1. 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 of Geriatric Medicine Center for Aging and Health Department of Emergency Medicine
AGS
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
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2. Objectives
To increase appreciation of the variety of presentations of acute abdominal pathology in elderly patients
To appreciate the differences in etiology of acute abdominal pain between elderly and younger patients
To increase proficiency of evaluation and management of elderly patients with acute abdominal pain

3. Why Care? Increasing Elderly Population (≥65 Years)

4. Why Care? Significant Mortality and Morbidity
Of patients ≥65 years old who come to the ED with acute abdominal pain:
50% admission
33% surgery
10% mortality (similar to ST-elevation myocardial infarction)
Kizer KW. Am J Emerg Med. 1998;16:

5. Case 1: Ms. Jones
85-year-old woman with past medical history of atrial fibrillation, GERD
Chief complaint: abdominal pain that started 8 hours before arrival, sudden onset
Intermittent pain, was able to eat dinner 3 hours after onset without difficulty
Afebrile, vital signs within normal limits (WNL), no vomiting, no diarrhea, normal bowel movement 2 hours before arrival
Exam: mildly tender epigastric and right upper quadrant (RUQ) region without peritonitis, no Murphy’s sign

6. Ms. Jones: Initial Results
WBC count 11.7
Hematocrit 49
Platelets 193
Chemistries WNL
Liver function tests (LFTs) WNL
Lipase WNL

7. Gall Bladder Disease: Are LFTs Helpful?
Total bilirubin, AST, or alkaline phosphate
Positive likelihood ratio
Negative likelihood ratio
All 3 elevated
1.6
0.8
Any 1 elevated
1.2
0.7
It 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):

8. Ms. Jones Ultrasound
Insert 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.

9. Cholecystitis #1 abdominal surgical emergency in elderly
Incidence increases with age
Often only epigastric pain (foregut innervation is visceral)
LFTs often not helpful
Ultrasound is study of choice

10. Case 2: Ms. Jones Returns Ms. Jones returns to the ED 4 days post-op
Chief complaint: RUQ pain
Pain worsened last night, able to eat, general fatigue
Vital signs WNL, afebrile
Moderate tenderness in RUQ

11. Ms. Jones: The Return Visit
Labs including LFTs are WNL
What to do?

12. Ms. Jones: The Return Visit
The diaphragm is an unsecured border; upper abdominal pain can be
Acute coronary syndrome
Pulmonary embolism
Pneumonia
Insert CT image of pulmonary embolism
It is important to remember that abdominal pain can be caused by intra-thoracic pathology.

13. Case 3: Ms. Smith
80-year-old woman with past medical history of breast cancer, hypothyroidism
Chief complaint: abdominal pain
Sudden onset 10 hours before arrival, right lower quadrant (RLQ) pain constant in location, 10/10 intensity, + diarrhea
Exam notable for moderate RLQ tenderness, Hemoccult negative

14. Ms. Smith: Appendicitis
Insert CT image of appendicitis.
Appendicitis is common and often difficult to diagnose in elderly patients.

15. Appendicitis IN THE ELDERLY
5% of acute abdominal cases
Rarely 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 pain
Kauvar DR. Clin Geriatr Med. 1993;9:
Storm-Dickerson TL. Am J Surg. 1983;185:

16. Case 4: Ms. Doe 67-year-old woman with HTN, COPD, CAD
Chief complaint: abdominal pain
3 days generalized, intermittent abdominal pain with nausea, vomiting, and diarrhea (n/v/d); no black stools; some urinary hesitancy
Seen by PCP 2 days prior, given phenergan
No apparent distress; exam notable for moderate RUQ and RLQ tenderness
HR 115, BP 160/100, T 37.0

17. Ms. Doe: INITIAL RESULTS
WBC 11.5; o/w CBC WNL
Chemistries 7 and LFTs WNL
UA shows 7 WBC, nitrite negative
Arterial lactate 1.0
What to do?
A diagnostic test was obtained several hours later…

18. LearningRadiology.com, retrieved June 1, 2011.

19. Mesenteric Ischemia Classically, pain out of proportion to exam
Risks include atrial fibrillation, hypercoagulable, low-flow, increasing age
Usually arterial; may be venous
Embolus or thrombosis
Sometimes “intestinal angina”
Usually superior mesenteric artery
Multidetector CT scan 77%90% sensitive
Elevated lactate is a late finding (check >1 time)
Newman TS. Am Surg. 1998;64:
Horton KM. Radiographics. 2002:22;161.

20. Case 5: Mr. Smith
82-year-old man with HTN, chronic renal insufficiency, diverticulosis
History also includes abdominal aortic aneurysm repair
Presents with a 2-week history of flank pain wrapping around to abdomen
Referred by PCP because of abnormal renal CT scan
Vital signs WNL including afebrile, BP 162/80, HR 65
Obese male in moderate amount of distress
Exam benign, including abdominal exam

21. Mr. Smith: Abdominal Aortic Aneurysm (AAA)
Elderly + low BP + abdominal pain = AAA
Get the ultrasound – Fast!
Same risk factors as CAD (men>women)
>3 cm defines, >5 cm rupture risk
What diagnosis to consider if simultaneous rectal bleeding?
Insert ultrasound image of enlarged abdominal aorta
Important 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.

22. Case 6: Ms. Connor 80-year-old woman with HTN, anxiety
2-day history of crampy lower abdominal pain; mild n/v/d
In no apparent distress
Vital signs WNL other than moderate HTN
Exam notable for moderate RLQ tenderness without peritonitis

23. Ms. Connor: IMAGING
LearningRadiology.com, retrieved June 1, 2011.

24. Sigmoid Volvulus Risk factors: chronic constipation, round worms
More common in males
Abdominal x-ray 65% sensitive
Usually presents with crampy left sided abdominal pain
Often decompressed with sigmoid scope
Can be subtle presentation
Time sensitive diagnosis
Some basic information regarding sigmoid volvulus.
Atamanalp SSJ Gastroenterol Hepatol 2007
Emedicine 2008

25. Case 7: Ms. Lane 79-year-old woman with HTN, diabetes
Chief complaint: 2 days of n/v/d
Well-appearing, vital signs WNL
Seen 48 hours ago for n/v/d: 6 WBC in UA, no nitrate, 4 squamous cells, levofloxacin started
Patient took 1 tab levofloxacin, had increased vomiting and diarrhea
Completely benign abdominal exam
WBC 5,000, chemistries WNL, UA WNL

26. Ms. Lane: Gastroenteritis (I hope)
Observed in ED for 5 hours
No vomiting or diarrhea; tolerating POs
D/C with close PCP follow-up
“You do not always have to be right, you just have to have a contingency plan”

27. Key Points
Acute abdominal pain in the elderly is associated with significant morbidity and mortality
LFTs often not revealing in acute gallbladder disease
The diaphragm is not a secure border
Consider mesenteric ischemia (especially with history of atrial fibrillation, pain out of proportion to exam)
Elderly + low BP + abdominal pain = AAA (until proven otherwise)
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28. Case 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.
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29. Case 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.
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30. Case 1, Question 1
What 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 disease
B. Constipation
C. Nonspecific abdominal pain
D. Urinary tract infection
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31. Case 1, Question 2
What is the negative likelihood ratio for all LFTs being normal in assessing whether a patient has acute cholecystitis?
A. 0.1
B. 0.3
C. 0.7
D. 1.0
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32. Case 1, Question 3 True or False:
The gallbladder’s visceral innervation originates in the midgut.
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33. Case 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.
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34. Case 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.
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35. Case 2, Question 1
Which of the following is NOT a risk factor for mesenteric ischemia?
A. Advancing age
B. Atrial fibrillation
C. Prior abdominal surgery
D. Recent myocardial infarction
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36. Case 2, Question 2
True or False: Elevated lactate levels are a highly sensitive marker of mesenteric ischemia.
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37. Case 2, Question 3
Regarding 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. Anorexia
B. Migration of pain
C. Pain localized to the RLQ
D. Peritoneal signs on abdominal exam
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38. Answer Key Case 1 Case 2 Question 1: A Question 2: C Question 3: False
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39. Acknowledgments 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.
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