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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. - PowerPoint PPT Presentation
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Nilesh Patel, D.O.March 11, 2009
St. Joseph’s Regional Medical CenterPaterson, NJ
OBJECTIVES
Epidemiology...The Problem
Pearls & PiftallsDiagnosisManagement
CasesDiseases’ which are specific to elderlyDiseases’ which present atypically in elderly
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
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%!
“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%
CASE
CC:Abdominal pain
HPI:91 y/o llq abdominal painPositive associated n/v/d
PMHx:COPD, Dementia, Colon CA, Glaucoma, DVT
PSHx:Colectomy * 2, ORIF R hip, Back surgery
CASE Cyproheptadine Timolol eye gtt Tramadol Percocet Lidoderm patch Protonix Spiriva MVI Aricept Prednisone Albuterol/Atrovent Tylenol Calcium with vitamin D Travatan eye gtt
PITFALLS: HX
Vague historiansAltered mental statusDementiasHearing deficitsCommunication difficultiesDownplay symptoms/stoic natureFear of hospital admission
PITFALLS: EXAM
Physical Exam…Lack of classic findingsFeverLeukocytosisPeritoneal signsFocal tendernessTachycardia
Patients do not read the textbook,
especially elderly patients!
PITFALLS
Delay in seeking medical attention >> Delays in diagnosis
Co-morbid disease
Chronic medications
PITFALLS: DISEASE
Age
Diabetes
Malignancy
Renal insufficiency
CV disease
PITFALLS: MEDS
“Medications may mask or create pathology” Mask pathology
SteroidsNSAIDSChronic pain medsCardiac meds
Create pathologySteroids/NSAIDSAntibioticsDigoxin
PITFALLS: MEDS
Consider prescription meds, otc meds, herbals
Drug-drug interactions
Mis-use of medications
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
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 medsA normal bp may reflect hypotensionRespiratory rate is importantIf temp normal, get a rectal tempIf temp low, think sepsis
MY RULE
The vast majority of elderly patients with abdominal pain deserve an imaging study!
ANOTHER RULE
Admit undifferentiated abdominal pain when the clinical presentation is concerning.
There is nothing wrong with observation.
“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
“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
“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
MESENTERIC ISCHEMIA/INFARCTION
EtiologyArterial (embolic or thrombotic)VenousNon-occlusive
Risk FactorsCAD, recent MI, CHF, Afib, Low flow states,
Hypercoagulable states, Sepsis, Medications
Age > 50 Mortality 50-70%
MESENTERIC ISCHEMIA/INFARCTION
Clinical presentationAbdominal pain out of proportion to examIntestinal anginaSevere intermittent abdominal painAcute/sub-acute/chronicDiffuse vs localizedBlood in stoolsN/V/D
MESENTERIC ISCHEMIA/INFARCTION
DiagnosticsLeukocytosis/LeukopeniaElevated amylaseAcidosis
X-rayCT scanAngiography is gold standard
TreatmentIVF, antibioticsSurgery
MESENTERIC ISCHEMIA IN ELDERLY
This is a disease of the old Myriad of presentations Abnormal labs are late manifestation Difficult diagnosis
Imaging is necessaryEarly angiography decreases mortalityDelays from consultants
LACTATE
“Usefulness of Plasma Lactate Concentration in the Diagnosis of Acute Abdominal Disease” Hartmut, L. European Journal 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
“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
“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
AAA
EtiologyAtherosclerosisFamilial
Risk FactorsSmoking, Age, HTN, Atherosclerosis, FHx,
COPD, Male sex
Age > 55 Mortality > 50% with rupture
AAA
Clinical presentationHypotensionAbdominal pain/Back, Flank painPulsatile abdominal mass
Asymptomatic until ruptureSyncopeSigns of shockVital sign abnormalitiesWeaknessSigns of peripheral embolic events
AAA
DiagnosticsLab abnormalities
○ Low H/HImaging
○ U/S○ CT scan○ MRI ○ Aortography
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
MESENTERIC ISCHEMIA & AAA
Unique to elderly populations High mortality (> 50%)
THE CHALLENGE… High index of suspicion Image liberally Involve consultants early
TUMORS, TWISTS, AND TELESCOPES
GI Tumors15-18% of elderly patients sent home with diagnosis
of nonspecific abdominal pain10% will have dx of GI tumor within one year
VolvulusSigmoid/Cecal volvulusSymptoms/Signs of obstruction
IntussuceptionOccurs in the elderly as well as pediatricsOften associated with tumors
VOLVULUS
5-10% of obstruction Hx of chronic constipation Populations at risk
NH patientsPsych patients (mental health facilities)Neuro patientsElderly
Clinical presentation Dx—plain film often diagnostic Tmt—decompression, often surgery required
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
“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
“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
“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
APPENDICITIS
5% of acute abdominal pain in elderly Higher rate of complications
5 times higher rate of perforationIncreased mortality
Atypical presentation is typical Delay in diagnosis is common
CHOLECYSTITIS
Most common cause abdominal surgery Acalculous & Calculous
Cholecystitis/Cholelithiasis/Cholangitis Early surgical intervention is key Higher mortality rate Higher rate of complications
Perforation Gangrene Sepsis Emphysematous cholecystitis/Ascending cholangitis/Gallstone ileus Pancreatitis
PANCREATITIS
Most common cause nonsurgical cause of abdominal pain
Increased mortality rate
Increased complication rate
DIVERTICULITIS
Increased prevalence with age WBC and VS often normal Complications
AbscessBowel obstructionFree PerforationSepsisFistula formation
PERFORATED VISCUS
Can occur from all cause of abdominal pain
Peptic ulcer diseaseIncreased incidence with NSAIDSComplications
○ GI bleed○ Perforation○ Obstruction○ Penetration into nearby organs
BOWEL OBSTRUCTION
Small bowel obstructionAdhesionsHerniasTumors
Large bowel obstructionTumorsDiverticulitisVolvulus
EXTRA-ABDOMINAL CAUSES
Acute coronary syndromes Aortic dissection Congestive heart failure Pulmonary embolus Pneumonia Pleural effusions Metabolic causes GU/Pelvic pathology
APPYS, STONES, TICS, PERFS, & BLOCKAGES
Present atypically in elderly populations Higher mortality
THE CHALLENGE… Recognize atypical presentations Be aware of increased rate of complications If in doubt, consult or admit
DISPOSITION
AdmitToxicAbnormal vital signsPersistent pain/vomiting
Discharge CriteriaThorough H & P completedNon-toxic Normal vital signsNormal imagingImproving abdominal examGood discharge instructions with close follow-up
SUMMARY
Pearls & Pitfalls Mesenteric Ischemia & AAA GI Tumors, Volvulus, Intussuception Appendicitis Cholecystitis, Pancreatitis, Diverticulitis,
Bowel Obstruction Perforated Viscus Extra-abdominal causes Disposition criteria