Presentation on theme: "ABDOMINAL PAIN IN THE ELDERLY Kevin Biese, MD, MAT Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD University of North Carolina at Chapel Hill Division."— Presentation transcript:
1ABDOMINAL PAIN IN THE ELDERLY Kevin Biese, MD, MAT Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD University of North Carolina at Chapel Hill Division of Geriatric Medicine Center for Aging and Health Department of Emergency MedicineAGSTHE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.Leading change. Improving care for older adults.Topic
2ObjectivesTo increase appreciation of the variety of presentations of acute abdominal pathology in elderly patientsTo appreciate the differences in etiology of acute abdominal pain between elderly and younger patientsTo increase proficiency of evaluation and management of elderly patients with acute abdominal pain
3Why Care? Increasing Elderly Population (≥65 Years)
4Why Care? Significant Mortality and Morbidity Of patients ≥65 years old who come to the ED with acute abdominal pain:50% admission33% surgery10% mortality (similar to ST-elevation myocardial infarction)Kizer KW. Am J Emerg Med. 1998;16:
5Case 1: Ms. Jones85-year-old woman with past medical history of atrial fibrillation, GERDChief complaint: abdominal pain that started 8 hours before arrival, sudden onsetIntermittent pain, was able to eat dinner 3 hours after onset without difficultyAfebrile, vital signs within normal limits (WNL), no vomiting, no diarrhea, normal bowel movement 2 hours before arrivalExam: mildly tender epigastric and right upper quadrant (RUQ) region without peritonitis, no Murphy’s sign
7Gall Bladder Disease: Are LFTs Helpful? Total bilirubin, AST, or alkaline phosphatePositive likelihood ratioNegative likelihood ratioAll 3 elevated1.60.8Any 1 elevated1.20.7It is often taught that the initial screening test to help determine if abdominal pain is from gall bladder disease is to order “LFTs” (liver function tests) and if they are elevated that gall bladder disease is suggested. However, the literature does not support that are LFTs are predictive enough to fill this function.Trowbridge RL. JAMA. 2003; 289(1):
8Ms. Jones UltrasoundInsert ultrasound image of cholecystitis with gall stones,thickened gall bladder wall, and edema.Ms. Jones ultrasound shows acute cholecystitis with gall bladder wall thicker than 3mm, edema, and a gallstone.
9Cholecystitis #1 abdominal surgical emergency in elderly Incidence increases with ageOften only epigastric pain (foregut innervation is visceral)LFTs often not helpfulUltrasound is study of choice
10Case 2: Ms. Jones Returns Ms. Jones returns to the ED 4 days post-op Chief complaint: RUQ painPain worsened last night, able to eat, general fatigueVital signs WNL, afebrileModerate tenderness in RUQ
11Ms. Jones: The Return Visit Labs including LFTs are WNLWhat to do?
12Ms. Jones: The Return Visit The diaphragm is an unsecured border; upper abdominal pain can beAcute coronary syndromePulmonary embolismPneumoniaInsert CT image of pulmonary embolismIt is important to remember that abdominal pain can be caused by intra-thoracic pathology.
13Case 3: Ms. Smith80-year-old woman with past medical history of breast cancer, hypothyroidismChief complaint: abdominal painSudden onset 10 hours before arrival, right lower quadrant (RLQ) pain constant in location, 10/10 intensity, + diarrheaExam notable for moderate RLQ tenderness, Hemoccult negative
14Ms. Smith: Appendicitis Insert CT image of appendicitis.Appendicitis is common and often difficult to diagnose in elderly patients.
15Appendicitis IN THE ELDERLY 5% of acute abdominal casesRarely have the 4 classic criteria (anorexia, elevated WBC, RLQ pain, and fever)Diagnosis often missed (presence of diarrhea or WBC in urine can be misleading)However, usually have at least RLQ painKauvar DR. Clin Geriatr Med. 1993;9:Storm-Dickerson TL. Am J Surg. 1983;185:
16Case 4: Ms. Doe 67-year-old woman with HTN, COPD, CAD Chief complaint: abdominal pain3 days generalized, intermittent abdominal pain with nausea, vomiting, and diarrhea (n/v/d); no black stools; some urinary hesitancySeen by PCP 2 days prior, given phenerganNo apparent distress; exam notable for moderate RUQ and RLQ tendernessHR 115, BP 160/100, T 37.0
17Ms. Doe: INITIAL RESULTS WBC 11.5; o/w CBC WNLChemistries 7 and LFTs WNLUA shows 7 WBC, nitrite negativeArterial lactate 1.0What to do?A diagnostic test was obtained several hours later…
19Mesenteric Ischemia Classically, pain out of proportion to exam Risks include atrial fibrillation, hypercoagulable, low-flow, increasing ageUsually arterial; may be venousEmbolus or thrombosisSometimes “intestinal angina”Usually superior mesenteric arteryMultidetector CT scan 77%90% sensitiveElevated lactate is a late finding (check >1 time)Newman TS. Am Surg. 1998;64:Horton KM. Radiographics. 2002:22;161.
20Case 5: Mr. Smith82-year-old man with HTN, chronic renal insufficiency, diverticulosisHistory also includes abdominal aortic aneurysm repairPresents with a 2-week history of flank pain wrapping around to abdomenReferred by PCP because of abnormal renal CT scanVital signs WNL including afebrile, BP 162/80, HR 65Obese male in moderate amount of distressExam benign, including abdominal exam
21Mr. Smith: Abdominal Aortic Aneurysm (AAA) Elderly + low BP + abdominal pain = AAAGet the ultrasound – Fast!Same risk factors as CAD (men>women)>3 cm defines, >5 cm rupture riskWhat diagnosis to consider if simultaneous rectal bleeding?Insert ultrasound image of enlarged abdominal aortaImportant information regarding AAA. Most important is to consider the diagnosis in elderly patients with abdominal pain and do a rapid bedside ultrasound. If rectal bleeding accompanies a AAA, consider aortic – enteric fistula.
22Case 6: Ms. Connor 80-year-old woman with HTN, anxiety 2-day history of crampy lower abdominal pain; mild n/v/dIn no apparent distressVital signs WNL other than moderate HTNExam notable for moderate RLQ tenderness without peritonitis
23Ms. Connor: IMAGINGLearningRadiology.com, retrieved June 1, 2011.
24Sigmoid Volvulus Risk factors: chronic constipation, round worms More common in malesAbdominal x-ray 65% sensitiveUsually presents with crampy left sided abdominal painOften decompressed with sigmoid scopeCan be subtle presentationTime sensitive diagnosisSome basic information regarding sigmoid volvulus.Atamanalp SSJ Gastroenterol Hepatol 2007Emedicine 2008
25Case 7: Ms. Lane 79-year-old woman with HTN, diabetes Chief complaint: 2 days of n/v/dWell-appearing, vital signs WNLSeen 48 hours ago for n/v/d: 6 WBC in UA, no nitrate, 4 squamous cells, levofloxacin startedPatient took 1 tab levofloxacin, had increased vomiting and diarrheaCompletely benign abdominal examWBC 5,000, chemistries WNL, UA WNL
26Ms. Lane: Gastroenteritis (I hope) Observed in ED for 5 hoursNo vomiting or diarrhea; tolerating POsD/C with close PCP follow-up“You do not always have to be right, you just have to have a contingency plan”
27Key PointsAcute abdominal pain in the elderly is associated with significant morbidity and mortalityLFTs often not revealing in acute gallbladder diseaseThe diaphragm is not a secure borderConsider mesenteric ischemia (especially with history of atrial fibrillation, pain out of proportion to exam)Elderly + low BP + abdominal pain = AAA (until proven otherwise)Topic
28Case 1 (1 of 2)An 85-year-old woman presents to the ED complaining of 8 hours of abdominal pain. The pain is centered in the epigastrium and she has had no n/v/d.She had a normal bowel movement 2 hours before arrival to the ED. She ate a meal last night without difficulty.Her past medical history is notable for atrial fibrillation and GERD.In the ED she is afebrile with normal vital signs other than mild HTN at 150/95.Topic
29Case 1 (2 of 2)Her exam is notable for a well-appearing elderly woman with mild epigastric tenderness and no peritonitis on exam. She does not have a Murphy’s sign on exam.After completing your history and exam, you order labs, including LFTs, CBC, and basic chemistries. Other than a WBC count of 11.7 without a left shift, these labs are all WNL, including the LFTs.You now need to decide how you wish to proceed with this patient.Topic
30Case 1, Question 1What is the most common etiology of acute abdominal pain presenting to the ED in patients over age 50? Select the one best answer.A. Biliary tract diseaseB. ConstipationC. Nonspecific abdominal painD. Urinary tract infectionTopic
31Case 1, Question 2What is the negative likelihood ratio for all LFTs being normal in assessing whether a patient has acute cholecystitis?A. 0.1B. 0.3C. 0.7D. 1.0Topic
32Case 1, Question 3 True or False: The gallbladder’s visceral innervation originates in the midgut.Topic
33Case 2 (1 of 2)A 67-year-old woman with a medical history of HTN and CAD disease presents to the ED with 3 days of generalized intermittent abdominal pain with n/v/d and some urinary hesitancy.She denies black stools or fevers.She was seen 2 days ago by her PCP and given phenergan for nausea. She is now presenting to the ED because her pain is not improving.Topic
34Case 2 (1 of 2)On exam she is in significant pain but has only moderate RUQ and RLQ abdominal tenderness.She is guaiac-negative on rectal exam and her vitals are notable for a heart rate of 115, BP of 160/100, and temperature of 37.0 C.In the ED, her WBC count is 11.5 without a left shift, her UA has 7 WBC without nitrite, squamous cells, or bacteria, and the rest of her labs are normal, including her arterial lactate level of 1.0.You now need to decide how to proceed in your evaluation of this patient.Topic
35Case 2, Question 1Which of the following is NOT a risk factor for mesenteric ischemia?A. Advancing ageB. Atrial fibrillationC. Prior abdominal surgeryD. Recent myocardial infarctionTopic
36Case 2, Question 2True or False: Elevated lactate levels are a highly sensitive marker of mesenteric ischemia.Topic
37Case 2, Question 3Regarding appendicitis, which of the following classic signs and symptoms do the majority of elderly patients with abdominal pain have? Select the one best answer.A. AnorexiaB. Migration of painC. Pain localized to the RLQD. Peritoneal signs on abdominal examTopic
38Answer Key Case 1 Case 2 Question 1: A Question 2: C Question 3: False Topic
39Acknowledgments and Disclaimer This project was supported by funds from the American Geriatrics Society John A. Hartford Geriatrics for Specialists Grant. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of the American Geriatrics Society or John A. Hartford Foundation, nor should any endorsements be inferred.The UNC Center for Aging and Health and UNC Department of Emergency Medicine also provided support for this activity. This work was compiled and edited through the efforts of Jennifer Link, BA.Topic
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