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Abdominal pain in the elderly Tintinalli Chap. 73

Abdominal pain in the elderly Tintinalli Chap. 73. Nicholas Cardinal, DO. Epidemiology. 4.2% of ED visits by patients over 65 Rated as most challenging clinical situation Perception or reporting is altered >50% require admission 25-33% require surgical intervention Mortality rate 11-14%.

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Abdominal pain in the elderly Tintinalli Chap. 73

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  1. Abdominal pain in the elderlyTintinalli Chap. 73 Nicholas Cardinal, DO

  2. Epidemiology • 4.2% of ED visits by patients over 65 • Rated as most challenging clinical situation • Perception or reporting is altered • >50% require admission • 25-33% require surgical intervention • Mortality rate 11-14%

  3. History • Time and mode of onset • Progression since onset • Location of pain • Character of pain • Referred/radiation • Precipitating/relieving factors • Prior episodes • Associated symptoms • Medications • Alcohol • Previous abdominal surgery

  4. Physical Exam • General • Do they look sick? • Vitals • Hypotensive– suspect AAA • Inspection/auscultation • Distention, abnormal bowel sounds • Palpation • May not have guarding/rigidity d/t thin abdominal musculature • Rectal exam • Hernias • Especially femoral in females • Femoral pulses • Dissection

  5. Appendicitis • Oftentimes delayed presentation contributing to higher perforation rate • RLQ pain may be poorly localized • Migration of pain (5-64%) • N/V (50%) • Anorexia (19-44%) • Fever • Tenderness • Rigidity • Rebound tenderness (20-80%) • Leukocytosis • 20% with WBC count < 10,000 • Hyperbilirubinemia (17%)

  6. Acute Cholecystitis • Most common surgical emergency in elderly with abdominal pain • High diagnostic accuracy • Overall mortality ~ 10% • RUQ pain • May be epigastric • 30% radiate to back/shoulder • N/V (50%) • Jaundice (10-30%) • Fever (50%) • Leukocytosis • 30-40% have normal WBC count • Ultrasound

  7. Small Bowel Obstruction • Usually straightforward in elderly • Mortality rate 14-45% • Prior surgery is principal risk factor • Colicky abdomnal pain • Distention • Vomiting • Gastric contents > bile-stained > feculent material

  8. Perforated Peptic Ulcer • Acute epigastric pain (50%) • Rigidity (21%) • Usually afebrile • Abdominal Xray • May not show free air • CT

  9. Diverticulitis • May be mistaken for pelvic mass • CT • Barium enema/colonoscopy are contraindicated

  10. Acute Mesenteric Infarction • Survival rate < 30% • Risk Factors • Embolus • A. fib • MI • Thrombosis • Atherosclerosis • Low cardiac output • Hypercoaguability • Liver disease • Severe abdominal pain with relatively normal abdominal exam • Often refractory to analgesics • N/V • Anorexia • Diarrhea • Mesenteric angiography

  11. Abdominal Aortic Aneurysm • Incidence • Men – increases rapidly after 55; peaks at 80 (5.9%) • Women – increases rapidly after 70; peaks at 90 (4.5%) • Rupture – 50% mortality • Common initial misdiagnosis • 30% in one trial • Most commonly renal colic • Abdominal pain (70-80%) • Back pain (50%) • Atypical pain • Hips, inguinal area, external genitalia • Syncope • Plain films • Calcified aortic outline • Loss of renal/psoas outline • Ultrasound for size • CT

  12. Other Conditions • Aortic Dissection • Pancreatitis • Intussusception • Acute gastric volvulus • Ischemic colitis • Esophageal ruptureCardiopulmonary • MI • PE • Pneumonia • Empyema • TB • CHF • Endocarditis • MI • Genitourinary • Pyelonephritis • Epididymitis • Testicular torsion • Toxic-metabolic • DKA • Herpes zoster • Hypercalcemia • Addisonian crisis • hemochromatosis • Abdominal wall • Rectus sheath hematoma

  13. Questions

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