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Abdominal pain in the elderly

Nilesh Patel, D.O. March 11, 2009 St. Joseph’s Regional Medical Center Paterson, NJ. Abdominal pain in the elderly. OBJECTIVES. Epidemiology ...The Problem Pearls & Piftalls Diagnosis Management Cases Diseases’ which are specific to elderly Diseases’ which present atypically in elderly.

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Abdominal pain in the elderly

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  1. Nilesh Patel, D.O. March 11, 2009 St. Joseph’s Regional Medical Center Paterson, NJ Abdominal pain in the elderly

  2. OBJECTIVES • Epidemiology...The Problem • Pearls & Piftalls • Diagnosis • Management • Cases • Diseases’ which are specific to elderly • Diseases’ which present atypically in elderly

  3. DDx of ABDOMINAL PAIN • Cholecystitis • Pancreatitis • Appendicitis • Diverticulitis • Peptic ulcer disease • GERD • Bowel obstruction • Renal colic • Mesenteric ischemia • Mesenteric adenitis • Inflammatory bowel disease • Volvulus (cecal, sigmoid) • Ovarian torsion • Ovarian cysts • Testicular torsion • PID • Gastroenteritis • Constipation • Perfortated viscus • Non-specific abdominal pain • Renal infarct • Colon CA • AAA • Irritable bowel syndrome • Epiploic appendigitis • Splenic infarcts • Splenic rupture • Abscess • Hepatitis • Cirrhosis • Uterine fibroids • Menstrual pain • Hernia • Acute coronary syndromes • Pneumonia • Pleural effusions • Herpes zoster

  4. EPIDEMIOLOGY • Abdominal pain is common chief complaint in ED • Geriatric population is growing! • 15% of population is > 65 y/o • >85 y/o fastest growing segment of population • Admission…>50% • Surgery…>30% • Mortality…10%!

  5. “Acute Abd. Pain in the Elderly” • Annals of EM 1990, Bugliosi et al. • Retrospective, one year period • > 65 y/o with atraumatic abd pain • 127 patients • Indeterminate 23% • Biliary colic, SBO 12% • Gastritis 8% • Perforated viscus 7% • Diverticulitis 6% • Admission rate…43% • Surgery…20%

  6. CASE • CC: • Abdominal pain • HPI: • 91 y/o llq abdominal pain • Positive associated n/v/d • PMHx: • COPD, Dementia, Colon CA, Glaucoma, DVT • PSHx: • Colectomy * 2, ORIF R hip, Back surgery

  7. CASE • Cyproheptadine • Timolol eye gtt • Tramadol • Percocet • Lidoderm patch • Protonix • Spiriva • MVI • Aricept • Prednisone • Albuterol/Atrovent • Tylenol • Calcium with vitamin D • Travatan eye gtt

  8. PITFALLS: HX • Vague historians • Altered mental status • Dementias • Hearing deficits • Communication difficulties • Downplay symptoms/stoic nature • Fear of hospital admission

  9. PITFALLS: EXAM • Physical Exam…Lack of classic findings • Fever • Leukocytosis • Peritoneal signs • Focal tenderness • Tachycardia

  10. Patients do not read the textbook, especially elderly patients!

  11. PITFALLS • Delay in seeking medical attention >> Delays in diagnosis • Co-morbid disease • Chronic medications

  12. PITFALLS: DISEASE • Age • Diabetes • Malignancy • Renal insufficiency • CV disease

  13. PITFALLS: MEDS • “Medications may mask or create pathology” • Mask pathology • Steroids • NSAIDS • Chronic pain meds • Cardiac meds • Create pathology • Steroids/NSAIDS • Antibiotics • Digoxin

  14. PITFALLS: MEDS • Consider prescription meds, otc meds, herbals • Drug-drug interactions • Mis-use of medications

  15. PITFALLS: PHYSICIANS • Failure to appreciate unique physiology of geriatric population • Delays in diagnosis • Under- resuscitation/Under-treatment • High rate of misdiagnosis • Mis-referral of surgical patients to medical service; lack of surgical consultation

  16. INITIAL EVAL…PEARLS • “Think the worst first” • Have a low threshold for labs & imaging • Medication history must be thorough • Focus on vital signs • HR may be affected by meds • A normal bp may reflect hypotension • Respiratory rate is important • If temp normal, get a rectal temp • If temp low, think sepsis

  17. MY RULE • The vast majority of elderly patients with abdominal pain deserve an imaging study!

  18. ANOTHER RULE • Admit undifferentiated abdominal pain when the clinical presentation is concerning. • There is nothing wrong with observation.

  19. “I HAVE BLOOD IN MY STOOL” • CC: Abdominal pain/Blood in stool • HPI: 75 y/o female presents with severe abd. pain and blood in stool for 2 days. Abd. pain is diffuse. Positive nauseau/diarrhea. No vomiting. • PMHx: DM, HTN, CAD, A-fib, Dementia, Hypercholesterolemia, CKD • PSHx: TAHBSO, R total hip replacement • Meds: Insulin, Norvasc, ASA, Dig, Nemenda, Lipitor, Lisinopril

  20. “I HAVE BLOOD IN MY STOOL” • VS: 160/110 110 96.4 24 95% RA • HEENT: MM mildly dry • CVS: Irregularly irregular, 2/6 HSM • Lungs: Decreased bs at bases b/l • Abd: Mild diffuse ttp, hypoactive bowel sounds, no distension, no R/G/R • Rectal: BRBPR, heme-positive

  21. “I HAVE BLOOD IN MY STOOL” • 13.6 Bands 13 5.6 185 LFTs normal 132 100 32 Lipase normal 210 3.2 17 2.0 UA normal

  22. MESENTERIC ISCHEMIA/INFARCTION • Etiology • Arterial (embolic or thrombotic) • Venous • Non-occlusive • Risk Factors • CAD, recent MI, CHF, Afib, Low flow states, Hypercoagulable states, Sepsis, Medications • Age > 50 • Mortality 50-70%

  23. MESENTERIC ISCHEMIA/INFARCTION • Clinical presentation • Abdominal pain out of proportion to exam • Intestinal angina • Severe intermittent abdominal pain • Acute/sub-acute/chronic • Diffuse vs localized • Blood in stools • N/V/D

  24. MESENTERIC ISCHEMIA/INFARCTION • Diagnostics • Leukocytosis/Leukopenia • Elevated amylase • Acidosis • X-ray • CT scan • Angiography is gold standard • Treatment • IVF, antibiotics • Surgery

  25. MESENTERIC ISCHEMIA IN ELDERLY • This is a disease of the old • Myriad of presentations • Abnormal labs are late manifestation • Difficult diagnosis • Imaging is necessary • Early angiography decreases mortality • Delays from consultants

  26. LACTATE • “Usefulness of Plasma Lactate Concentration in the Diagnosis of Acute Abdominal Disease” Hartmut, L. EuropeanJournal of Surgery 1994. • 85 patients admitted to surgical service for acute abd. pain • Mesenteric ischemia 20 • Peritonitis 15 • Intestinal obstruction 20 • Other (pancreatitis, diverticulitis, appendicitis, cholecystitis, abscess, UC,Crohn’s) 30 • Conclusion: Lactate 100% sensitive, 42% specific for mesenteric ischemia. • Abd pain/elevated lactate usually signifies surgical pathology

  27. “I PASSED OUT” • CC: Syncope & Abdominal Pain • HPI: 75 y/o male presents with syncope. Pt. has had diffuse anterior abd. pain which started this am. Positive nasueau/vomiting, no fevers. No cp. • PMHx: HTN, COPD, CAD • PSHx: None • Meds: Cardizem, Lisinopril, Spiriva, ASA • SHx: > 40 pack year history, no ETOH

  28. “I PASSED OUT” • VS: 80/50 120 97.0 26 96% RA • CVS: Tachycardic, regular, no murmur • Abd: Moderate ttp epigastric/periumbilical area, no rebound, positive voluntary guarding, pulsatile tender mass palpated in abdomen • Ext: Weakened femoral and distal pulses bilaterally • Skin: Cool, diaphoretic • Neuro: AAO times three, nonfocal

  29. AAA • Etiology • Atherosclerosis • Familial • Risk Factors • Smoking, Age, HTN, Atherosclerosis, FHx, COPD, Male sex • Age > 55 • Mortality > 50% with rupture

  30. AAA • Clinical presentation • Hypotension • Abdominal pain/Back, Flank pain • Pulsatile abdominal mass • Asymptomatic until rupture • Syncope • Signs of shock • Vital sign abnormalities • Weakness • Signs of peripheral embolic events

  31. AAA • Diagnostics • Lab abnormalities • Low H/H • Imaging • U/S • CT scan • MRI • Aortography

  32. AAA IN THE ELDERLY • This is a disease of the old • Variety of presentations • Wide ddx for symptoms of flank pain, abd pain, and syncope in isolation • High mortality with rupture • Misdiagnosed 1/3 of the time (remember renal colic) • Often have to make diagnosis without formal imaging

  33. MESENTERIC ISCHEMIA & AAA • Unique to elderly populations • High mortality (> 50%) • THE CHALLENGE… • High index of suspicion • Image liberally • Involve consultants early

  34. TUMORS, TWISTS, AND TELESCOPES • GI Tumors • 15-18% of elderly patients sent home with diagnosis of nonspecific abdominal pain • 10% will have dx of GI tumor within one year • Volvulus • Sigmoid/Cecal volvulus • Symptoms/Signs of obstruction • Intussuception • Occurs in the elderly as well as pediatrics • Often associated with tumors

  35. VOLVULUS • 5-10% of obstruction • Hx of chronic constipation • Populations at risk • NH patients • Psych patients (mental health facilities) • Neuro patients • Elderly • Clinical presentation • Dx—plain film often diagnostic • Tmt—decompression, often surgery required

  36. GI TUMORS • Esophagus—Stomach—Small bowel—Large bowel—Rectum • Variety of presentation • Larger tumors >> Symptoms >> May be late stage • Abdominal pain • Constitutional symptoms • Obstruction • GI bleed

  37. “MY BELLY HAS BEEN HURTING FOR 5 DAYS” • CC: Abdominal pain, vomiting • HPI: 72 y/o female presents with abdominal pain for 5 days. Positive intermittent vomiting and diarrhea. Positive subjective fevers. Pain is diffuse but worst in hypogastric area and rlq • PMHx: DM, HTN, CHF, Pneumonia, Dementia • PSHx: Cholecystectomy • Meds: per NH list

  38. “MY BELLY HAS BEEN HURTING FOR 5 DAYS” • VS: 145/90 85 20 101.3 98% RA • HEENT: MM mildly dry • Abd: Diffuse ttp (mild to moderate), most tender lower quadrants, no R/G/R, diminished bowel sounds • GU: normal

  39. “MY BELLY HAS BEEN HURTING FOR 5 DAYS” • 12.4 Bands 7 11.5 200 133 108 20 155 UA 5-9 WBC 3.8 23 1.5

  40. APPENDICITIS • 5% of acute abdominal pain in elderly • Higher rate of complications • 5 times higher rate of perforation • Increased mortality • Atypical presentation is typical • Delay in diagnosis is common

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