The Emergency Management of Abdominal Pain in the Elderly Geriatric Grand Rounds April 3rd, 2001

1. The Emergency Management of Abdominal Pain in the ElderlyGeriatric Grand RoundsApril 3rd, 2001 Dr. Richard Lee MD, CCFP(EM), FRCPC Assistant Professor, Emergency Medicine University Of Alberta

2. Objectives To introduce the topic of the emergency management of abdominal pain in the elderly To review some diagnostic challenges when dealing with this issue in clinical practice To review certain key disease entities that cause abdominal pain in the elderly

3. Outline Introduction The Challenge of Diagnosis

4. Outline Specific disease entities Biliary Tract Disease Appendicitis Abdominal Aortic Aneurysm Ischemic Bowel Mechanical Obstruction

5. Outline Extra-abdominal sources of pain Abdominal pain NYD Summary Questions

6. Introduction Elderly comprise 13% of society Fastest growing segment of population By the year 2030, elderly will comprise 20% of our population

7. Introduction Over-represented in health care utilization Present more often Stay longer Get more investigations

8. Elder vs. Non-Elder ED Utilization

9. Introduction 1 in 10 ED visits for abdominal pain 50-63% (versus 10%) require admission 22-42% (versus 16%) require surgery

10. Introduction Emergency physicians find it more difficult and time consuming to manage abdominal pain in elderly Mortality higher (up to 70X) Diagnostic accuracy lower (~50%)

11. Mortality Compared to Agewith Abdominal Pain

12. Diagnostic Accuracy Compared to Age with Abdominal Pain

13. The Challenge of Diagnosis History confounded by stoicism alterations in pain perception memory deficits communication problems mental status changes

14. The Challenge of Diagnosis Ensure adequate time to take a history Assess cognitive functioning of patient Collaborate history with family, nursing home attendants, etc.

15. The Challenge of Diagnosis Physical exam unreliable 79% will not have rigidity with peritonitis 56% will be afebrile with acute cholecystitis

16. The Challenge of Diagnosis Physical exam must be complete and include all potential hernia sites, the abdominal aorta, the rectum and pelvis if indicated. Only 5.1% of female elderly patients had a pelvic exam, 72.9% of which were abnormal

17. The Challenge of Diagnosis Ancillary testing unreliable 61% of elderly requiring surgery will have a WBC <10,000 40% with a perforated ulcer will not have free air on X-ray Ancillary testing may DELAY diagnosis

22. The Challenge of Diagnosis Do not rely on traditional ancillary testing to rule out disease Other imaging techniques such as CT and ultrasound must be used liberally

23. Biliary Tract Disease 50% of >80 year olds will have gallstones (compared with 9% of 30-40 year olds) Most common cause of surgery in elderly

24. Biliary Tract Disease Diagnosis of acute cholecystitis usually straightforward BUT 16% will have no epigastric or RUQ pain 5% will have no pain at all 41% will have a normal WBC 13% will be afebrile with all lab tests normal Ultrasound diagnostic 91%

25. Appendicitis Elderly account for 5-10% of cases but >50% of deaths from appendicitis 1/3 present late (>72 hours) 72% present with perforation or gangrene Misdiagnosed 50% on admission and 30% at time of surgery

26. Appendicitis Only 20% have classic presentation of anorexia, fever, RLQ pain, high WBC >25% of plain X-rays consistent with another diagnosis CT or graded compression ultrasound may be helpful

27. Abdominal Aortic Aneurysm 6% prevalence in >80 year old group Typical presentation of rupture includes Hypotension (70-96%) Abdominal pain (70-80%) Back pain (>50%)

28. Abdominal Aortic Aneurysm Misdiagnosed 31% of time DESPITE classic findings Key finding is an enlarged, tender aorta

29. Abdominal Aortic Aneurysm Late diagnosis increases mortality from 5% to 50-100% Beware of renal colic symptoms in elderly labeling hypotension as vagal atypical location of abdominal pain

30. Abdominal Aortic Aneurysm Supine flat plate superior to cross table lateral Ultrasound 98% sensitive for leaking AAA CT with contrast useful in stable patient

33. Ischemic Bowel Severe, visceral pain out of proportion with physical exam in a patient with risk factors Pain can be absent 25% of the time Hard signs = TOO LATE! Early angiography = 90% survival Anticipate delays by consultants!

34. Ischemic Bowel CAUSE SMA embolus SMA thrombosis Venous thrombosis Non-occlusive RISK FACTOR A Fib, recent MI CAD, low flow states Hypercoaguable states Low CO (CHF, sepsis, digoxin, hypovolemia)

35. Mechanical Obstruction May result from adhesions, hernias, appendicitis, malignancy, volvulus, diverticulitis or AAA Delayed surgery increases complication rate by 250%

36. Extra-Abdominal Sources of Pain Cardiac ischemia 40% of patients >85 years will have chest pain with an acute MI

37. Symptom Prevalence in Acute Myocardial Infarct Related to Age J Am Geriatr Soc. 1986;34:263-266

38. Extra-Abdominal Sources of Pain Pneumonia, Pulmonary Embolism Metabolic HyperCalcemia Addison�s Diabetic Ketoacidosis Glaucoma et al Do not limit work up to GI system

39. Abdominal Pain NYD Be very careful of sending an elder patient home without a diagnosis for their abdominal pain <20% of elderly will have a diagnosis of Abdominal pain NYD (vs >40% in young) 10% of these will be diagnosed with a GI malignancy in one year

40. Summary Abdominal pain in the elderly is a difficult and dangerous disease that must be aggressively investigated and managed Clinical and ancillary data are less useful and may be misleading Must maintain a high level of suspicion

41. Questions? Thank You!