Transcript Abdominal pain in the elderly

Nilesh Patel, D.O.
March 11, 2009
St. Joseph’s Regional Medical Center
Paterson, NJ
OBJECTIVES
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Epidemiology...The Problem
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Pearls & Piftalls
 Diagnosis
 Management
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Cases
 Diseases’ which are specific to elderly
 Diseases’ which present atypically in elderly
DDx of ABDOMINAL PAIN
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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
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Abdominal pain is common chief complaint
in ED
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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%!
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“Acute Abd. Pain in the
Elderly”
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Annals of EM 1990, Bugliosi et al.
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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%
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CASE
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CC:
 Abdominal pain
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HPI:
 91 y/o llq abdominal pain
 Positive associated n/v/d
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PMHx:
 COPD, Dementia, Colon CA, Glaucoma, DVT
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PSHx:
 Colectomy * 2, ORIF R hip, Back surgery
CASE
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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
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Vague historians
 Altered mental status
 Dementias
 Hearing deficits
 Communication difficulties
 Downplay symptoms/stoic nature
 Fear of hospital admission
PITFALLS: EXAM
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Physical Exam…Lack of classic findings
 Fever
 Leukocytosis
 Peritoneal signs
 Focal tenderness
 Tachycardia
Patients do not read the textbook,
especially elderly patients!
PITFALLS
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Delay in seeking medical attention >>
Delays in diagnosis
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Co-morbid disease
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Chronic medications
PITFALLS: DISEASE
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Age
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Diabetes
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Malignancy
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Renal insufficiency
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CV disease
PITFALLS: MEDS
“Medications may mask or create
pathology”
 Mask pathology
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 Steroids
 NSAIDS
 Chronic pain meds
 Cardiac meds
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Create pathology
 Steroids/NSAIDS
 Antibiotics
PITFALLS: MEDS
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Consider prescription meds, otc meds,
herbals
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Drug-drug interactions
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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
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INITIAL EVAL…PEARLS
“Think the worst first”
 Have a low threshold for labs & imaging
 Medication history must be thorough
 Focus on vital signs
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 HR may be affected by meds
 A normal bp may reflect hypotension
 Respiratory rate is important
 If temp normal, get a rectal temp
 If temp low, think sepsis
MY RULE
The
vast majority of elderly
patients with abdominal pain
deserve an imaging study!
ANOTHER RULE
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Admit undifferentiated abdominal pain
when the clinical presentation is concerning.
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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
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“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
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“I HAVE BLOOD IN MY
STOOL”
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13.6
5.6
132
100
185
Bands 13
LFTs normal
32
Lipase normal
210
3.2
17
2.0
UA normal
MESENTERIC
ISCHEMIA/INFARCTION
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Etiology
 Arterial (embolic or thrombotic)
 Venous
 Non-occlusive
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Risk Factors
 CAD, recent MI, CHF, Afib, Low flow states,
Hypercoagulable states, Sepsis, Medications
Age > 50
 Mortality 50-70%
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MESENTERIC
ISCHEMIA/INFARCTION
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Clinical presentation
 Abdominal pain out of proportion to exam
 Intestinal angina
 Severe intermittent abdominal pain
 Acute/sub-acute/chronic
 Diffuse vs localized
 Blood in stools
 N/V/D
MESENTERIC
ISCHEMIA/INFARCTION
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Diagnostics
 Leukocytosis/Leukopenia
 Elevated amylase
 Acidosis
 X-ray
 CT scan
 Angiography is gold standard
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Treatment
 IVF, antibiotics
 Surgery
MESENTERIC ISCHEMIA
IN ELDERLY
This is a disease of the old
 Myriad of presentations
 Abnormal labs are late manifestation
 Difficult diagnosis
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 Imaging is necessary
 Early angiography decreases mortality
 Delays from consultants
LACTATE
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“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
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“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
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AAA
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Etiology
 Atherosclerosis
 Familial
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Risk Factors
 Smoking, Age, HTN, Atherosclerosis, FHx,
COPD, Male sex
Age > 55
 Mortality > 50% with rupture
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AAA
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Clinical presentation
 Hypotension
 Abdominal pain/Back, Flank pain
 Pulsatile abdominal mass
 Asymptomatic until rupture
 Syncope
 Signs of shock
 Vital sign abnormalities
 Weakness
 Signs of peripheral embolic events
AAA
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Diagnostics
 Lab abnormalities
○ Low H/H
 Imaging
○ 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
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MESENTERIC ISCHEMIA
& AAA
Unique to elderly populations
 High mortality (> 50%)
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THE
CHALLENGE…
High index of suspicion
 Image liberally
 Involve consultants early
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TUMORS, TWISTS, AND
TELESCOPES
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GI Tumors
 15-18% of elderly patients sent home with
diagnosis of nonspecific abdominal pain
 10% will have dx of GI tumor within one year
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Volvulus
 Sigmoid/Cecal volvulus
 Symptoms/Signs of obstruction
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Intussuception
 Occurs in the elderly as well as pediatrics
 Often associated with tumors
VOLVULUS
5-10% of obstruction
 Hx of chronic constipation
 Populations at risk
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 NH patients
 Psych patients (mental health facilities)
 Neuro patients
 Elderly
Clinical presentation
 Dx—plain film often diagnostic
 Tmt—decompression, often surgery
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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
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“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
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“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
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“MY BELLY HAS BEEN
HURTING FOR 5 DAYS”
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12.4
11.5
133
Bands 7
200
108
20
155
3.8
23
1.5
UA 5-9 WBC
APPENDICITIS
5% of acute abdominal pain in elderly
 Higher rate of complications
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 5 times higher rate of perforation
 Increased mortality
Atypical presentation is typical
 Delay in diagnosis is common
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CHOLECYSTITIS
Most common cause abdominal surgery
 Acalculous & Calculous
Cholecystitis/Cholelithiasis/Cholangitis
 Early surgical intervention is key
 Higher mortality rate
 Higher rate of complications
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 Perforation
 Gangrene
 Sepsis
 Emphysematous cholecystitis/Ascending cholangitis/Gallstone
ileus
 Pancreatitis
PANCREATITIS
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Most common cause nonsurgical cause of
abdominal pain
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Increased mortality rate
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Increased complication rate
DIVERTICULITIS
Increased prevalence with age
 WBC and VS often normal
 Complications
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 Abscess
 Bowel obstruction
 Free Perforation
 Sepsis
 Fistula formation
PERFORATED VISCUS
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Can occur from all cause of abdominal pain
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Peptic ulcer disease
 Increased incidence with NSAIDS
 Complications
○ GI bleed
○ Perforation
○ Obstruction
○ Penetration into nearby organs
BOWEL OBSTRUCTION
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Small bowel obstruction
 Adhesions
 Hernias
 Tumors
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Large bowel obstruction
 Tumors
 Diverticulitis
 Volvulus
EXTRA-ABDOMINAL
CAUSES
Acute coronary syndromes
 Aortic dissection
 Congestive heart failure
 Pulmonary embolus
 Pneumonia
 Pleural effusions
 Metabolic causes
 GU/Pelvic pathology
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APPYS, STONES, TICS,
PERFS, & BLOCKAGES
Present atypically in elderly populations
 Higher mortality
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THE
CHALLENGE…
Recognize atypical presentations
 Be aware of increased rate of complications
 If in doubt, consult or admit
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DISPOSITION
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Admit
 Toxic
 Abnormal vital signs
 Persistent pain/vomiting
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Discharge Criteria
 Thorough H & P completed
 Non-toxic
 Normal vital signs
 Normal imaging
 Improving abdominal exam
 Good 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
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