Abdominal Pain Among Older Adults

M. Bachir Tazkarji, MD, CCFP

Disclosures

Geriatrics and Aging. 2008;11(7):410-415. 

In This Article

Differential Diagnosis

Acute abdominal pain can be categorized in multiple methods. The most common method is by dividing the causes into two main categories, such as surgical versus nonsurgical pain, and intra-abdominal versus extra-abdominal causes.

Biliary disease is the leading reason for acute abdominal surgery among older adults. The mortality rate for emergency cholecystectomy is four times higher than for an elective cholecystectomy. The risk for complications in older adults has been always high. Complications may include gallbladder perforation, gangrene, emphysematous cholecystitis, ascending cholangitis, gallstone ileus, choledocholithiasis, and gallstone-induced pancreatitis.[6]

Older adults who have cholecystitis have symptoms of right upper quadrant or epigastric pain with tenderness over the gallbladder. Other signs may be absent—more than half of older adults who have acute cholecystitis have no nausea or vomiting, and half also lack fever. Older adults have an increased likelihood of acalculous cholecystitis. A radionuclide (hepatobiliary iminodiacetic acid scan [HIDA]) scan should be ordered in cases with negative findings on ultrasonography, combined with a high clinical suspicion for cholecystitis. Delayed surgical treatment is associated with increased morbidity and mortality.[7]

Appendicitis is common in middle age; however, it is also the third most common indication for abdominal surgery in the older adult population. The mortality rate in the general population is <1%, whereas among older adults it ranges from 4-8%. Older adults account for half of all deaths from appendicitis.[8]

Older adults with appendicitis tend to present late, and symptoms are atypical. Twenty percent of older adults who have appendicitis present after 3 days of symptoms, and another 5-10% after 1 week of symptoms.[9] Classic symptoms of fever, anorexia, right lower quadrant pain, and leukocytosis are seen in <30% of older patients. So, nearly half of patients are afebrile, half demonstrate no rebound or involuntary guarding, and nearly one quarter have no right lower quadrant tenderness at all. Early surgical consultation should be obtained in suspicious or equivocal cases because delays in diagnosis lead to an increased risk for perforation, with resultant increases in morbidity and mortality.

Hernias and adhesions from prior surgeries are the most common causes of small bowel obstruction (SBO). The symptoms of SBO are usually typical. Abdominal pain, distension, and vomiting commonly are seen, accompanied by constipation. Diarrhea may be present because of hyperperistalsis distal to the obstruction. It remains the second most common condition (behind appendicitis) to be inappropriately discharged home. The mortality rate for SBO in the older adult population remains high at 14-35%. Although plain radiographs may show SBO, abdominal CT is more sensitive and may lead to the definitive cause of the obstruction.

Large Bowel Obstruction

Large bowel obstruction (LBO) is usually caused by cancer, diverticulitis, or volvulus. It is less common than SBO. The classic description is abdominal pain, severe constipation, and intractable vomiting. However, nearly 20% of older adults have diarrhea, and only half report constipation or vomiting. The mortality rate of nearly 40% is mainly due to late diagnosis. Volvulus causes only 15% of cases of LBO but is more likely to require emergent surgical intervention. Symptomatology depends on the site of the volvulus. Sigmoid volvulus accounts for nearly 80% of cases and tends to present with a more gradual onset of pain. Virtually all cases of cecal volvulus require operative repair, whereas selected cases of sigmoid volvulus can be managed nonoperatively by decompressing the bowel with a rectal tube placed by way of a sigmoidoscope (Figure 1).[10]

Figure 1.

Large Bowel Obstruction: Volvulus

Pancreatitis

Pancreatitis remains the most common nonsurgical abdominal condition in the older adult population. The incidence of pancreatitis increases 200-fold after the age of 65 years. Similar to most other abdominal conditions, the mortality rate among older adults is much higher than for younger adults, approaching 40% after the age of 70 years.[11] The presentation among older adults is varied. It may present classically with a boring pain radiating to the back that is associated with nausea, vomiting, and dehydration. About 10% of cases of pancreatitis in older adults may present initially with hypotension and altered mental status. A CT scan should always be performed in an older adult with pancreatitis, especially if there are signs of impending sepsis.

Peptic Ulcer Disease

Pain is the presenting symptom in 50% of older adults with peptic ulcer disease. Complications are perforation, hemorrhage, gastric outlet obstruction, and penetration into an adjacent viscous.

Rigidity is absent in nearly 80%.[12] Free intraperitoneal air seen on plain radiographs is absent in 40% of patients who have perforation. When it is present, it is often best visualized on a lateral film, which frequently is not obtained. The mortality of perforation in the general population is approximately 10%, whereas in the older adult population it is 30% and increases eightfold if the diagnosis is delayed by 24 hours.

Hemorrhagic complications of peptic ulcer disease are also more common in older adults and more often require surgery and blood transfusions.

Diverticular Disease

Diverticular disease increases in prevalence with age. The incidence is approximately 50% among individuals older than age 70 years and 80% after age 85 years. Diverticular disease typically manifests as lower gastrointestinal bleeding or diverticulitis.

The classic findings of nausea, dis-tension, fever, palpable left lower quadrant mass, and leukocytosis are frequently absent. As with many other conditions in this population, leukocytosis may be lacking in a large number of cases. Irritation of the bladder or ureter by the inflamed diverticulum may induce pyuria or hematuria and result in the erroneous diagnosis of nephrolithiasis or urinary tract infection. Diverticulitis may in turn result in abscess formation, bowel obstruction, free perforation, or fistula and may be a cause of overwhelming sepsis.

Diverticulosis is the most common etiology of lower gastrointestinal bleeding among older adults, and it may result in massive bleeding. Unfortunately, it is misdiagnosed 50% of the time.[13] Abdominal and pelvic CT scans can usually help with the diagnosis. Early diverticulitis and early appendicitis may be missed by CT scan.

Vascular Catastrophes

Ruptured Abdominal Aortic Aneurysm. Ruptured AAA remains the 13th leading cause of death in the U.S. The mortality is extremely high. Although the diagnosis is fairly straightforward for the older adult who has abdominal pain, hypovolemic shock, and a pulsatile abdominal mass, this is the exception rather than the rule. Hypotension is absent in nearly 65% of cases, presumably because of tamponade in the left retroperitoneal space. Atypical presentations are common, and the misdiagnosis rate is as high as 30-50%.

Individuals who have a ruptured AAA often have back pain radiating toward the groin; this is associated with microscopic hematuria caused by irritation of the ureter by the AAA. As a general rule, any older adults presenting with symptoms of new-onset nephrolithiasis should have an evaluation of their aorta to detect AAA. This can be accomplished using ultrasonography or noncontrast CT scan, which is often used to diagnose renal colic. Conditions that are mimicked by ruptured AAA include renal colic, diverticulitis, lower gastrointestinal bleed (from an aortoenteric fistula), and acute coronary syndrome (if the patient presents with syncope). Any patient who has had a previous aneurysm repair and who presents with gastrointestinal bleeding must be considered to have an aortoenteric fistula until proven otherwise. Delayed diagnosis increases mortality. The diagnosis of AAA should be considered for any patient who has syncope or hypotension in combination with abdominal or back pain.

Treatment decisions should be based on the stability of the patient. Early consultation with a vascular surgeon in suspected cases of AAA is essential. High-suspicion cases should be transferred to operating room emergently.

Advanced age is not a contraindication for repair. Mortality rates do not differ significantly with age, and AAA rupture is uniformly fatal without surgical treatment.

Mesenteric Ischemia. Acute mesenteric ischemia is one of the most difficult diagnoses to make. It requires a high index of suspicion, coupled with the willingness to image suspected cases aggressively. It presents as severe abdominal pain out of proportion to the physical examination and may be associated with vomiting and diarrhea. Typically the patient has risk factors for embolic disease, such as atrial fibrillation or valvular disease. Patients who have superior mesenteric artery thrombosis typically have a long history of pain after meals (intestinal angina) and may report "food fear" and a subsequent weight loss.

The physical examination is often benign. Abdominal tenderness, peritoneal signs, and bloody stools are absent early in the course until transmural necrosis develops. No specific laboratory studies have been found to date. Aleukocytosis is generally present, as are some degree of metabolic acidosis and elevated lactate. Hyperamylasemia frequently is seen, but clinicians should not be confused with a diagnosis of pancreatitis.

Angiography remains the gold standard. The early, aggressive use of angiography is the only step that has been shown to reduce overall mortality from mesenteric ischemia.[14] Treatment of acute mesenteric ischemia is primarily surgical, although there have been studies investigating intra-arterial thrombolytics, vasodilators, and angioplasty.[15,16]

Extra-abdominal Causes. Older adults who have abdominal pain often have causes for their pain located outside of the abdominal cavity. The most important is acute myocardial infarction (MI). Older adults who have acute MI frequently lack chest pain. Nearly one-third of women older than age 65 years have abdominal pain as their presenting symptom of acute MI.[17] Abdominal pain also may accompany other cardiac causes, such as decompensated heart failure, pericarditis, and endocarditis.

Pulmonary etiologies, including lower lobe pneumonias or pulmonary emboli, also may cause abdominal pain. Pleural effusions, empyemas, and pneumothoraces can mimic intra-abdominal conditions. Endocrine conditions, such as diabetic ketoacidosis, hypercalcemia, and adrenal crisis, may result in nonspecific abdomen pain. Herpes zoster, porphyria, medication effects, and gynecological or genitourinary conditions are additional etiologies to consider.

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