvis
      1. Frequently needed to exclude serious pathology (e.g. AAA, Intestinal Obstruction, Mesenteric Ischemia, Appendicitis, biliary disease)
  6. Diagnostics
    1. Electrocardiogram
      1. Especially indicated in upper Abdominal Pain
  7. 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
  8. Evaluation: Approach
    1. See Abdominal Pain Evaluation
    2. ABC Management
    3. Vital Signs predictive of more serious illness
      1. Bedside Glucose
      2. Oxygen Saturation
      3. Respiratory Rate with Tachypnea
        1. Sensitive marker for early systemic infection
    4. Predictors of older patients needing surgery
      1. Hypotension
      2. Bowel sounds abnormal
      3. Leukocytosis
        1. WBC Count often normal in elderly with Acute Abdomen, so when increased suggests a serious infection
        2. Consider Mesenteric Ischemia when the WBC Count >25,000, especially if concurrent Lactic Acidosis
      4. Abdominal Pain with coughing or with shaking the stretcher
        1. Suggestive of peritonitis
      5. Abdominal imaging abnormalities
        1. Abdominal free air (upright Chest XRay)
        2. Dilated loops of bowel
        3. Bowel air-fluid levels
  9. Evaluation: Pitfalls for Abdominal Pain in older patients
    1. History may be difficult
      1. Hearing Impairment
      2. Elderly patients often down play their symptoms or attribute them to benign conditions
      3. Altered Level of Consciousness or Dementia
        1. Consider brief bedside mental status evaluation (e.g. Mini-Cognitive Assessment Instrument)
        2. Consider collateral information from family or nursing facility
    2. Vital Signs are often unreliable
      1. Fever is often absent (or only low-grade)
        1. Hypothermia often is clinical equivalent of fever
        2. Lower typical threshold Temperature for fever by 1 F in the elderly (i.e. fever at 99.5 F)
      2. Tachycardia is often absent
        1. Beta Blocker use
        2. Decreased endogenous Catecholamine response
      3. Blood Pressure often does not reflect degree of hemodynamic instability
        1. Chronic Hypertension (comparison with baseline Blood Pressures may be helpful)
        2. Decreased vascular compliance
    3. Examination and lab data may underestimate severity of disease
      1. Abdominal Examination has poor Test Sensitivity in the elderly
        1. Peritonitis may present with minimal abdominal exam findings
        2. Pain out of proportion to the examination is a red flag, and is not benign or reassuring
          1. Consider Mesenteric Ischemia
      2. Local tenderness, rigidity, guarding and rebound often absent
      3. Leukocytosis is often absent (typically delayed inflammatory response)
        1. Normal Leukocyte count in 40% of Cholecystitis and 45% of Appendicitis
        2. Band Neutrophils may have increased Test Sensitivity
        3. Lactic Acidosis may be an earlier marker for Sepsis
    4. Diagnosis
      1. Exclude serious Abdominal Pain causes before making a benign diagnosis
        1. Avoid early determination of diagnoses of exclusion (e.g. GERD, Constipation, Gastroenteritis)
      2. Consider referred pain (e.g. Myocardial Infarction)
  10. References
    1. Lin and Shenvi in Herbert (2014) EM:Rap 14(6):8-9
    2. Majoewsky (2012) EM:Rap 2(9): 4
    3. Abi-Hanna (1997) Geriatrics 52:72-4 [PubMed]
    4. Dang (2002) Geriatrics 57:30-42 [PubMed]
    5. Lyon (2006) Am Fam Physician 74: 1537-44 [PubMed]
    6. Marco (1998) Acad Emerg Med 5:1163-8 [PubMed]

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