Acute Abdominal Pain in a Geriatric: An Emergency Medicine Perspective

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Acute Abdominal Pain in a Geriatric An Emergency
Medicine Perspective

• Ali R. Rahimi,MD

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Geriatrics as an increasing segment of the
population

• 1 in 8 is gt64yo in 1994
• 1 in 5 projected to be gt64yo in 2030

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The Geriatric Functional Continuum
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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

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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

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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

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RULES

• YOU MUST GIVE A DIFFERENTIAL DX BEFORE YOU CT
  SCAN OR ELSE

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Actual ER Physicians
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CASE UNO!

• Belly pain, green vomit x 3, distended belly,
  painful throughout, tinkly bowel sounds
• Upright Abd film ?

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Bowel Obstruction

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

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CASE DOS!

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

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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.

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CASE TRES!

• Intense belly pain, N/V/D, pain out of proportion
  to exam
• Oh snap!
• Think CTA (if Vital signs stable- cause you
  dont want to run a code in CT)

Geriatric Hippies A High Risk Population
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Mesenteric Ischemia

• High mortality 45-90
• Occlusion in SMA most common
• Big Risk factor A-fib
• Get vascular surgery pronto

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CASE CUATRO!

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

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Perforated Bowel

• Free Air! 40 of upright abd xrays will miss the
  free air
• Most common cause peptic ulcers
• Poorer outcome in gt70yo w/o surgical intervention

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CASE CINCO!

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

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Acute Pancreatitis

• Gallstones the cause in 70 of pts gt80yo
• Frequently present in shock
• Amylase/Lipase and CT

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CASE SEIS!

• Colicky RUQ pain, no N/V, no fever
• Bedside ultrasound available and shows --gt

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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

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CASE SIETE!

• Belly Pain all over, TTP over RLQ, no fever or
  leukocytosis
• Told she had a stomach bug at walk-in clinic

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Appendicitis

• 5 of all surgical abdomens in geriatric
• gt Half of geriatric appys are misdiagnosed on
  initial presentation
• Watch for perfs!

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CASE OCHO!

• Belly pelvic pain, vag bleeding, tachy, low BP

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Ruptured Ectopic

• Yeah.
• Right.
• Think endomertrial CA, you doofus

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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!
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References

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  abdominal pain in the elderly. Ann Emerg Med
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  Pearls and pitfalls in the emergency department
  evaluation of abdominal pain. Emerg Med Clin
  North Am 2003 2161.
• Kizer, KW, Vassar, MJ. Emergency department
  diagnosis of abdominal disorders in the elderly.
  Am J Emerg Med 1998 16357.
• 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 23259.
• 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 727.
• Yeh, E, McNamara, R.Abdominal Pain. Clin Geriatr
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