Nilesh Patel, D.O.March 11, 2009

St. Joseph’s Regional Medical CenterPaterson, NJ

OBJECTIVES

Epidemiology...The Problem

Pearls & PiftallsDiagnosisManagement

CasesDiseases’ which are specific to elderlyDiseases’ which present atypically in elderly

DDx of ABDOMINAL PAIN 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

Abdominal pain is common chief complaint in ED

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%!

“Acute Abd. Pain in the Elderly”

Annals of EM 1990, Bugliosi et al. 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%

CASE

CC:Abdominal pain

HPI:91 y/o llq abdominal painPositive associated n/v/d

PMHx:COPD, Dementia, Colon CA, Glaucoma, DVT

PSHx:Colectomy * 2, ORIF R hip, Back surgery

CASE 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

Vague historiansAltered mental statusDementiasHearing deficitsCommunication difficultiesDownplay symptoms/stoic natureFear of hospital admission

PITFALLS: EXAM

Physical Exam…Lack of classic findingsFeverLeukocytosisPeritoneal signsFocal tendernessTachycardia

Patients do not read the textbook,

especially elderly patients!

PITFALLS

Delay in seeking medical attention >> Delays in diagnosis

Co-morbid disease

Chronic medications

PITFALLS: DISEASE

Age

Diabetes

Malignancy

Renal insufficiency

CV disease

PITFALLS: MEDS

“Medications may mask or create pathology” Mask pathology

SteroidsNSAIDSChronic pain medsCardiac meds

Create pathologySteroids/NSAIDSAntibioticsDigoxin

PITFALLS: MEDS

Consider prescription meds, otc meds, herbals

Drug-drug interactions

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

INITIAL EVAL…PEARLS

“Think the worst first” Have a low threshold for labs & imaging Medication history must be thorough Focus on vital signs

HR may be affected by medsA normal bp may reflect hypotensionRespiratory rate is importantIf temp normal, get a rectal tempIf temp low, think sepsis

MY RULE

The vast majority of elderly patients with abdominal pain deserve an imaging study!

ANOTHER RULE

Admit undifferentiated abdominal pain when the clinical presentation is concerning.

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

“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

“I HAVE BLOOD IN MY STOOL”

13.6 Bands 13

5.6 185 LFTs normal

132 100 32 Lipase normal

210

3.2 17 2.0 UA normal

MESENTERIC ISCHEMIA/INFARCTION

EtiologyArterial (embolic or thrombotic)VenousNon-occlusive

Risk FactorsCAD, recent MI, CHF, Afib, Low flow states,

Hypercoagulable states, Sepsis, Medications

Age > 50 Mortality 50-70%

MESENTERIC ISCHEMIA/INFARCTION

Clinical presentationAbdominal pain out of proportion to examIntestinal anginaSevere intermittent abdominal painAcute/sub-acute/chronicDiffuse vs localizedBlood in stoolsN/V/D

MESENTERIC ISCHEMIA/INFARCTION

DiagnosticsLeukocytosis/LeukopeniaElevated amylaseAcidosis

X-rayCT scanAngiography is gold standard

TreatmentIVF, antibioticsSurgery

MESENTERIC ISCHEMIA IN ELDERLY

This is a disease of the old Myriad of presentations Abnormal labs are late manifestation Difficult diagnosis

Imaging is necessaryEarly angiography decreases mortalityDelays from consultants

LACTATE

“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

“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

AAA

EtiologyAtherosclerosisFamilial

Risk FactorsSmoking, Age, HTN, Atherosclerosis, FHx,

COPD, Male sex

Age > 55 Mortality > 50% with rupture

AAA

Clinical presentationHypotensionAbdominal pain/Back, Flank painPulsatile abdominal mass

Asymptomatic until ruptureSyncopeSigns of shockVital sign abnormalitiesWeaknessSigns of peripheral embolic events

AAA

DiagnosticsLab abnormalities

○ Low H/HImaging

○ 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

MESENTERIC ISCHEMIA & AAA

Unique to elderly populations High mortality (> 50%)

THE CHALLENGE… High index of suspicion Image liberally Involve consultants early

TUMORS, TWISTS, AND TELESCOPES

GI Tumors15-18% of elderly patients sent home with diagnosis

of nonspecific abdominal pain10% will have dx of GI tumor within one year

VolvulusSigmoid/Cecal volvulusSymptoms/Signs of obstruction

IntussuceptionOccurs in the elderly as well as pediatricsOften associated with tumors

VOLVULUS

5-10% of obstruction Hx of chronic constipation Populations at risk

NH patientsPsych patients (mental health facilities)Neuro patientsElderly

Clinical presentation Dx—plain film often diagnostic Tmt—decompression, often surgery required

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

“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

“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

“MY BELLY HAS BEEN HURTING FOR 5 DAYS”

12.4 Bands 7

11.5 200

133 108 20

155 UA 5-9 WBC

3.8 23 1.5

APPENDICITIS

5% of acute abdominal pain in elderly Higher rate of complications

5 times higher rate of perforationIncreased mortality

Atypical presentation is typical Delay in diagnosis is common

CHOLECYSTITIS

Most common cause abdominal surgery Acalculous & Calculous

Cholecystitis/Cholelithiasis/Cholangitis Early surgical intervention is key Higher mortality rate Higher rate of complications

Perforation Gangrene Sepsis Emphysematous cholecystitis/Ascending cholangitis/Gallstone ileus Pancreatitis

PANCREATITIS

Most common cause nonsurgical cause of abdominal pain

Increased mortality rate

Increased complication rate

DIVERTICULITIS

Increased prevalence with age WBC and VS often normal Complications

AbscessBowel obstructionFree PerforationSepsisFistula formation

PERFORATED VISCUS

Can occur from all cause of abdominal pain

Peptic ulcer diseaseIncreased incidence with NSAIDSComplications

○ GI bleed○ Perforation○ Obstruction○ Penetration into nearby organs

BOWEL OBSTRUCTION

Small bowel obstructionAdhesionsHerniasTumors

Large bowel obstructionTumorsDiverticulitisVolvulus

EXTRA-ABDOMINAL CAUSES

Acute coronary syndromes Aortic dissection Congestive heart failure Pulmonary embolus Pneumonia Pleural effusions Metabolic causes GU/Pelvic pathology

APPYS, STONES, TICS, PERFS, & BLOCKAGES

Present atypically in elderly populations Higher mortality

THE CHALLENGE… Recognize atypical presentations Be aware of increased rate of complications If in doubt, consult or admit

DISPOSITION

AdmitToxicAbnormal vital signsPersistent pain/vomiting

Discharge CriteriaThorough H & P completedNon-toxic Normal vital signsNormal imagingImproving abdominal examGood 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