KUBAfter seeing your fifth young patient of the day with chronic pelvic pain, constipation, and irritable bowel syndrome, it is easy to be lulled into the mindset that abdominal pain is nothing to worry about. Not so with the elderly. These 10 tips will help focus your approach to atraumatic abdominal pain in older adults and explain why presentations are frequently subtle and diagnoses challenging.

1. The atypical is typical.

Normal vital signs, lab tests, and the history and physical exam findings are not necessarily reassuring in older patients. Why are older adults so hard to diagnose?

  • History: Patients with dementia, or those with an acute delirium may be unable to reliably answer your questions and explain the progression of symptoms or their past surgeries and medical problems. Also, their past medical history is usually more complicated than younger patients. It would be hard for anyone to remember the 12 different pills they take, even moreso if they have baseline cognitive deficits.
  • Vitals
    • They may lack a fever despite infection or sepsis.
    • They may not be tachycardic in response to pain or hypovolemia because of beta-blockers, other medications, and intrinsic cardiac disease.
    • A normal blood pressure may be falsely reassuring. A blood pressure of 120/80 in the ED may seem fine, but it could be 50 points lower than their usual blood pressure.
  • Physical exam: They may lack pain or localizing symptoms. Pain nerve fiber function deteriorates with age, so older adults may have no pain, or it may feel diffuse rather than focal.  Patients with prior abdominal surgeries may also have decreased pain perception. Over 30% of older patients with peptic ulcer disease have no pain. In patients with peritonitis, only 55% have pain, and 34% have rigidity.
  • Labs: They may not have an elevated WBC despite infection or sepsis. 30% of older patients who require abdominal surgery do not have a fever or leukocytosis. The immune system ages along with the patient, in a process that sounds more pleasant than it is: immunosenescence.
  • Delays in care: Because their pain sensation is blunted, or because patients have dementia and are unable to articulate their symptoms or call 911, older adults tend to present later in their course. They may also delay seeking care because of financial concerns, fears that they could lose their independence, and the very real concern that there could be something terrible going on.
  • They also have less physiologic reserve, so can decompensate more quickly. A young person could easily tolerate vomiting for a day, and not keeping any liquids down. By contrast an older person may be mildly dehydrated at baseline, may be on diuretics, and overall will be less able to increase cardiac output in order to compensate for hypovolemia or loss of fluid into the interstitial space as in sepsis.

2. Take a worst-first approach to the differential.

Assume there is an abdominal catastrophe until proven otherwise. A time-based approach may help: Ask what the patient could have that would need immediate intervention, and how you would diagnose it or rule it out.

  • Could this be an aortic dissection or rupture? Bedside ultrasound may help.
  • Is this a perforated viscus? Order an upright plain film
  • Is this sepsis from an intra-abdominal source, such as cholecystitis, ascending cholangitis, diverticulitis, appendicitis, or abscess? Appendicitis accounts for 3-4% of older patients with acute abdominal pain, and older adults are more likely to have perforations or abscesses from appendicitis because of delays in seeking care and diagnosis.

3. Get to know your surgeon.

You’re going to need him or her. About 50% of older adults with abdominal pain are admitted to the hospital, and of those 30% require surgery during their hospitalization, twice as many as in younger adults. The most common causes for surgery in older adults are:

  • #1 – Biliary disease – and if you diagnose pancreatitis, think about the biliary tree because most pancreatitis is secondary to gallstones in older adults
  • #2 – SBO – most often caused by the ABCs: adhesions, bowel herniation, and cancer

4. Don’t diagnose a diagnosis of exclusion.

Constipation is common in older adults, as are gastroenteritis, IBS, and non-specific chronic abdominal pain, but be wary of charting these as your final diagnoses, as they are diagnoses of exclusion.

5. Not all pyuria is a simple UTI.

Don’t hang your hat on 7 WBC in the urine as the cause of abdominal pain. Appendicitis and other focal inflammation near the bladder can also cause pyuria. It could also be pyelonephritis or a renal abscess. Or the pyuria may be incidental and unrelated.

6. Special cases

Certain histories should increase your suspicion for specific etiologies. Consider the following:

  • Recent cardiac catheterization – retroperitoneal hematoma
  • History of AAA repair – rupture, leak, or aorto-enteric fistula
  • Recent colonoscopy – perforation or intra-abdominal bleeding or hematoma
  • Poor mobility and chronic constipation – sigmoid volvulus
  • History of hiatal hernia – gastric volvulus
  • History of peptic ulcers – ruptured ulcer or erosion and bleeding
  • Atrial fibrillation – mesenteric ischemia
  • Prior surgeries – bowel obstruction or internal hernia
  • Ascites – spontaneous bacterial peritonitis
  • Abdominal pain AND another symptom (such as chest pain, back pain, pulse differences, leg pain, focal weakness, or syncope) – aortic dissection

7. Be wary of a benign exam in an older patient with abdominal pain.

Instead of labeling it a ‘benign exam’, think of it as POOP: Pain Out Of Proportion to exam, which could mean mesenteric ischemia. Mesenteric ischemia has several causes:

  • 50% are due to arterial emboli (usually to the superior mesenteric artery)
  • 15-25% are due to arterial thrombi
  • 20% are due to low flow states from hypotension, dehydration, etc
  • 5% are due to venous thrombi, think about this particularly in patients with hypercoagulable states or history of venous thrombi.

8. A picture is worth the $1000.

In older adults with no clear cause of their pain, consider a CT scan. Deciding to perform a CT scan always involves a risk/benefit analysis. The main risks or downsides are cost and radiation exposure. In older adults the radiation is not as big a concern, as their lifetime risk of acquiring a radiation-induced malignancy from the scan is low. On the benefit side, given the high prevalence of surgical causes of abdominal pain, there is a higher likelihood of diagnosing the cause of pain by CT. The risk/benefit ratio therefore more strongly favors imaging for the average older patient compared with the average younger patient.

9. Don’t anchor to what the patient tells you.

How many times have you seen an older patient who presents with abdominal pain, convinced it’s just “a little indigestion” or “something I ate” and it turns out to be an MI, a dissection, or necrotizing pancreatitis? Listen to what the patient tells you, but then put it away from your mind during your initial evaluation. Once you’ve thought through all the options, you can bring it back and see if it fits. But be very careful not to anchor to the patient’s assumed diagnosis and fail to look at the situation with an open mind,

10. It may not be their abdomen at all!

Abdominal pain or nausea and vomiting can be the sole symptoms in an MI. So in a patient with abdominal pain, consider whether the pain could be arising from a contiguous area. Does the pathology really lie in the chest, such as pneumonia, ACS, or CHF. Or is the pain actually back pain, flank pain, or from a metabolic process such as DKA?

Expect to see more and more older patients with abdominal pain! As Dr. Diane Birnbaumer said in EP Monthly:

Don’t look now, but that gentle lapping at your toes is the first hint of the “silver tsunami” coming soon to an emergency department near you.

This has been the 4th post in a series on Geriatric Emergency Medicine. If you have ideas for topics you would like to see covered, post a comment!

Additional Resources

Here are some great reviews and references on the topic of abdominal pain in the elderly: 1–4

Geriatric EM Video Series from ACEP

1.
Marco C, Schoenfeld C, Keyl P, Menkes E, Doehring M. Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes. Acad Emerg Med. 1998;5(12):1163-1168. [PubMed]
2.
Martinez J, Mattu A. Abdominal pain in the elderly. Emerg Med Clin North Am. 2006;24(2):371-88, vii. [PubMed]
3.
Lyon C, Clark D. Diagnosis of acute abdominal pain in older patients. Am Fam Physician. 2006;74(9):1537-1544. [PubMed]
4.
Ragsdale L, Southerland L. Acute abdominal pain in the older adult. Emerg Med Clin North Am. 2011;29(2):429-48, x. [PubMed]

Expert Peer Review

Although our study was published in 1998, the basic principles still apply: geriatric patients with abdominal pain are often very ill with conditions that require hospitalization, and in many cases, surgery. My clinical experience since publishing this study confirms the importance of a high index of suspicion for severe disease in this patient population.

One important shortcoming of our study was the retrospective design. We looked at the medical records of 375 patients at a single institution. We looked at primary outcome measures of final diagnosis, outcome (death, or need for surgical intervention), and looked at factors associated with those outcomes measures.

We found that conditions associated with poor outcomes included hypotension, abnormalities on  abdominal radiography, leukocytosis, abnormal bowel sounds, and advanced age. To experienced clinicians, there are no surprises here. Sick patients are sick!

This study emphasizes several points that are important to clinicians:

  1. Geriatric patients with abdominal pain frequently have serious disease (including infection, obstruction, ulcer, UTI, and malignancy)
  2. Geriatric patients with abdominal pain frequently have bad outcomes (5% of them will die from the presenting condition).
  3. Geriatric patients with abdominal pain frequently require surgery (22%).\"
Catherine A. Marco, MD, FACEP
Professor, Department of Emergency Medicine, University of Toledo College of Medicine
Christina Shenvi, MD PhD
ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina
www.gempodcast.com