What is the leading cause of the acute surgical abdomen in the elderly population? Appendicitis Biliary tract disease Diverticulitis Peptic ulcer disease Pancreatitis

A 70-year-old patient with a history of diabetes and hypertension presents to the emergency department with syncope and severe sudden onset of low back pain. Vital signs: BP 80/50,P 120,R24,T37 C. The most appropriate initial diagnostic test is: Angiogram Ultrasonography CAT scan of the abdomen Magnetic resonance cholangiopancreatography (MRCP) Supine obstruction series

Which of the following statements is true regarding abdominal pain in the elderly? White blood cell counts are specifically elevated in the acute abdomen. Lactate elevations are not an early sign of mesenteric ischemia. Lipase elevation is a specific test for pancreatitis. Positive fecal occult blood testing is specifically useful. Amylase elevation is a non-specific test for pancreatitis.

Acute Geriatric Abdomen Wayne Tamaska, D.O., FACOI, FACOEP

Acute Geriatric Abdomen This Care of the Aging Medical Patient in the Emergency Room (CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

By the year 2030, one in five Americans will be elderly. According to the US Census Bureau, one in eight Americans are elderly (over the age of 64). By the year 2030, one in five Americans will be elderly. U.S. Census Bureau, 2006.

Their length of stay is 20% longer than younger patients. The elderly patient who has abdominal pain consumes more time and resources than any other emergency department patient presentation. Their length of stay is 20% longer than younger patients. They require admission half the time. They require surgical intervention one third of the time. Kizer KW, Vassar MJ. Am J Emerg Med 1998;16(4):357-362. Brewer RJ, Golden GT, Hitch DC, et al. Am J Surg 1976;131(2):219-223.

The overall mortality for elderly emergency department patients with a chief complaint of abdominal pain exceeds 10%, rivaling that of an acute ST elevation MI. Kizer KW, Vassar MJ. Am J Emerg Med 1998;16(4):357-362.

Difficulties In Diagnosing The Elderly History: dementia, stroke with aphasia, hearing and vision loss. Altered pain perception. Medications that interfere with diagnosis. Lack of fever and leukocytosis. Co-morbid medical conditions. Atypical presentations. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

Difficulties In Diagnosing The Elderly Fever tachycardia and hypotension may be absent even in the seriously ill. Guarding and rigidity may be lacking because of the laxity in abdominal wall musculature. 21% of patients older than 70 with a perforated ulcer present with epigastric rigidity. Fenyo G. Am J Surg 1982;143(6):751-754.

Medications That Interfere With Diagnosis NSAIDs block inflammatory response and decrease the degree of abdominal tenderness and contributes to peptic ulcer disease. NSAIDs and APAP diminish febrile response. Narcotics can blunt the pain response. Beta blockers and negative chronotropes blunt tachycardia. Normal blood pressure may not reflect the relative hypotension in patients with chronic hypertension. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

Differential Diagnosis Of Abdominal Pain In The Elderly Cholecystitis Nonspecific abdominal pain Obstruction Hernia Appendicitis Diverticular disease Perforation Pancreatitis 12-41% 9.6-23% 7.3-14% 4-9.6% 2.5-15.2% 3.4-7% 2.3-7% 2-7.3% Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition. Philadelphia, PA: Mosby Elsevier, 2009.

History: High Yield Questions Age : advanced age means increased risk. Which came first pain or vomiting: pain first is worse( more likely surgical) Surgical history: obstruction more likely. Pain constant or intermittent: constant worse. Previous episodes: no prior episodes worse. History: Cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease. All suggest more serious disease. Alcohol: consider pancreatitis, cirrhosis, hepatitis. Colucciello SA, Lukens TW, Morgan DL. Emergency Medicine Practice 1999;1(1):1-20.

High-Yield Questions HIV status: drug-related pancreatitis. Antibiotics or steroids: May mask infection. Did pain starts centrally and migrate to RLQ: appendicitis. Vascular , heart disease, hypertension, atrial fibrillation: consider mesenteric ischemia or abdominal aortic aneurysm. Colucciello SA, Lukens TW, Morgan DL. Emergency Medicine Practice 1999;1(1):1-20.

Physical Examination Ill appearing verses well appearing. Well appearing patients may still have a serious medical condition. Fever, tachycardia, and hypotension may be absent in the elderly. Guarding and rigidity may be absent . The location of tenderness is generally a reliable guide to the cause of pain.

Physical Examination Examined the skin for signs of herpes zoster, Cullen’s or Grey Turner’s sign. Auscultate for bowel sounds and bruits. Rectal exam may be useful in diagnosing bowel ischemia, GI malignancies and bleeding.

Laboratory Testing Many tests are nonspecific in the elderly. White blood cell count may be normal even in the seriously ill. Lipase level is specific for pancreatitis. Lactate levels are helpful in diagnosing mesenteric ischemia. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

Radiographs Abdominal radiographs are of limited value. May identify obstruction, free air, or abdominal aortic calcifications.

Abdominal Ultrasound Most useful in evaluating gallbladder and pelvic organs. Bedside ultrasonography is most useful in evaluating for abdominal aortic aneurysm in hypotensive patients.

Computerized Tomography CT scanning has become one of the most viable tools in diagnosing acute abdomen and the elderly. CT angiography is replacing traditional angiography in diagnosing mesenteric ischemia. Limitations include those with contrast allergies and those with renal insufficiency.

Case Number 1 A 73-year-old female presents with nausea vomiting and progressive abdominal pain over the past two days. Vital signs: BP 90/60 , P88,R 24,T 38C PMH: Hypertension, Hyperlipidemia, TIA. PSH: Appendectomy, hysterectomy, partial colectomy. Meds: Metoprolol, Atorvastatin, Aspirin.

Physical Exam Ill appearing 72-year-old with active vomiting. Heart: RRR 1/6 SEM LSB, Lungs: Diminished breath sounds bases Abdomen: distended, high pitched bowel sounds, diffuse nonspecific tenderness, no rebound, no bruits, no hernias. Skin: Dry mucus membranes, no rashes Neurologic: Awake alert and oriented, nonfocal. Extremities: +1 edema, symmetric pulses. Rectal exam: No masses, heme positive brown stool.

Laboratory Values WBC 12,000 HB 9.9 SMA 7: Na 150,K 4.8,CL 105,CO2 18,BUN 33, Creat 2.8 LFTS: T.Bili 2.0,AST 44,ALT 50 Amylase 200, Lipase 34 UA: SG 1.030,20 WBC,10 RBC, Nitrate pos

Differential Diagnosis?

Abdominal Radiograph Image Source: Kennedy Health Systems

Diagnoses?

Small Bowel Obstruction

Discussion Tachycardia lacking due to beta blockade. WBC, Amylase, Bilirubin nonspecific in this case. IV contrast CT scan limited with renal insufficiency. Elderly may have more extensive past surgical history which predisposes the patient to greater risk of bowel obstruction.

Bowel Obstruction SBO :The most common cause for emergent surgical intervention in the elderly. LBO : Less common then SBO. Prevalence increases with age.(Colon cancer, diverticulitis) Sigmoid and cecal volvulus also cause LBO. Most cases of LBO must be managed by surgical intervention, but some cases of volvulus may be decompressed by endoscopy.

Case Number 2 An 85-year-old man presents to the emergency department after syncopal episode. The patient complains of sudden onset of abdominal and back pain. Vital signs: BP 95/50, P 120, R 24,T 38C. PMH: Hypertension, diabetes, hyperlipidemia, prostate cancer. PSH: Prostatectomy, appendectomy. Medications: Captopril, ASA, Glucophage, Niacin

Physical Exam Uncomfortable, ill appearing, 85-year-old male writhing in pain. Heart: Reg 120 no murmur Lungs: Clear Abdomen: Distended, obese, mild diffuse tenderness, no rebound. No bruits. Extremities: No edema, cool with cyanosis and decreased pulses.

Laboratory Testing WBC 15,000 HB 8.0 SMA 7;Na140,K4.8,Cl 100,CO2 18,BUN 22,Creat 1.5 LFTS: Bili 1.4,AST 55,ALT 60.Amylase 160.Lipase 55

Differential Diagnosis ?

Bedside Ultrasonography Image Source: Cooper Health System Bedside Ultrasonography Image Source: Cooper Health Systems

Bedside Ultrasonography Image Source: Cooper Health System Image Source: Cooper Health Systems

Diagnosis

Ruptured Abdominal Aortic Aneurysm Image Source: Kennedy Health System Ruptured Abdominal Aortic Aneurysm Image Source: Kennedy Health Systems

Discussion and Management

Abdominal Aortic Aneurysm Syncope can be an ominous sign in the elderly. One should always consider aortic aneurysm in any geriatric patient presenting with back pain. Any patient over the age of 55 with cardiovascular risk factors who presents to the emergency department with a complaint of back pain should have their aorta visualized by ultrasound or CAT scan.* *Emergency Medicine Reports

Abdominal Aortic Aneurysm Early recognition Aggressive resuscitation Early vascular surgical intervention Utility of bedside ultrasonography Don’t wait for a CAT scan diagnosis to mobilize vascular surgical intervention

Case Number 3 An 85-year-old male presents to the emergency department with increasing postprandial abdominal pain. Vital signs: BP 180/95,P 120,R 26,T 39 C PMH: A Fib, PVD, HTN, DM PSH: Fem Pop Bypass, CEA, Appendectomy. Meds: Digoxin, Warfarin, Metoprolol, Metformin, Aspirin.

Physical Exam 85 year old ill appearing male in considerable pain. Heart: irregularly irregular 120 Lungs: CTA Abdomen: Diffuse nonspecific tenderness, abdominal bruit present. Guarding present Neurologic: Confused, non-focal. Extremities: +1 edema. Diminished pulses.

Laboratory Data WBC: 18,000 Hb: 12 SMA-7: Na148,K 5.0.CL 100,CO2 16,BUN25,Creat 1.6.Glucose 380 LFTS: Normal Amylase: 400,Lipase: 60 Lactate: 6.0 INR: 1.4 Digoxin : 1.9

Radiograph Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Differential Diagnosis

CAT Scan Findings Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Diagnosis: Intestinal Ischemia Rare disorder: less than 1/1000 hospital admissions. High mortality: 30% to 90%. Mortality is dependent on time of diagnosis. Mortality approaches 100% when the diagnosis is delayed greater than 24 hours. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

Clinical Diagnosis Pain out of proportion of the exam. Rebound is initially absent. When rebound is present the prognosis is poor. The patients may present with: nausea, vomiting, diarrhea. The elderly may present with less abdominal pain and other signs such as tachypnea and mental status changes. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

Laboratory Data Really nonspecific Leukocytosis, elevated amylase, metabolic acidosis, elevated AST and alkaline phosphatase, hyperphosphatemia. Elevated lactic acid is helpful but is often a late indicator. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

Radiographic Studies Plain radiographs are often normal early on. Thumb printing is a late sign. Angiography is the gold standard.( 74-100% sensitivity; 100% specificity. Standard CT has a sensitivity of 64%. CT Angiography may replace traditional angiography. Some studies show a 96% sensitivity. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

Discussion

Case Number 4 A 60-year-old male presents with postprandial nausea vomiting and epigastric pain without radiation. Vital signs: BP 90/55, P 80, R 24, T 37C PMH: hypertension, hyperlipidemia, PUD. PSH: Repair of a perforated gastric ulcer. Medications: Clonidine, aspirin, Omeprazole.

Physical Exam A 60-year-old male presents diaphoretic and uncomfortable appearing. Heart: RRR no M. Lungs: CTA Abdomen: epigastric tenderness, soft, no rebound, no guarding, no bruits. Extremities: no clubbing, cyanosis, or edema. Pulses symmetric. Rectal exam: Brown stool heme positive.

Laboratory Data WBC 10,000 HB 11 T. Bili 2.0,ALT 40,AST 65,Amylase 150,Lipase 60. Na 134,K4.0,CL98,CO2 24,BUN 25,Creat 1.4,Glucose 190

Radiographic Studies Image Source: Kennedy Health Systems

Discussion and Differential Diagnosis

Diagnosis Image Source: Kennedy Health Systems

Diagnosis: Acute Inferior Wall Myocardial Infarction

Discussion Have a low threshold for ordering an EKG on any elderly patient that presents with an abdominal complaint. The incidence of atypical presentations of acute myocardial infarction increases with age. Elderly patients may present without any chest pain. The elderly may present with flulike symptoms, nausea, vomiting, or syncope. Marx JA, et al.. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition, 2009.

Case Number 5 A 60-year-old female presents with severe postprandial epigastric pain. The patient has had several episodes over the past few months but not sought medical attention until today. Vital signs: BP 135/85, P 110, R 22,T 37.5C PMH: hyperlipidemia, osteoarthritis. PSH: hysterectomy. Medications: Ibuprofen.

Physical Exam To 60 year old female presents with moderate epigastric discomfort that radiates to the back with associated nausea and vomiting. Heart: tachycardia at 110 BPM Lungs: CTA Abdomen: tender epigastric and RUQ, guarding, no rebound, no bruits, no CVAT. Extremities: no C/C/E. pulses symmetric.

Laboratory Data WBC 15,000 Hb 14 T. bili 3.5, AST 125, ALT 150, Alk Phos 200 Amylase 300, Lipase 304 Na 140.K 4.0, CL 98, BUN 20, Creat 1.2, Glucose 150

Electrocardiogram

Radiographic Studies Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Differential Diagnosis

Diagnosis: Gallstones/Gallstone Pancreatitis Biliary disease is the leading cause for acute abdominal surgery in the elderly. When performed urgently and the elderly mortality rate is increased fourfold. Cholelithiasis increases with age. Acalculous cholecystitis is increased in the elderly and may not be readily apparent on ultrasound. Elderly patients may not have nausea and vomiting and fever. Laboratory testing is also unreliable. Leukocytosis is absent in 30 to 40% of the elderly. Martinez JP, Mattu A. Emerg Med Clin N Am 2006;24(2):371-388.

Pancreatitis The most common nonsurgical abdominal condition and the elderly Incidence increases 200-fold after age 65. Mortality approaches 40% after age 70. 10% of cases present with hypotension and altered mental status in the elderly. The threshold for performing CAT scans and the elderly when pancreatitis is suspected should be low. Martinez JP, Mattu A. Emerg Med Clin N Am 2006;24(2):371-388.

Biliary Disease & Pancreatitis: Diagnostic Tools Ultrasound is most useful in diagnosing biliary disease. The elderly have a higher incidence of acalculus cholecystitis. HIDA scanning should be considered in these patients. Laboratory findings may be absent in biliary disease in the elderly. Lipase levels are helpful in diagnosing pancreatitis. CAT scan is useful in diagnosing pancreatitis. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

Case Number 6 A 65-year-old male presents an increasing nausea of vomiting and abdominal pain. The pain preceded the vomiting. Vital signs: BP 100/70, P 100,R 20,T 37 C PMH: rheumatoid arthritis PSH: inguinal hernia repair, appendectomy, cholecystectomy Medications: Prednisone, methotrexate.

Physical Exam A 65-year-old male presents with nausea and vomiting. The patient is ill appearing, appears uncomfortable. Heart: regular at 100BPM. No murmur. Lungs: CTA Abdomen: distended, diffusely tender, high-pitched bowel sounds, no rebound, guarding present, no masses or hernias palpable. Extremities: No C/C/E, pulses symmetric.

Laboratory Data WBC: 15,000 Hb:15 Na 150, K 5.0,CL 101, CO2 30, BUN 30,Creat 1.4, glucose 130. T. Bili 1.4, AST 44,ALT 45, amylase 150, lipase 40 UA:SG >1.030,20 RBC/HPF

Radiograph Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Discussion and Differential Diagnosis

Large Bowel Obstruction Less common than small bowel obstruction. Prevalence rises with increasing age. Most common causes: Colon cancer, diverticulitis, volvulus. Most require surgical intervention, however sigmoid volvulus may be decompressed endoscopically. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

Case Number 7 Same clinical presentation physical exam and laboratory data as the last case. Diagnose the case with the following substituted radiograph.

Radiograph Image Source: Kennedy Health System Image Source: Kennedy Health Systems

CAT Scan Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Discussion and Differential Diagnosis

Perforated Viscus: Peptic Ulcer Disease An acute abdomen is the first presentation of PUD in 50% of elderly patients.(1) Less than half of elderly patients have classic acute onset of abdominal pain.(2) Rigidity is absent in nearly 80% of elderly patients.(2) Free air is absent in 40% of plain radiographs.(3) Caesar R. Emergency Medicine Reports 1994;15:191-202. Fenyo G. Am J Surg 1982;143(6):751-754. McNamara R. In: Saunders AB, ed. Emergency Care Of the Elder Person. St. Louis, MO: Beverly Cracom Publications, 1996:219-243.

Case Number 8 A 75-year-old female patient presents with increasing lower abdominal pain nausea without vomiting and low-grade fevers over three days. Vitals: BP120/80,P 100,R20.T37.8C PMH: hypertension PSH: hysterectomy Medications: hydrochlorothiazide

Physical Exam A non-toxic, uncomfortable appearing 75-year-old female. Heart: Reg 100. No M Lungs: CTA Abdomen: Soft bilateral lower quadrant tenderness. Guarding in the lower quadrants. No rebound. No bruits or masses. Bowel sounds present but decreased. Extremities: No C/C/E. Pulses Symmetric.

Laboratory Data WBC 10,500 HB 14 Na 140,K 3.0,CL 100,CO2 23,BUN 15,Creat 1.2,Glucose 120 Tbili 1.4,AST 44,ALT45,Amylase 120,Lipase 40. UA SG 1.030,40 WBC/HPF,30 RBC/HPF

Differential Diagnosis and Discussion

Radiographic Study 1 Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Diagnosis: Diverticulitis (sigmoid)

Diverticular Disease Incidence: 50% in patients older than 70. 80% after the age of 85.(1) Complications include: Abscess formation, bowel obstruction, perforation, fistula, sepsis. Perforation is more common in the elderly it carries a 25 percent mortality rate.(2) Clinically misdiagnosed 50% of the time.(3) Diverticular irritation of the urinary system may produce hematuria pyuria, complicating the diagnosis. Ferzoco L, Raptopoulos V, Silen W. N Engl J Med 1998;338(21):1521-1526. Krukowski Z, Matheson NA. Br J Surg 1984;71(12):921-927. Ponka JL, Welborn JK, Brush BE. J Am Geriatr Soc 1963;11:993-1007.

Case Number 9 Same presentation as previous case with the exception of the radiograph.

Radiographic Image Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Differential Diagnosis And Discussion

Diagnosis: Appendicitis

Appendicitis Thought to be a disease of young. It is the third most common indication for abdominal surgery in the elderly.(1) Less than one third of elderly patients have fever, anorexia, RLQ pain, and leukocytosis.(2) Up to 1/5 of elderly patients present after three days of symptoms.(5-10% after one week) (3) Mortality: General <1%. Elderly 4-8%.(4) Kauvar DR. Clin Geriatr Med 1993;9(3):547-548. McNamara R. Emergency Care Of the Elder Person. 1996. Freund HR, Rubinstein E. Am Surg 1984;50(10):573-576. Gupta H, Dupuy D. Surg Clin North Am 77 1997;77(6);1245-1264.

Extra Credit: Case Number 1 A 56-year-old male presents to the emergency department with sudden onset of stabbing epigastric pain.

Diagnosis ? Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Extra Credit: Case Number 2 A 55-year-old male presents with increasing abdominal pain and rectal bleeding over the past day.

Diagnosis? Image Source: Kennedy Health System Image Source: Kennedy Health Systems

Conclusions United States population is aging at a tremendous rate. Abdominal pain remains one of the most common and potentially serious complaints. Atypical presentations are common in the elderly. Laboratory testing often lacks sensitivity and specificity. Normal vital signs may be misleading in the elderly even in the face of significant disease.

Conclusions Keep the differential diagnosis broad in elderly patients. Liberal use of imaging and early surgical consultation in the elderly. Serial examinations are extremely important.

Disposition An elderly patient with persistent abdominal pain despite a negative initial evaluation should be admitted to the hospital or an ED observation unit. Those patients discharged home should have clinical improvement noted, negative acute diagnostic testing, and should be able to tolerate POs. Timely follow-up should be arranged. Caretakers need to be educated.

References Brewer RJ, Golden GT, Hitch DC, et al. Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg 1976;131(2):219-223. Caesar R. The acute geriatric abdomen. Emergency Medicine Reports 1994;15:191-202. Cangemi JR, Picco MF. Intestinal ischemia in the elderly. Gastroenterol Clin N Am 2009;38(3):527-540. Colucciello SA, Lukens TW, Morgan DL. Assessing abdominal pain in adults: A rational, cost-effective, and evidence-based strategy. Emergency Medicine Practice 1999;1(1):1-20. Fenyo G. Acute abdominal disease in the elderly: Experience from two series in Stockholm. Am J Surg 1982;143(6):751-754. Ferzoco L, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med 1998;338(21):1521-1526. Freund HR, Rubinstein E. Appendicitis in the aged. Is it really different? Am Surg 1984;50(10):573-576. Gupta H, Dupuy D. Abdominal emergencies: Has anything changed? Surg Clin North Am 77 1997;77(6);1245-1264.

References Kauvar DR. The acute geriatric abdomen. Clin Geriatr Med 1993;9(3):547-548. Kizer KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med 1998;16(4):357-362. Krukowski Z, Matheson NA. Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: A review. Br J Surg 1984;71(12):921-927. Martinez JP, Mattu A. Abdominal pain in the elderly. Emerg Med Clin N Am 2006;24(2):371-388. Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition. Philadelphia, PA: Mosby Elsevier, 2009. McNamara R. Acute abdominal pain. In: Saunders AB, ed. Emergency Care Of the Elder Person. St. Louis, MO: Beverly Cracom Publications, 1996:219-243. Ponka JL, Welborn JK, Brush BE. Acute abdominal pain in aged patients: An analysis of 200 cases. J Am Geriatr Soc 1963;11:993-1007. Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med 2007;23(2):255-270.