4Geriatric with CC of abdominal pain in ED 50% will be admitted10% Overall MortalityAround 1 in 4 patients seen for abdominal pain are discharged with a diagnosis of “undifferentiated abdominal pain
5Difficulties 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
7You Make the Call!All he follow case presentations refer to a 82 year old white femaleTriage Note-“CC: belly pain. – 82 yo WF, demented, conversing with wall, dropped off by friend, no additional history, in obvious pain”
8YOU MUST GIVE A DIFFERENTIAL DX BEFORE YOU CT SCAN OR ELSE RULES:YOU MUST GIVE A DIFFERENTIAL DX BEFORE YOU CT SCAN OR ELSE
14Ruptured AAAThe 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.
15CASE 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
16Mesenteric Ischemia High mortality – 45-90% Occlusion in SMA most commonBig Risk factor = A-fibGet vascular surgery pronto
17CASE CUATRO!Severe epigastric pain, rigid abd with guarding, found some Prilosec in her handbagPeritonitis! Yeehaw!
18Perforated BowelFree Air! 40% of upright abd xrays will miss the free airMost common cause = peptic ulcersPoorer outcome in >70yo w/o surgical intervention
19CASE CINCO!Belly pain, boring to the back, N/V, feels very sick, ecchymosed on flanksVitals are muy loco
20Acute Pancreatitis Gallstones the cause in ~ 70% of pts >80yo Frequently present in shockAmylase/Lipase and CT
21CASE SEIS! Colicky RUQ pain, no N/V, no fever Bedside ultrasound available and shows -->
22Acute cholecystitis Nonoperative mgmt can result in ~17% mortality Use HIDA scan if high suspicion and neg U/SLook for atypical presentations in elderly
23CASE SIETE!Belly Pain all over, TTP over RLQ, no fever or leukocytosisTold she had a “stomach bug” at walk-in clinic
24Appendicitis 5% of all surgical abdomens in geriatric > Half of geriatric appy’s are misdiagnosed on initial presentationWatch for perfs!
25CASE OCHO!Belly & pelvic pain, vag bleeding, tachy, low BP
26Ruptured EctopicYeah.Right.Think endomertrial CA, you doofus
27Conclusions Geriatric Emergencies demand attention and diligence Often present atypicallyRemember to ROWC it! (Rule Out Worst Case)‘Cause Jerry goes down fast!Tele Medicine – Scary!
28ReferencesBugliosi, TF, Meloy, TD, Vukov, LF. Acute abdominal pain in the elderly. Ann Emerg Med 1990; 19:1383.Kamin, RA, Nowicki, TA, Courtney, DS, Powers, RD. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am 2003; 21:61.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)