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Abdominal Pain in Elderly Persons


The evaluation of elderly patients presenting with abdominal pain poses a difficult challenge for the emergency physician. It will become an increasingly common problem because the elderly population in the United States is growing rapidly. The definition of elderly varies among authors, but for the purpose of this subject, age 60 years is a reasonable starting point.

Studies published in the 1980s and 1990s demonstrated that, among elderly patients presenting to the ED with abdominal pain, at least 50% were hospitalized and 30-40% eventually had surgery for the underlying condition. These studies also showed that approximately 40% of these patients were misdiagnosed, contributing to an overall mortality rate of approximately 10%. The image below illustrates an inflammatory mass of an elderly woman with a ruptured appendix.

Inflammatory mass in the right lower quadrant of a

Inflammatory mass in the right lower quadrant of an 84-year-old woman with mild abdominal pain of 2 days’ duration. A ruptured appendix was found at surgery.

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In the period of time since the last of these studies was published, the availability and accuracy of emergency diagnostic techniques have improved dramatically. Computed tomography and ultrasonography were not widely used in most EDs before the mid 1990s. Today, it is relatively rare for a patient with significant abdominal pain to leave the ED without some type of advanced imaging. Diagnostic accuracy and presumably short-term mortality very likely have improved since the bulk of the studies on this subject were published. In fact, two newer studies showed that CT scanning significantly improved the certainty of diagnosis and altered therapy in elderly patients.
Even though imaging has improved diagnostic accuracy, the risk for adverse outcome in this patient population remains high. The only studies published since the widespread use of advanced imaging showed that nearly 60% were hospitalized, and, in the following 2 weeks, 20% underwent surgery and 5% died.

Multiple factors contribute to the diagnostic difficulty and high incidence of complications seen in elderly patients. Immune function tends to decrease with advancing age. Many elderly patients have underlying conditions such as diabetes or malignancy, further suppressing immunity. Elderly patients often have underlying cardiovascular and pulmonary disease, which decreases physiologic reserve and predisposes them to conditions such as abdominal aortic aneurysm (AAA) and mesenteric ischemia. Elderly patients also have a high incidence of asymptomatic underlying pathology. Up to one half of elderly patients have underlying cholelithiasis, one half have diverticula, and 5-10% have AAA.

Understanding that elderly patients may present very differently than their younger counterparts also is important. Elderly patients tend to wait much longer to seek medical attention than younger patients, and they are much more likely to present with vague symptoms and have nonspecific findings on examination. Many elderly patients have a diminished sensorium, allowing pathology to advance to a dangerous point prior to symptom development. Elderly patients with acute peritonitis are much less likely to have the classic findings of rebound tenderness and local rigidity.
They are less likely to have fever, leukocytosis, or elevated C-reactive protein level. In addition, their pain is likely to be much less severe than expected for a particular disease.

Because of these factors, many elderly patients with serious pathology initially are misdiagnosed with benign conditions such as gastroenteritis or constipation. They also are at greater risk of being admitted to the wrong service (eg, internal medicine when a surgeon may be required).

A careful history and physical examination as well as a high index of suspicion are crucial to prevent missed diagnoses.

Mortality varies greatly depending on the underlying pathology. Approximately 30-40% of patients require surgery, and overall mortality is approximately 10%.

For patient education resources, see Digestive Disorders Center, as well as Abdominal Pain (Adults), Appendicitis, Diverticulitis (Diverticulosis), Gastroenteritis (Stomach Flu), Constipation (Adults), and Blood in the Urine.

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