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Abdominal Pain in the Elderly

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Abdominal Pain in the Elderly

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    1. Abdominal Pain in the Elderly 75 yo M presents from a nursing home History of dementia, CVA with R hemiparesis, and Parkinsons disease Chronically constipated, but worse over the past week, now has abdominal pain, vomiting and lethargy. Other questions?

    2. Abdominal Pain in the Elderly Vital signs 100.9, 124, 101/48, 22, 97% RA Physical examination = Distended abdomen, diffusely tender and tympanitic, with high-pitched bowel sounds. No stool in vault. What is your differential diagnosis and treatment plan?

    3. X Ray

    4. Diagnostic Workup Are any further diagnostic tests necessary? No. In sigmoid volvulus, the diagnosis can often be made by plain radiograph and further imagery could delay treatment. Cecal volvuli can be more difficult to diagnose and may require barium enema, CT scan or even laparotomy for proper diagnosis.

    5. Treatment What is the treatment of choice? ABCs NGT, NPO, IVF, analgesics, anti-emetics PRN For uncomplicated patients Sigmoidoscopy with volvulus reduction or Regular or barium enema and colonoscopy/rectal tube Operative treatment is required for patients with signs or symptoms of perforation, bleeding, shock, infection, failed initial treatment, or signs of gangrene on sigmoidoscopic exam.

    6. Disposition Which patients with a volvulus should be admitted to the hospital? All of them. Even uncomplicated sigmoid volvuli that are resolved with an enema, sigmoidoscope, or rectal tube tend to recur as often as 90%. Elective resection is recommended, usually during the same hospitalization.

    7. Teaching Points What is the pathophysiology of a volvulus? An axial twist of a portion of the GI tract on its mesentery Some genetic predisposition occurs

    8. Teaching Points What conditions predispose patients to sigmoid and/or cecal volvuli? Advanced age (sigmoid) Institutionalization (sigmoid) Neurologic diseases such as CVA, Parkinsons, seizure disorder, multiple sclerosis Psychiatric disorders Systemic diseases such as autonomic dysmotility of DM

    9. Teaching Points What are some other factors that increase the elderly patients risk of developing a volvulus? Chronic constipation Medications such as laxatives, anticholinergics, tranquilizers, ganglionic blocking agents, and antiparkinsonians Adhesions from prior surgeries

    10. References Simmons W: Volvulus, in Meldon S (ed): Geriatric Emergency Medicine. New York, McGraw-Hill, 2004.

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