Geriatric Abdominal Pain

Educational Objectives

The goal of this program is to improve clinical outcomes in geriatric patients with abdominal pain. After hearing and assimilating this program, the clinician will be better able to:

1. Identify common causes of abdominal pain in the geriatric population.
2. Explain limitations of laboratory tests and urinalysis.
3. List difference in presentation between geriatric and younger patients.

Summary

Background: geriatric patient is any patient ≥65 yr of age; with geriatric patients that have abdominal pain presenting in the emergency department or to emergency medical services, or walk-ins, mortality is 10% to 14%; patients present in unusual fashions, present late, and have comorbid disease, often missed on initial presentation; a patient may present with, eg, appendicitis, followed by, eg, a heart attack, pneumonia, resulting in morbidity and mortality; abdominal pain is the fourth most common complaint for presentation; vague presentations (eg, weakness, dizziness, fatigue) are common; history or aspects of the examination may be misleading; in patient >80 yr of age, literature shows mortality is doubled if there is delay in initial diagnosis

Presentation in geriatric vs younger patients: geriatric patients — present later in the disease; they avoid hospital visit by waiting; they are more likely to have hearing, speech, or vision issues (makes the history unreliable); presentation is vague; there is more comorbid disease; they are less likely to have fever or be tachycardic; as a consequence of these factors, they have higher mortality; nongeriatric patients — they come in earlier, have more localized presentation, less comorbid disease, and are more likely to have fever or be tachycardic; because of these factors they are more likely to come to diagnosis more quickly and have lower mortality; challenges with diagnosis — geriatric patient with abdominal pain is more likely to have increased mimics of intra-abdominal pathology (ie, they have pathology outside of the abdominal cavity referring pain to the abdominal cavity); negative computed tomography (CT) can be falsely reassuring; strongly consider admission, especially if concerned before obtaining CT; elderly patients are more likely to ascribe their symptoms to a benign etiology

Six pearls: 1) in order to produce peritoneal signs, muscle mass is required; abdominal pain evaluation in geriatric patients who have surgical disease is much less likely to produce an expected peritoneal examination when catastrophe in the abdominal cavity suspected; 2) core temperature should be considered; as patients get older their hypothalamus lowers their normal body temperature; ≤40% of patients who have fever would be diagnosed afebrile assessing only oral temperature; 3) patients are more likely to be on medications that affect their ability to mount tachycardia; they are more likely to be on nonsteroidal anti-inflammatory drugs (NSAIDs; these can mask fever and increase likelihood of peptic ulcer disease and upper gastrointestinal bleed) or chronic steroids (masking fever and increasing likelihood of bowel perforation and infectious etiologies); 4) do not expect leukocytosis in geriatric patient with abdominal pain; 5) numerous factors can refer pain to abdomen, eg, pneumonia, heart failure, pulmonary embolism, pneumothorax, empyema, cardiac pathologies (most important); study in 2004 looked at women ≥75 yr of age with cardiac pathology; 45% who presented with ST-elevation myocardial infarction had no chest pain; the only symptoms were gastrointestinal in nature; important to consider ordering electrocardiography for any geriatric patient presenting with abdominal pain; 6) in addition to geriatric status, patients may be immunocompromised; this adds to the complexity of their evaluation; novel immunosuppressants (eg, increased use of checkpoint inhibitors), can change presentation and increase the risk of infectious complications; other immunocompromised conditions (eg, diabetes, alcoholism, cirrhosis) should be considered

Biliary disease: most common cause of acute abdominal surgery in the geriatric population; ≤50% of patients do not have nausea or vomiting, fever is absent in many patients, and leukocytosis is absent in ≤50% of patients with acute biliary disease; 50% of cases of pancreatitis in this age group are associated with gallstones, increasing the value of CT imaging

Peptic ulcer disease (PUD): NSAIDs users are 5 to 10 times more likely to develop PUD; more common pathology in geriatric demographic; likelihood increases if NSAIDs are combined with corticosteroid; patient >70 yr of age has 14-fold higher risk of bleeding from peptic ulcers, and 100-fold higher risk of mortality, compared with patient <40 yr of age; CT is the diagnostic modality of choice if perforation from PUD suspected

Appendicitis: 50% of geriatric patients have diagnosis of appendicitis missed on initial encounter with health care system; <20% of geriatric patients have the classic presentation of the appendicitis (triad of fever, right lower quadrant [RLQ] pain, and leukocytosis); 25% have no RLQ pain with appendicitis

Less common causes of abdominal pain in geriatric patients: diabetic ketoacidosis could be a consequence of intra-abdominal pathology; make sure to look for signs of herpes zoster virus infection, especially if the pain is described in the dermatomal distribution; urinary retention, more common in geriatric population, causes abdominal pain

Limitations of blood laboratory tests in geriatric patients with abdominal pain: lack of sensitivity and specificity for leukocytosis for intra-abdominal pathology; elevated lipase is nonspecific and can be seen in any intra-abdominal pathology; lactic acid, often used as adjunctive test for mesenteric ischemia, is neither sensitive nor specific

Limitations of urinalysis (UA): not recommended to review or order UA before examining the patient; elderly patients, especially women, are more likely to have asymptomatic bacteriuria (≤20% if they live in community, 50% if they live in long-term care facility, and guaranteed if they have indwelling catheter); if the patient is septic and this is ascribed to genitourinary source, consider CT

CT imaging: risk of radiation minimal; in 2004 study, 104 patients with mean age of 75 yr, having abdominal pain; after CT, 25% had altered admission decision, 23 of 72 expected to be admitted were then discharged, and 4 of 32 expected to be discharged were admitted; 6 patients had been planned to go to operating room prior to CT, and 4 were not found to have surgical pathology; 10 patients were found to have surgical pathology after CT, and 8 of these were not suspected to have surgical pathology prior to CT; malignancy found in 5, perforated viscus in 2, biliary tract disease in 1, renal colic in 2, and diverticulitis in 2

Disposition: CT may be the most valuable adjunctive test that can be performed in geriatric patient with abdominal pain; if initial presentation was concerning, observational stay may be warranted for the patient before discharging

Questions and Answers

Value of lactic acid in the evaluation of mesenteric ischemia: literature would suggest lactic acid is elevated late in the process of mesenteric ischemia; patient already likely has end organ damage; these patients have very high operative mortality once they start having end organ damage

Imaging with intravenous (IV) contrast in geriatric patients with abdominal pain and underlying renal insufficiency: incidence of contrast-induced nephropathy and the patient-centered outcome of morbidity and mortality are likely overestimated; strongly consider giving patients IV contrast even if they have renal insufficiency because of the effectiveness in finding vascular pathology

Acceptability of discharge of geriatric patients with abdominal pain after negative CT: if extremely concerned about the patient because of vital signs, laboratory abnormalities, or comorbid conditions, it is not recommended to discharge the patient because the CT is negative; there is a higher likelihood of missing nonabdominal pathology, so bringing them in for observation for 24 hr is reasonable, especially because comorbidities mount in these patients

Readings

Gardner CS et al. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. doi:10.1007/s00261-015-0419-7; Leuthauser A, McVane B. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(2):363-375. doi:10.1016/j.emc.2015.12.009; Miettinen P et al. The outcome of elderly patients after operation for acute abdomen. Ann Chir Gynaecol. 1996;85(1):11-15; Reyner K et al. Urinary obstruction is an important complicating factor in patients with septic shock due to urinary infection. Am J Emerg Med. 2016;34(4):694-696. doi:10.1016/j.ajem.2015.12.068.

Disclosures

For this program, members of faculty and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Perkins was recorded for Audio Digest, on June 10, 2020, using teleconferencing. Audio Digest thanks the speakers and the Larner College of Medicine at The University of Vermont for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM380403

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.