Abdominal Pain in Older Adults

Aka: Abdominal Pain in Older Adults, Elderly with Acute Abdominal Pain, Acute Abdomen in the Elderly, Intra-Abdominal Infection in Older Patients

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II. Epidemiology

  1. Abdominal Pain is the third most common presenting complaint to ED in age >65 years (behind Chest Pain, Dyspnea)
  2. Older adults present later in Acute Abdominal Pain
  3. Older adults present with higher level of severity
    1. ER presentations requiring hospital admission: 50-60%
    2. ER presentations requiring surgery: 20-33%
    3. Surgical mortality: 2-13% (up to 34% if emergent)

III. Causes: Acute Abdominal Pain over age 55 years

  1. See Acute Abdominal Pain Causes
  2. Biliary disease (e.g. Cholecystitis): up to 33% of cases
    1. Most common cause of acute surgical Abdomen in older adults
    2. Classic symptoms, signs often absent in older adults
      1. Nausea, Vomiting, fever, Abdominal Pain and Flank Pain may be absent in >50% of cases
      2. Leukocyte count and Temperature may be normal
      3. Liver Function Tests may be normal
      4. Murphy's Sign less efficacious in older adults
    3. Complications of Acute Cholecystitis: >50% of elderly
      1. Risk for acute Ascending Cholangitis, Choledocholithiasis
  3. Appendicitis (4-15%)
    1. Elderly represent 10% of appendectomies
    2. Elderly often present late in course
      1. Appendicitis is initially misdiagnosed in more than 50% of older adult patients
      2. Generalized pain and peritoneal signs common by the time elderly present
      3. Presentation at 3 days in 20% and at 7 days in 8% of elderly patients
      4. Mortality approaches 20%
    3. Classic diagnostic criteria are often absent
      1. Fever, Nausea, Vomiting, Anorexia, abdominal gaurding are each present in only 50% of patients
      2. Classic Periumbilical Pain migrating to right lower quadrant is present in only 40% of elderly with Appendicitis
      3. Leukocytosis is absent in 40% of patients
      4. Urinalysis may show Hematuria or pyuria leading to missed diagnosis
      5. Missed diagnosis is common with 20-25% of elderly being sent home on their initial Appendicitis presentation
    4. Complications are common due to delay in presentation
      1. Increased Appendiceal gangrene risk
      2. Increased Appendiceal rupture risk
  4. Peptic Ulcer Disease (16%) and Upper Gastrointestinal Bleeding
    1. Causes and Risk Factors: NSAIDs (most common) and Helicobacter Pylori; Anticoagulants have higher bleeding risk
    2. Abdominal Pain is often absent or non-specific
    3. Responsible for higher mortality in older patients
    4. Initial presentation after perforation is common
      1. Suggested by Leukocytosis and high Serum Amylase
      2. Perforation may be difficult to detect
        1. Free air may be absent on abdominal XRay
        2. Consider CT Abdomen or Ultrasound if suspected
  5. Intestinal Obstruction (12%)
    1. As with other conditions, presentations are delayed in elderly
    2. Small Bowel Obstruction causes in older adults
      1. Adhesion from prior surgery (50-70%)
      2. Incarcerated Hernia (15-30%)
      3. Gallstone ileus (20% of SBO in the elderly)
        1. Air in biliary tree, Xray with ileal Gallstone
        2. High mortality in delayed diagnosis
    3. Large Bowel Obstruction causes
      1. Colon Cancer (most common)
      2. Diverticulitis
      3. Volvulus
  6. Acute Pancreatitis
    1. Abdominal Pain is absent in 90% of Acute Pancreatitis in older adult patients
      1. Altered Mental Status and Hypotension is the presentation of 10% of advanced Pancreatitis
    2. Gallstone Pancreatitis accounts for 50% (age >65) to 75% (age >85 years) of cases
    3. Presentation is similar to younger patients
    4. Mortality is 2-3 fold higher than that of younger patients (20%)
  7. Abdominal Aortic Aneurysm
    1. Present in 5% of men over age 65 years
    2. Bedside Ultrasound can rapidly identify large AAA
    3. Typical presentations (abdominal or Flank Pain, pulsatile mass, Hypotension) is present in <50% of cases
      1. Atypical presentations are often misdiagnosed as Renal Colic and musculoskeletal back pain
  8. Acute Mesenteric Ischemia
    1. Suspected in pain out of proportion to exam and a Lactic Acid elevated despite rehydration and no infection
    2. Superior Mesenteric Artery Embolism (esp. Atrial Fibrillation, Cardiomyopathy) is most common acute sudden cause
    3. Superior Mesenteric Artery Thrombosis causes gradually worsening Abdominal Pain worse with eating
    4. Mesenteric Venous Thrombosis is more common in Hypercoagulable state (i.e. DVT Risk factors)
  9. Diverticulitis (6%)
  10. Other causes
    1. Abdominal causes
      1. Renal Colic or Nephrolithiasis
      2. Urinary Tract Infection or Pyelonephritis (see UTI in Older Adults)
        1. Distinguish between Asymptomatic Bacteriuria and acute UTI
      3. Constipation
      4. Abdominal Muscle wall injury (rectus sheath Hematoma)
    2. Extra-abdominal referred Cardiopulmonary causes
      1. Acute Coronary Syndrome (e.g. Inferior wall Myocardial Infarction)
        1. Up to 45% of older women present with gastrointestinal symptoms as a coronary equivalent
      2. Pulmonary Embolism
      3. Pneumothorax
      4. Congestive Heart Failure
      5. Pericarditis
      6. Pneumonia
    3. Extra-abdominal referred Miscellaneous causes
      1. Adrenal Insufficiency
      2. Diabetic Ketoacidosis
      3. Hypercalcemia
      4. Uremia
      5. Herpes Zoster

IV. Labs

  1. Complete Blood Count
    1. Leukocyte count is often normal despite peritonitis
  2. Comprehensive metabolic panel
  3. Blood Cultures
  4. Lipase
  5. Lactic Acid
  6. Urinalysis
    1. Urinalysis may show Hematuria or pyuria in Appendicitis

V. Imaging

  1. Upright Chest XRay (or left lateral decubitus xray)
    1. Evaluate for abdominal free air
  2. CT Abdomen and Pelvis
    1. Frequently needed to exclude serious pathology (e.g. AAA, Intestinal Obstruction, Mesenteric Ischemia, Appendicitis, biliary disease)

VI. Diagnostics

  1. Electrocardiogram
    1. Especially indicated in upper Abdominal Pain

VII. Prognosis

  1. Mortality risks for Acute Abdominal Pain in elderly
    1. XRay demonstrates abdominal free air
    2. Leukocytosis with Left Shift (high Band Neutrophils)
    3. Age over 84 years old

VIII. Evaluation: Approach

  1. See Abdominal Pain Evaluation
  2. ABC Management
  3. Vital Signs predictive of more serious illness
    1. Bedside Glucose
    2. Oxygen Saturation
    3. Respiratory Rate with Tachypnea
      1. Sensitive marker for early systemic infection
  4. Predictors of older patients needing surgery
    1. Hypotension
    2. Bowel sounds abnormal
    3. Leukocytosis
      1. WBC Count often normal in elderly with Acute Abdomen, so when increased suggests a serious infection
      2. Consider Mesenteric Ischemia when the WBC Count >25,000, especially if concurrent Lactic Acidosis
    4. Abdominal Pain with coughing or with shaking the stretcher
      1. Suggestive of peritonitis
    5. Abdominal imaging abnormalities
      1. Abdominal free air (upright Chest XRay)
      2. Dilated loops of bowel
      3. Bowel air-fluid levels

IX. Evaluation: Pitfalls for Abdominal Pain in older patients

  1. History may be difficult
    1. Hearing Impairment
    2. Elderly patients often down play their symptoms or attribute them to benign conditions
    3. Presenting symptoms are often atypical for a given complaint (e.g. respiratory or GI complaints for Pyelonephritis)
    4. Altered Level of Consciousness or Dementia
      1. Consider brief bedside mental status evaluation (e.g. Mini-Cognitive Assessment Instrument)
      2. Consider collateral information from family or nursing facility
  2. Vital Signs are often unreliable
    1. Fever is often absent (or only low-grade)
      1. Hypothermia often is clinical equivalent of fever
      2. Lower typical threshold Temperature for fever by 1 F in the elderly (i.e. fever at 99.5 F)
      3. Fever is absent in up to 80% of older patients with bacteremia
    2. Tachycardia is often absent
      1. Beta Blocker use
      2. Decreased endogenous Catecholamine response
    3. Blood Pressure often does not reflect degree of hemodynamic instability
      1. Chronic Hypertension (comparison with baseline Blood Pressures may be helpful)
      2. Decreased vascular compliance
    4. Tachypnea
      1. Only Vital Signs that remains reliable and retains its test sensivity
  3. Examination and lab data may underestimate severity of disease
    1. Abdominal Examination has poor Test Sensitivity in the elderly
      1. Peritonitis may present with minimal abdominal exam findings
      2. Pain out of proportion to the examination is a red flag, and is not benign or reassuring
        1. Consider Mesenteric Ischemia
    2. Local tenderness, rigidity, guarding and rebound often absent
    3. Leukocytosis is often absent (typically delayed inflammatory response)
      1. Normal Leukocyte count in 40% of Cholecystitis and 45% of Appendicitis
      2. Band Neutrophils may have increased Test Sensitivity
      3. Lactic Acidosis may be an earlier marker for Sepsis
  4. Diagnosis
    1. Exclude serious Abdominal Pain causes before making a benign diagnosis
      1. Avoid early determination of diagnoses of exclusion (e.g. GERD, Constipation, Gastroenteritis)
    2. Consider referred pain (e.g. Myocardial Infarction)

X. References

  1. Herbert (2012) EM:Rap 2(9): 4
  2. Lin and Shenvi in Herbert (2014) EM:Rap 14(6):8-9
  3. Magidson and Khoujah (2019) Crit Dec Emerg Med 33(11): 17-23
  4. Abi-Hanna (1997) Geriatrics 52:72-4 [PubMed]
  5. Dang (2002) Geriatrics 57:30-42 [PubMed]
  6. Lyon (2006) Am Fam Physician 74: 1537-44 [PubMed]
  7. Marco (1998) Acad Emerg Med 5:1163-8 [PubMed]

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