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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”
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.