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  • 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

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  • 1. Abdominal Pain in the Elderly Prepared by Lasonya A. Fletcher Medical Student Emergency Medicine Clerkship October 2013
  • 2. Objectives • Discuss the major causes of abdominal pain in the elderly • 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
  • 3. Introduction • 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
  • 5. Abdominal Pain: Summary Picture Credits: http://Abdominalpainddx.org
  • 6. Who is considered ‘Elderly’? • Most countries define elderly as being age 65 and over. • Chronological age of 60 (World Assembly on Aging) • National council for Senior Citizens, Jamaica define elderly as over age 65 Picture credits: http://www.wallmonkeys.com/index.php?main_page=product_info&products_id=1367
  • 7. “ "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 Diminished sensorium, allowing pathology to advance to dangerous point prior to symptom development. Immunity; may have underlying conditions such as diabetes or malignancy, further suppressing immunity Treatment issues of altered pharmacodynamics and pharmacokinetics Underlying CV and pulmonary disease  physiologic reserve & predisposes to AA and mesenteric ischemia High incidence of asymptomatic underlying pathology. E.g. cholelithiasis, diverticulitis Picture Credits: http://www.fanpop.com/clubs/courage-the-cowardly-dog/images/20469219/title/courage-cowardly-dog-photo
  • 9. Elderly Patients: • tend to wait longer before seeking medical attention. • are more likely to present with vague symptoms and on examination tend to have nonspecific findings. • usually have a less pronounced muscular response to pain. • may be unable to adequately describe the pain. • tend to be more stoic in their response to pain Picture credits: http://www.wallmonkeys.com/index.php?main_page=product_info&products_id=1367
  • 10. Epidemiology • 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 their stay.1 • Mortality depended on underlying pathology; overall mortality 10%. 1,2 • Some causes may vary by race due to the incidence of predisposing diseases. 2 • Diagnostic accuracy decreases and mortality increases with increasing age.2 1. Tintinallis, J ‘Abdominal Pain in the Elderly’ Emergency Medicine 6th ed. Pg 541; 2. Abdominal Pain in the Elderly, Medscape. <http://emedicine.medscape.com/article/776663-overview#a0199>
  • 11. Pathophysiology Table: Influence of Aging on Abdominal Pain (Tintinallils)
  • 12. Hx Clinical Features: History • Obtaining a full history is important in elderly patients but not always possible due to various factors including dementia and stroke. Important Points • Time of onset and course of the pain • Sudden or gradual onset • Location, quality, and severity of pain • Radiation (eg, to back, groin, shoulder)
  • 13. Hx 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 causes. • Do a careful review of medications including OTC analgesics and natural remedies.
  • 14. Clinical Features: History Past medical and surgical history may be able to provide clues as to the diagnosis. Information to elicit include: • Diabetes • Cardiovascular disease (hypertension, coronary artery disease, atrial fibrillation, peripheral vascular disease) • Previous abdominal surgery • Smoking history • Alcohol use • NSAID use Hx
  • 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 pain. • Observe general appearance (ill-looking etc.) and vital signs (esp. important in AAA) • Inspection and auscultation (rule out intestinal obstruction) • Abdominal palpation (may not produce findings typical of underlying condition e.g. abdominal wall rigidity) O/E
  • 16. Clinical Features: Physical Examination • Routinely do rectal examination and investigation for fecal occult blood. • Perform careful inspection for hernias (e.g. femoral canal in females) • Examine heart and lungs for possible non-abdominal cause of pain. O/E
  • 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 O/E
  • 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 fever.
  • 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.
  • 20. APPENDICITIS  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 younger patients.  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 quadrant.  A quarter of elderly persons do not have appreciable right lower quadrant tenderness.
  • 22. ACUTE CHOLECYSTITIS IN THE ELDERLY  This is the sudden inflammation of the gallbladder which causes severe abdominal pain.  This is the most common surgical emergency in older patients with abdominal pain.  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, jaundice.  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 epigastric pain  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 cecal volvulus.  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.
  • 27. DIVERTICULITIS  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- 90% mortality)  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 - 25%  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 genitalia.  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 confirmatory testing.  Supine plain radiograph may reveal a clue to diagnosis such as a calcified aortic outline or loss of renal or psoas outline  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 nasogastric tube.  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.
  • 35. DISPOSITION  Underlying pathology where identified should addressed in the appropriate manner.  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.
  • 36. References • 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. <http://emedicine.medscape.com/article/776663overview#a0199>
  • 37. QUESTIONS?