Matthews, P. J. Q Aziz Functional Abdominal Pain. Post Graduate Medical Journal. 2005Simplified diagram showing the major pain pathways from the viscera to the central nervous system. Note the inclusion of the dorsal columns whose role in visceral pain perception is becoming increasingly recognised. pACC, perigenual anterior cingulate cortex; MCC, midcingulate cortex.As well as the ascending pathways a number of descending inhibitory pathways play a part in the perception of normal visceral sensation. The origin of the pathways is the opioid rich ACC and from here inhibitory signals are conveyed to the periaqueductal grey either directly or via second order neurones from the amygdala. Other midbrain regions where synaptic connections are made include the locus coeruleus and rostral ventral medulla. Third order opioidergic, serotoninergic and second order noradrenergic neurones connect to the dorsal horn neurones where they “gate” or modulate ascending visceral afferent signals
1. Abdominal Pain in the
Prepared by Lasonya A. Fletcher
Emergency Medicine Clerkship
• Discuss the major causes of abdominal pain in the
• Explore the physiological changes in the elderly
that pose a challenge to diagnosis and
management of abdominal pain.
• Briefly describe the major causes of abdominal
pain in the elderly
• Abdominal pain is the presenting symptom in a wide range of
diseases in elderly patients.
• The pathophysiology of abdominal pain in the elderly is similar to
that of the rest of the population, however it is observed that the
perception and reporting of pain is altered in the elderly.
• Ageing is associated with a number of factors that affect the
spectrum of abdominal conditions seen in this population
4. Picture Credits: Matthews, P. J. Q Aziz Functional Abdominal Pain. Post Graduate Medical Journal. 2005
6. Who is considered ‘Elderly’?
• Most countries define elderly as being age 65
• Chronological age of 60 (World Assembly on
• National council for Senior Citizens, Jamaica
define elderly as over age 65
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"The ageing process is of course a biological reality which has its
own dynamic, largely beyond human control. The age of 60 or 65,
roughly equivalent to retirement ages in most developed countries, is
said to be the beginning of old age.
- Gorman, 2000
8. Physiological Changes in the Elderly that Affect
Diagnosis and Management
allowing pathology to
advance to dangerous
point prior to symptom
Immunity; may have
such as diabetes or
Treatment issues of
Underlying CV and
pulmonary disease 
physiologic reserve &
predisposes to AA and
High incidence of
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9. Elderly Patients:
• tend to wait longer before seeking medical
• are more likely to present with vague
symptoms and on examination tend to have
• usually have a less pronounced muscular
response to pain.
• may be unable to adequately describe the
• tend to be more stoic in their response to
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• Approximately 4.5% of elderly (>65 yrs) visits to the hospital were
for abdominal pain.1
• More than 50% or elderly reporting for abdominal pain had to be
admitted; about one third required surgical intervention during
• Mortality depended on underlying pathology; overall mortality
• Some causes may vary by race due to the incidence of
predisposing diseases. 2
• Diagnostic accuracy decreases and mortality increases with
1. Tintinallis, J ‘Abdominal Pain in the Elderly’ Emergency Medicine 6th ed. Pg 541; 2. Abdominal Pain in the Elderly, Medscape.
Table: Influence of Aging on Abdominal Pain (Tintinallils)
Clinical Features: History
• Obtaining a full history
is important in elderly
patients but not always
possible due to various
dementia and stroke.
• Time of onset and course of the pain
• Sudden or gradual onset
• Location, quality, and severity of pain
• Radiation (eg, to back, groin, shoulder)
Clinical Features: History
• Aggravating or precipitating factors
(eg, food, position, medication)
• Palliative factors
• Prior similar episodes
• Ability to pass stool or flatus
• Detailed Review of Systems
should be taken to seek out
other causes of abdominal pain
such as cardiopulmonary
• Do a careful review of
medications including OTC
analgesics and natural
14. Clinical Features: History
Past medical and surgical history may be able to provide clues as
to the diagnosis. Information to elicit include:
• Cardiovascular disease (hypertension, coronary artery
disease, atrial fibrillation, peripheral vascular disease)
• Previous abdominal surgery
• Smoking history
• Alcohol use
• NSAID use
15. Clinical Features: Physical Examination
• Physical examination of the elderly done in a similar way
as in younger persons.
• May be complicated by stoicism or inability to report
• Observe general appearance (ill-looking etc.) and vital
signs (esp. important in AAA)
• Inspection and auscultation (rule out intestinal
• Abdominal palpation (may not produce findings typical of
underlying condition e.g. abdominal wall rigidity)
16. Clinical Features: Physical Examination
• Routinely do rectal examination
and investigation for fecal occult
• Perform careful inspection for
hernias (e.g. femoral canal in
• Examine heart and lungs for
possible non-abdominal cause of
17. Clinical Features: Physical Examination
• By system: Vital signs – tachycardia and hypotension may
be a sign of ruptured AAA or septic shock
• Cardiovascular – Acute MI may present with epigastric
pain; signs of diminished cardiac output, atrial
fibrillation may indicate mesenteric ischemia
• Gastrointestinal – bowel sounds (high pitched in SBO),
palpable mass *elderly may not present with classic
muscular signs of peritoneal irritation.
• Genitourinary – pelvic and rectal examinations
18. Case A
• A 26 y-o male presents with a 14 hour history of mild pain in
the right lower quadrant while eating, followed by severe
pain. He now presents to the emergency department with
severe abdominal pain,anorexia, nausea and a low-grade
19. Case B
• An 85-year-old man presented to the ED with a 3
day history of moderate lower quadrant abdominal
pain. There was a history of nausea but no
vomiting. On examination, the patient’s vital signs
were found to be normal with a slight hypothermia.
Abdominal examination elicited mild tenderness in
the right lower quadrants. Rebound tenderness and
guarding were absent.
 This is a medical emergency characterized by the
inflammation of the appendix.
 Untreated, the mortality is high due to rupture and
perforation of the organ and eventual sepsis.
 Presents with pain, fever and vomiting and pain tends to
be localized in the right lower quadrant.
 The abdomen becomes sensitive to palpation and may
exhibit rebound tenderness
21. APPENDICITIS IN THE ELDERLY
 Less common cause of abdominal pain in elderly patients than in
 Rate of perforation is higher in the elderly than young adults as
older persons tend to seek medical help later.
 Diagnosis can be difficult as many patients in this age group do not
present with leukocytosis or fever.
 A number of patients do not localize pain to the right lower
 A quarter of elderly persons do not have appreciable right lower
22. ACUTE CHOLECYSTITIS IN THE ELDERLY
 This is the sudden inflammation of the gallbladder which causes severe
 This is the most common surgical emergency in older patients with
 Classic findings (right upper quadrant or epigastric pain and radiation to
the back) are similar in the elderly to those in the young adult.
 Associated symptoms are nausea and vomiting, and in a small population,
 In some elderly patients, there is fever, altered mental status and jaundice
23. SMALL BOWEL OBSTRUCTION IN THE ELDERLY
 This diagnosis is usually straightforward in the older patient.
 Characteristically there is colicky pain, distention, and vomiting
that progresses from gastric contents to bile-stained to feculent.
 The most important risk factor for SBO is previous surgery.
 Mortality rate for SBO  14-45%
24. PERFORATED PEPTIC ULCER IN THE ELDERLY
 This condition most frequently presents as gastrointestinal bleeding,
perforation is an important cause of abdominal pain in the older patient.
 Half of the patients however, will not present with the typical sudden
 There are generalized pain or lower-quadrant symptoms
 Vomiting is not normally present.
 On examination there is epigastric tenderness. However, in the the elderly,
muscle guarding is variable
 Plain radiographs and CT may show the presence of free air under the
diaphragm which indicates perforation.
25. LARGE BOWEL OBSTRUCTION
 The leading cause of large bowel obstruction is carcinoma present
in the bowel followed by volvulus and diverticulitis.
 Overall mortality is approx. 40%
 Patients often present with distension, vomiting and constipation
and less commonly diarrhea.
 There may be a history of rectal bleeding, altered bowel habits, or
weight loss which my indicate underlying carcinoma.
26. LARGE BOWEL OBSTRUCTION
 Pain is gradual in onset but may be acute, severe and colicky in
 Sigmoid volvulus: cecal volvulus  2.3:1
 Risk factors for sigmoid volvulus in the elderly include inactivity
and laxative use.
 Plain abdominal radiography is often used to make the diagnosis.
 Distension of the colon >9cm can signal impending perforation.
 Diverticula form in the colon largely as a product of diet and age and
are rarely found in persons under the age of 40.
age # of diverticula risk of diverticulitis
 Diverticulitis results when the diverticula become obstructed by fecal
matter lymphatic obstruction  inflammation and perforation
 Elderly patients are often afebrile and less than 50% present with an
elevated white cell count. Even less present with guaic-positive stool
28. ACUTE MESENTERIC INFARCTION
 Accounts for <1% of cases of abdominal pain in the elderly.
 Complicated by diagnostic delays and often has a fatal outcome (70-
 Patients present with severe abdominal pain, gradually increasing in
intensity but have little tenderness on physical exam.
 Vomiting and diarrhea are often present
 The key to making the diagnosis is to consider it a possibility in an
elderly person with abdominal pain and risk factors
29. ACUTE MESENTERIC INFARCTION
 Classically, the superior mesenteric artery is occluded by an embolus
or thrombus. Low flow states also cause infarction
 Other causes of this condition include occlusion of the inferior
mesenteric artery, venous thrombosis and arteritis.
 Occasionally patients may present with recurrent episodes of
postprandial abdominal pain (intestinal angina)
30. ACUTE MESENTERIC INFARCTION
 Major Risk Factors : ASCVD, atrial fibrillation and low ejection fraction.
Risk Factors for Mesenteric Ischemia (Tintinallis, J Emergency Medicine 6th ed. Pg 544)
31. ABDOMINAL AORTIC ANEURYSM
 Seen almost exclusively in elderly patients.
 M:F 7:1
 Dx in hemodynamically stable patient  mortality -
 Dx in hemodynamically unstable patient 
mortality – 80%
 Favorable outcome depends on rapid diagnosis
and early surgical intervention
32. ABDOMINAL AORTIC ANEURYSM
 Most common symptom is abdominal pain followed by back
pain. Pain is said to be sudden and severe
 Pain may be felt in the hips, inguinal area, and external
 The patient may present with syncope and hypotension.
 Examination findings may include palpation of a tender
enlarged aorta (>5cm)
33. ABDOMINAL AORTIC ANEURYSM
 Management of the unstable patient with a clinically
suspected ruptured abdominal aortic aneurysm
involves immediate operative intervention without
 Supine plain radiograph may reveal a clue to diagnosis
such as a calcified aortic outline or loss of renal or
 If patient is stable, ultrasound may be used to delineate
size and CT can give information on rupture.
34. OTHER CAUSES
 Aortic dissection is common in the elderly and may cause abdominal pain
directly or by causing ischemia of intraabdominal organs, including the bowel.
 The diagnosis of pancreatitis in this age group is generally straightforward.
 Tumors may provide lead points for intussusception in elderly patients.
 Acute gastric volvulus should be considered in the older patient with sudden
epigastric pain, repetitive nonproductive retching, and inability to pass a
 Older patients with underlying vascular disease may develop ischemic colitis,
which can be difficult to distinguish from other forms of colitis.
 Also, consider almost all other chest and genitourinary conditions as possible
causes of abdominal pain in the elderly.
 Underlying pathology where identified should addressed in the appropriate
 An elderly patient with undifferentiated abdominal pain should be observed for
a period of time and subjected to serial abdominal examinations.
 If the patient has severe or worsening pain, they should not be sent home.
 If pain resolves while in the emergency department, and the patient is not
assessed to be in any immediate danger, the patient should be sent home for
follow-up with a primary care provider
 They should also be instructed to return to the ED should symptoms worsen
or do not resolve within a brief period of time.
 If there is vomiting after discharge, re-evaluation is warranted.
• Matthews, P. J. Q Aziz Functional Abdominal Pain. Post Graduate
Medical Journal. 2005
• Tintinallis, J ‘Abdominal Pain in the Elderly’ Emergency Medicine
6th ed. Pg 541;
• Abdominal Pain in the Elderly, Medscape.