Acute Abdominal Pain in a Geriatric: An Emergency Medicine Perspective Ali R. Rahimi,MD

Geriatrics as an increasing segment of the population 1 in 8 is >64yo in 1994 1 in 5 projected to be >64yo in 2030

The Geriatric Functional Continuum

Geriatric with CC of abdominal pain in ED 50% will be admitted 10% Overall Mortality Around 1 in 4 patients seen for abdominal pain are discharged with a diagnosis of “undifferentiated abdominal pain

Difficulties in making the Dx Sometimes Jerry is a poor historian (present with altered mental status) Lack of consistent physiological responces (ie. may not be febrile or tachycardic) They often have little reserve capacity

You Make the Call! All he follow case presentations refer to a 82 year old white female Triage Note- “CC: belly pain. – 82 yo WF, demented, conversing with wall, dropped off by friend, no additional history, in obvious pain”

YOU MUST GIVE A DIFFERENTIAL DX BEFORE YOU CT SCAN OR ELSE RULES: YOU MUST GIVE A DIFFERENTIAL DX BEFORE YOU CT SCAN OR ELSE

Actual ER Physicians

CASE UNO! Belly pain, green vomit x 3, distended belly, painful throughout, “tinkly” bowel sounds Upright Abd film 

Bowel Obstruction Most common risk factor – prior abd. Surgery Look for dilated loops of bowel on imaging Needs surgical intervention (LOA)

CASE DOS! Back or Belly pain, Low BP and pulsatile abdominal mass Get crackin’! Bedside U/S then CTA (if Vital signs stable)

Ruptured AAA The survival rate of patients who experience a ruptured abdominal aortic aneurysm is less than 50 percent. The symptoms of a ruptured or leaking aneurysm may mimic other acute conditions such as renal colic, diverticulitis, pancreatitis, inferior wall coronary ischemia, mesenteric ischemia, or biliary tract disease. In addition, elderly patients who present with hypotension from a leaking abdominal aortic aneurysm may have electrocardiographic changes consistent with coronary ischemia.

CASE TRES! Intense belly pain, N/V/D, pain out of proportion to exam Oh snap! Think CTA (if Vital signs stable- ‘cause you don’t want to run a code in CT) Geriatric Hippies – A High Risk Population

Mesenteric Ischemia High mortality – 45-90% Occlusion in SMA most common Big Risk factor = A-fib Get vascular surgery pronto

CASE CUATRO! Severe epigastric pain, rigid abd with guarding, found some Prilosec in her handbag Peritonitis! Yeehaw!

Perforated Bowel Free Air! 40% of upright abd xrays will miss the free air Most common cause = peptic ulcers Poorer outcome in >70yo w/o surgical intervention

CASE CINCO! Belly pain, boring to the back, N/V, feels very sick, ecchymosed on flanks Vitals are muy loco

Acute Pancreatitis Gallstones the cause in ~ 70% of pts >80yo Frequently present in shock Amylase/Lipase and CT

CASE SEIS! Colicky RUQ pain, no N/V, no fever Bedside ultrasound available and shows -->

Acute cholecystitis Nonoperative mgmt can result in ~17% mortality Use HIDA scan if high suspicion and neg U/S Look for atypical presentations in elderly

CASE SIETE! Belly Pain all over, TTP over RLQ, no fever or leukocytosis Told she had a “stomach bug” at walk-in clinic

Appendicitis 5% of all surgical abdomens in geriatric > Half of geriatric appy’s are misdiagnosed on initial presentation Watch for perfs!

CASE OCHO! Belly & pelvic pain, vag bleeding, tachy, low BP

Ruptured Ectopic Yeah. Right. Think endomertrial CA, you doofus

Conclusions Geriatric Emergencies demand attention and diligence Often present atypically Remember to ROWC it! (Rule Out Worst Case) ‘Cause Jerry goes down fast! Tele Medicine – Scary!

References Bugliosi, TF, Meloy, TD, Vukov, LF. Acute abdominal pain in the elderly. Ann Emerg Med 1990; 19:1383. Kamin, RA, Nowicki, TA, Courtney, DS, Powers, RD. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am 2003; 21:61. Kizer, KW, Vassar, MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med 1998; 16:357. Hustey, FM, Meldon, SW, Banet, GA, et al. The use of abdominal computed tomography in older ED patients with acute abdominal pain. Am J Emerg Med 2005; 23:259. Yamamoto, W, Kono, H, Maekawa, M, Fukui, T. The relationship between abdominal pain regions and specific diseases: an epidemiologic approach to clinical practice. J Epidemiol 1997; 7:27. Yeh, E, McNamara, R.Abdominal Pain. Clin Geriatr Med 23 (2007) 255-270.