Acute Abdominal Pain in a Geriatric: An Emergency

Medicine Perspective

Ali R. Rahimi,MD

Geriatrics as an increasing segment of the population

1 in 8 is >64yo in 1994 1 in 5 projected to be >64yo in 2030

The Geriatric Functional Continuum

Geriatric with CC of abdominal pain in ED

50% will be admitted

10% Overall Mortality

Around 1 in 4 patients seen for abdominal pain are discharged with a diagnosis of “undifferentiated abdominal pain

Difficulties in making the Dx Sometimes Jerry is a poor

historian (present with altered mental status)

Lack of consistent physiological responces (ie. may not be febrile or tachycardic)

They often have little reserve capacity

You Make the Call! All he follow case

presentations refer to a 82 year old white female

Triage Note- “CC: belly pain. – 82 yo

WF, demented, conversing with wall, dropped off by friend, no additional history, in obvious pain”

RULES:

YOU MUST GIVE A DIFFERENTIAL DX

BEFORE YOU CT SCAN OR ELSE

Actual ER Physicians

CASE UNO! Belly pain, green vomit x 3, distended

belly, painful throughout, “tinkly” bowel sounds

Upright Abd film

Bowel Obstruction

Most common risk factor – prior abd. Surgery

Look for dilated loops of bowel on imaging

Needs surgical intervention (LOA)

CASE DOS! Back or Belly pain, Low

BP and pulsatile abdominal mass

Get crackin’!

Bedside U/S then CTA (if Vital signs stable)

Ruptured AAA The survival rate of patients who

experience a ruptured abdominal aortic aneurysm is less than 50 percent.

The symptoms of a ruptured or leaking aneurysm may mimic other acute conditions such as renal colic, diverticulitis, pancreatitis, inferior wall coronary ischemia, mesenteric ischemia, or biliary tract disease. In addition, elderly patients who present with hypotension from a leaking abdominal aortic aneurysm may have electrocardiographic changes consistent with coronary ischemia.

CASE TRES! Intense belly pain, N/V/D,

pain out of proportion to exam

Oh snap!

Think CTA (if Vital signs stable- ‘cause you don’t want to run a code in CT)

Geriatric Hippies – A High Risk Population

Mesenteric Ischemia

High mortality – 45-90% Occlusion in SMA most

common Big Risk factor = A-fib Get vascular surgery

pronto

CASE CUATRO! Severe epigastric pain,

rigid abd with guarding, found some Prilosec in her handbag

Peritonitis! Yeehaw!

Perforated Bowel

Free Air! 40% of upright abd xrays will miss the free air

Most common cause = peptic ulcers

Poorer outcome in >70yo w/o surgical intervention

CASE CINCO! Belly pain, boring to the back, N/V, feels very

sick, ecchymosed on flanks

Vitals are muy loco

Acute Pancreatitis

Gallstones the cause in ~ 70% of pts >80yo

Frequently present in shock

Amylase/Lipase and CT

CASE SEIS! Colicky RUQ pain, no

N/V, no fever

Bedside ultrasound available and shows -->

Acute cholecystitis Nonoperative mgmt

can result in ~17% mortality

Use HIDA scan if high suspicion and neg U/S

Look for atypical presentations in elderly

CASE SIETE! Belly Pain all over, TTP over RLQ, no fever

or leukocytosis Told she had a “stomach bug” at walk-in

clinic

Appendicitis 5% of all surgical

abdomens in geriatric

> Half of geriatric appy’s are misdiagnosed on initial presentation

Watch for perfs!

CASE OCHO!

Belly & pelvic pain, vag bleeding, tachy, low BP

Ruptured Ectopic

Yeah. Right.

Think endomertrial CA, you doofus

Conclusions

Geriatric Emergencies demand attention and diligence

Often present atypically Remember to ROWC it!

(Rule Out Worst Case) ‘Cause Jerry goes down

fast!

Tele Medicine – Scary!

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Kizer, KW, Vassar, MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med 1998; 16:357.

Hustey, FM, Meldon, SW, Banet, GA, et al. The use of abdominal computed tomography in older ED patients with acute abdominal pain. Am J Emerg Med 2005; 23:259.

Yamamoto, W, Kono, H, Maekawa, M, Fukui, T. The relationship between abdominal pain regions and specific diseases: an epidemiologic approach to clinical practice. J Epidemiol 1997; 7:27.

Yeh, E, McNamara, R.Abdominal Pain. Clin Geriatr Med 23 (2007) 255-270.