Abdominal Pain in the Elderly

Report
ABDOMINAL PAIN IN
THE ELDERLY
AGS
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
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
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
Slide 2
WHY CARE?
Increasing Elderly Population (≥65 Years)
Slide 3
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;16:357-362.
Slide 4
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
Slide 5
MS. JONES: INITIAL RESULTS
WBC count 11.7
Hematocrit 49
Platelets 193
Chemistries WNL
Liver function tests (LFTs) WNL
Lipase WNL
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
Trowbridge RL. JAMA. 2003; 289(1): 80-86.
MS. JONES ULTRASOUND
Insert ultrasound image of cholecystitis with gall stones,
thickened gall bladder wall, and edema.
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
Slide 9
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
Slide 10
MS. JONES: THE RETURN VISIT
• Labs including LFTs are WNL
• What to do?
Slide 11
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
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
Slide 13
MS. SMITH: APPENDICITIS
Insert CT image of appendicitis.
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;9:547-558.
Storm-Dickerson TL. Am J Surg. 1983;185:198-201.
Slide 15
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
Slide 16
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…
Slide 17
LearningRadiology.com, retrieved June 1, 2011.
Slide 18
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;64:611-616.
Horton KM. Radiographics. 2002:22;161.
Slide 19
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
Slide 20
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
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
Slide 22
MS. CONNOR: IMAGING
LearningRadiology.com, retrieved June 1, 2011.
Slide 23
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
Atamanalp SSJ Gastroenterol Hepatol 2007
Emedicine 2008
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
Slide 25
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”
Slide 26
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)
Slide 27
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.
Slide 28
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.
Slide 29
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.
B.
C.
D.
Biliary tract disease
Constipation
Nonspecific abdominal pain
Urinary tract infection
Slide 30
CASE 1, QUESTION 2
What is the negative likelihood ratio for all
LFTs being normal in assessing whether a
patient has acute cholecystitis?
A.
B.
C.
D.
0.1
0.3
0.7
1.0
Slide 31
CASE 1, QUESTION 3
True or False:
The gallbladder’s visceral innervation originates
in the midgut.
Slide 32
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.
Slide 33
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.
Slide 34
CASE 2, QUESTION 1
Which of the following is NOT a risk factor for
mesenteric ischemia?
A.
B.
C.
D.
Advancing age
Atrial fibrillation
Prior abdominal surgery
Recent myocardial infarction
Slide 35
CASE 2, QUESTION 2
True or False:
Elevated lactate levels are a highly sensitive
marker of mesenteric ischemia.
Slide 36
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.
B.
C.
D.
Anorexia
Migration of pain
Pain localized to the RLQ
Peritoneal signs on abdominal exam
Slide 37
ANSWER KEY
• Case 1
 Question 1: A
 Question 2: C
 Question 3: False
• Case 2
 Question 1: C
 Question 2: False
 Question 3: C
Slide 38
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.
Slide 39
THANK YOU FOR YOUR TIME!
Visit us at:
www.americangeriatrics.org
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
linkedin.com/company/american-geriatricssociety
Slide 40

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