Kevin Biese MD MAT Ellen Roberts PhD MPH Jan BusbyWhitehead MD University of North Carolina at Chapel Hill Division of Geriatric Medicine Center for Aging and Health Department of Emergency Medicine ID: 920886
Download Presentation The PPT/PDF document "ABDOMINAL PAIN IN THE ELDERLY" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
ABDOMINAL PAIN IN THE ELDERLY
Kevin Biese, MD, MATEllen Roberts, PhD, MPH Jan Busby-Whitehead, MDUniversity of North Carolina at Chapel HillDivision of Geriatric MedicineCenter for Aging and Health Department of Emergency Medicine
THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.Leading change. Improving care for older adults.
AGS
Slide2ObjectivesTo increase appreciation of the variety of presentations of acute abdominal pathology in elderly patientsTo appreciate the differences in etiology of acute abdominal pain between elderly and younger patientsTo increase proficiency of evaluation and management of elderly patients with acute abdominal painSlide 2
Slide3Why Care?Increasing Elderly Population (≥65 Years)Slide 3
Slide4Why Care?Significant Mortality and MorbidityOf patients ≥65 years old who come to the ED with acute abdominal pain:50% admission33% surgery10% mortality (similar to ST-elevation myocardial infarction)
Kizer KW. Am J Emerg Med. 1998;16:357-362.Slide 4
Slide5Case 1: Ms. Jones85-year-old woman with past medical history of atrial fibrillation, GERDChief complaint: abdominal pain that started 8 hours before arrival, sudden onsetIntermittent pain, was able to eat dinner 3 hours after onset without difficultyAfebrile, vital signs within normal limits (WNL), no vomiting, no diarrhea, normal bowel movement 2 hours before arrival Exam: mildly tender epigastric and right upper quadrant (RUQ) region without peritonitis, no Murphy’s sign
Slide 5
Slide6Ms. Jones: Initial ResultsWBC count 11.7Hematocrit 49Platelets 193Chemistries WNLLiver function tests (LFTs) WNLLipase WNL
Slide7Gall Bladder Disease: Are LFTs Helpful? Total bilirubin, AST, or alkaline phosphatePositive likelihood ratioNegative likelihood ratioAll 3 elevated1.6
0.8Any 1 elevated1.20.7Trowbridge RL. JAMA. 2003; 289(1): 80-86.
Slide8Ms. Jones UltrasoundInsert ultrasound image of cholecystitis with gall stones,thickened gall bladder wall, and edema.
Slide9Cholecystitis #1 abdominal surgical emergency in elderlyIncidence increases with ageOften only epigastric pain (foregut innervation is visceral) LFTs often not helpfulUltrasound is study of choice
Slide 9
Slide10Case 2: Ms. Jones ReturnsMs. Jones returns to the ED 4 days post-opChief complaint: RUQ painPain worsened last night, able to eat, general fatigue Vital signs WNL, afebrileModerate tenderness in RUQSlide 10
Slide11Ms. Jones: The Return VisitLabs including LFTs are WNLWhat to do?Slide 11
Slide12Ms. Jones: The Return VisitThe diaphragm is an unsecured border; upper abdominal pain can be Acute coronary syndromePulmonary embolismPneumoniaInsert CT image of pulmonary embolism
Slide13Case 3: Ms. Smith80-year-old woman with past medical history of breast cancer, hypothyroidismChief complaint: abdominal painSudden onset 10 hours before arrival, right lower quadrant (RLQ) pain constant in location, 10/10 intensity, + diarrheaExam notable for moderate RLQ tenderness, Hemoccult negativeSlide 13
Slide14Ms. Smith: AppendicitisInsert CT image of appendicitis.
Slide15Appendicitis IN THE ELDERLY5% of acute abdominal casesRarely have the 4 classic criteria (anorexia, elevated WBC, RLQ pain, and fever)Diagnosis often missed (presence of diarrhea or WBC in urine can be misleading)However, usually have at least RLQ pain
Kauvar DR. Clin Geriatr Med. 1993;9:547-558.Storm-Dickerson TL. Am J Surg. 1983;185:198-201.Slide 15
Slide16Case 4: Ms. Doe67-year-old woman with HTN, COPD, CADChief complaint: abdominal pain3 days generalized, intermittent abdominal pain with nausea, vomiting, and diarrhea (n/v/d); no black stools; some urinary hesitancySeen by PCP 2 days prior, given phenerganNo apparent distress; exam notable for moderate RUQ and RLQ tendernessHR 115, BP 160/100, T 37.0
Slide 16
Slide17Ms. Doe:INITIAL RESULTSWBC 11.5; o/w CBC WNLChemistries 7 and LFTs WNLUA shows 7 WBC, nitrite negativeArterial lactate 1.0What to do?A diagnostic test was obtained several hours later…Slide
17
Slide18LearningRadiology.com, retrieved June 1, 2011.Slide 18
Slide19Mesenteric IschemiaClassically, pain out of proportion to examRisks include atrial fibrillation, hypercoagulable, low-flow, increasing ageUsually arterial; may be venousEmbolus or thrombosisSometimes “intestinal angina”Usually superior mesenteric arteryMultidetector CT scan 77%
90% sensitiveElevated lactate is a late finding (check >1 time)Newman TS. Am Surg. 1998;64:611-616.Horton KM. Radiographics. 2002:22;161. Slide 19
Slide20Case 5: Mr. Smith82-year-old man with HTN, chronic renal insufficiency, diverticulosisHistory also includes abdominal aortic aneurysm repair Presents with a 2-week history of flank pain wrapping around to abdomenReferred by PCP because of abnormal renal CT scanVital signs WNL including afebrile, BP 162/80, HR 65Obese male in moderate amount of distressExam benign, including abdominal exam
Slide 20
Slide21Mr. Smith: Abdominal Aortic Aneurysm (AAA)Elderly + low BP + abdominal pain = AAAGet the ultrasound – Fast!Same risk factors as CAD (men>women)>3 cm defines, >5 cm rupture riskWhat diagnosis to consider if simultaneous rectal bleeding?Insert ultrasound image of enlarged abdominal aorta
Slide22Case 6: Ms. Connor80-year-old woman with HTN, anxiety2-day history of crampy lower abdominal pain; mild n/v/dIn no apparent distressVital signs WNL other than moderate HTNExam notable for moderate RLQ tenderness without peritonitisSlide
22
Slide23Ms. Connor: IMAGING
LearningRadiology.com, retrieved June 1, 2011.Slide 23
Slide24Sigmoid Volvulus Risk factors: chronic constipation, round wormsMore common in malesAbdominal x-ray 65% sensitiveUsually presents with crampy left sided abdominal painOften decompressed with sigmoid scopeCan be subtle presentation Time sensitive diagnosis
Atamanalp SSJ Gastroenterol Hepatol 2007Emedicine 2008
Slide25Case 7: Ms. Lane79-year-old woman with HTN, diabetesChief complaint: 2 days of n/v/dWell-appearing, vital signs WNL Seen 48 hours ago for n/v/d: 6 WBC in UA, no nitrate, 4 squamous cells, levofloxacin startedPatient took 1 tab levofloxacin, had increased vomiting and diarrhea Completely benign abdominal exam
WBC 5,000, chemistries WNL, UA WNLSlide 25
Slide26Ms. Lane: Gastroenteritis (I hope)Observed in ED for 5 hoursNo vomiting or diarrhea; tolerating POsD/C with close PCP follow-up“You do not always have to be right, you just have to have a contingency plan”Slide 26
Slide27Key PointsAcute abdominal pain in the elderly is associated with significant morbidity and mortalityLFTs often not revealing in acute gallbladder diseaseThe diaphragm is not a secure borderConsider mesenteric ischemia (especially with history of atrial fibrillation, pain out of proportion to exam)Elderly + low BP + abdominal pain = AAA(until proven otherwise)
Slide 27
Slide28Case 1 (1 of 2)An 85-year-old woman presents to the ED complaining of 8 hours of abdominal pain. The pain is centered in the epigastrium and she has had no n/v/d.She had a normal bowel movement 2 hours before arrival to the ED. She ate a meal last night without difficulty.Her past medical history is notable for atrial fibrillation and GERD.In the ED she is afebrile with normal vital signs other than mild HTN at 150/95. Slide
28
Slide29Case 1 (2 of 2)Her exam is notable for a well-appearing elderly woman with mild epigastric tenderness and no peritonitis on exam. She does not have a Murphy’s sign on exam.After completing your history and exam, you order labs, including LFTs, CBC, and basic chemistries. Other than a WBC count of 11.7 without a left shift, these labs are all WNL, including the LFTs.You now need to decide how you wish to proceed with this patient.Slide
29
Slide30Case 1, Question 1 What is the most common etiology of acute abdominal pain presenting to the ED in patients over age 50? Select the one best answer.A. Biliary tract diseaseB. ConstipationC. Nonspecific abdominal painD. Urinary tract infection
Slide 30
Slide31Case 1, Question 2 What is the negative likelihood ratio for all LFTs being normal in assessing whether a patient has acute cholecystitis?A. 0.1B. 0.3C. 0.7D. 1.0Slide 31
Slide32Case 1, Question 3True or False:The gallbladder’s visceral innervation originates in the midgut.Slide 32
Slide33Case 2 (1 of 2)A 67-year-old woman with a medical history of HTN and CAD disease presents to the ED with 3 days of generalized intermittent abdominal pain with n/v/d and some urinary hesitancy.She denies black stools or fevers.She was seen 2 days ago by her PCP and given phenergan for nausea. She is now presenting to the ED because her pain is not improving.Slide 33
Slide34Case 2 (1 of 2)On exam she is in significant pain but has only moderate RUQ and RLQ abdominal tenderness.She is guaiac-negative on rectal exam and her vitals are notable for a heart rate of 115, BP of 160/100, and temperature of 37.0 C.In the ED, her WBC count is 11.5 without a left shift, her UA has 7 WBC without nitrite, squamous cells, or bacteria, and the rest of her labs are normal, including her arterial lactate level of 1.0.You now need to decide how to proceed in your evaluation of this patient.Slide
34
Slide35Case 2, Question 1Which of the following is NOT a risk factor for mesenteric ischemia?A. Advancing ageB. Atrial fibrillationC. Prior abdominal surgeryD. Recent myocardial infarction
Slide 35
Slide36Case 2, Question 2True or False:Elevated lactate levels are a highly sensitive marker of mesenteric ischemia.Slide 36
Slide37Case 2, Question 3 Regarding appendicitis, which of the following classic signs and symptoms do the majority of elderly patients with abdominal pain have? Select the one best answer.A. AnorexiaB. Migration of painC. Pain localized to the RLQD. Peritoneal signs on abdominal examSlide
37
Slide38Answer KeyCase 1Question 1: AQuestion 2: CQuestion 3: FalseCase 2Question 1: CQuestion 2: FalseQuestion 3: C Slide 38
Slide39Acknowledgmentsand DisclaimerThis project was supported by funds from the American Geriatrics Society John A. Hartford Geriatrics for Specialists Grant. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of the American Geriatrics Society or John A. Hartford Foundation, nor should any endorsements be inferred.The UNC Center for Aging and Health and UNC Department of Emergency Medicine also provided support for this activity. This work was compiled and edited through the efforts of Jennifer Link, BA.
Slide 39
Slide40Visit us at:
Facebook.com/AmericanGeriatricsSocietyTwitter.com/AmerGeriatricswww.americangeriatrics.orgThank you for your time!
linkedin.com/company/american-geriatrics-society
Slide
40