Abdominal Pain in Elderly


TYPES OF PAIN

  1. Visceral
  2. Somatic
  3. Referred pain
Acute abdominal pain   PLUS    Very OLD pt.
Sigmoid Volvulus Mesenteric Ischemia
- RUQ pain
X-Ray: Parrot's beak, Air-fluid level
- Obstructive symptoms

Tx:
-GI consult
- Old pt. w/ Hx of A-Fib or MI

Dx: CT Angio

Tx:
-Avoid digoxin, beta-blocker, pressors
-Surgical Consult

General

Specific Diagnosis Pearls: 

CHOLECYSTITIS

  • 10-14% mortality in older pts
  • May appear deceptively well but can deteriorate quickly
     
  • Lab:
    • WBC count <10,000 [10x10^9/L] in 30-35%
    • Normal temperature in 30-35%
       
  • Imaging
    • HIDA scan US most useful test, more sensitive but access limited
 

PERFORATED PEPTIC ULCER

  • Pain may be generalized or also in lower quadrants
  • Epigastric rigidity may be absent
  • Lack of free air on plain films in 40%
 

APPENDICITIS

  • Diagnosis missed approx 50% of time
  • Delayed presentation is common (20%>3d)
  • Migration of pain may be lacking
  • Anorexia may be absent
  • Nausea or vomiting in one half or less
  • Normal temperatures common (up to 50%)
  • WBC count less than 10,000 [10x10^9/L] in 20%
  • Plain radiographs misinterpreted as small bowel obst
 

LARGE BOWEL OBSTRUCTION

  • Mortality 40%
  • Carcinoma, volvulus, diverticulitis
  • Diarrhea frequently reported (19%)
  • Obstipation may be lacking (50%)
  • Vomiting often absent
  • Gradual onset of pain in volvulus, esp sigmoid
  • Colonic pseudo-obstruction (Ogilvie's Syndrome):
    • Suspect in pts appearing to have large bowel obst who have non-tender abd or cavernous rectal vault
 

ACUTE MESENTERIC ISCHEMIA

  • Most report gradual onset of pain
  • Prior episodes can be reported
  • Hard evidence lacking early on
  • Guaiac-negative stool early on
  • Laboratory abnormalities are late findings
  • Acute mesenteric infarction must be suspected in any older pt w/ abd pain, particularly if underlying cardiovascular disease or hypotension is present
  • Pt w/ suspect mesenteric infarction must undergo angiography before development of "hard evidence"
  • Atherosclerosis of SMA can cause "intestinal angina"-Postprandial abdominal pain, early satiety and weight loss
 

ABDOMINAL AORTIC ANEURYSM

  • Ruptured aortic aneurysm MUST be considered in any older pt w/acute abd pain or back pain
  • Pulsatile mass will often not be detectable on PE
  • When renal colic is suspect in older pt, care should be taken to exclude possibility of ruptured AAA
  • Back pain present in only one half
  • Syncope possible as primary complaint
  • Hypotension ascribed to other causes (i.e., vagal from misdiagnosed "renal colic")
  • Hematuria may be present
  • Rupture  70% mortality

DIVERTICULITIS

  • WBC may be normal in 1/2
  • Many patients have had prior episodes
  • CT scan to search for complications (abscess, perforation)
  • F/U endoscopy required to R/O colon Ca
  • May be treated as outpatient if no evidence of perforation or abscess
  • Treat w/ broad spectrum abx IV if indicated (severe infections can't tolerate PO)

ACUTE MYOCARDIAL INFARCTION

  • May present w/ vague GI symptoms only
  • Other diseases not to miss: pneumonia, pulmonary embolus, CHF, etc