Elderly Patients With Abdominal Pain: Tricky in the ED

An Expert Interview With Joseph P. Martinez, MD

Laird Harrison

February 17, 2012

February 17, 2012 — Editor's note: Elderly patients with abdominal pain can be difficult to diagnose in the emergency department (ED) because their symptoms are different than those of younger patients.

A presentation on abdominal pain in the elderly was featured at the American Academy of Emergency Medicine 18th Annual Scientific Assembly, held February 8 to 10, in San Francisco, California.

Medscape Medical News interviewed presenter Joseph P. Martinez, MD, assistant professor of emergency medicine at the University of Maryland School of Medicine, in Baltimore, about the best approach to the elderly patients who present with abdominal pain in the ED.

Medscape: Do elderly patients have different signs and symptoms than younger patients presenting with abdominal pain?

Dr. Martinez: They don't present with fever and vomiting. They don't present as early. But you have a 70% [gastrointestinal] perforation rate. So by the time they present to the ED, they may already have a ruptured appendix. The important thing is to have a high index of suspicion for this disease. If they have their appendix, you really have to look for this diagnosis. Get a CT [computed tomography] scan. Get a surgical diagnosis.

Medscape: What are some of the most challenging causes of abdominal pain that bring elderly patients to the ED?

Dr. Martinez: Mesenteric ischemia, ruptured abdominal aortic aneurysm, and appendicitis all pose special challenges.

Medscape: How prevalent and how serious is mesenteric ischemia?

Dr. Martinez: Mesenteric ischemia accounts for 1 in 1000 hospital admissions and 1 in 100 admissions for abdominal pain. If you can catch it early, you can drop the mortality rate from 70% to 10%.

Medscape: How can you catch it early?

Dr. Martinez: When you take patient histories, and they had mesenteric ischemia in the past, it makes it more likely to be mesenteric ischemia. Pain after eating is another clue. If you think about it, when you eat, that's a stress test for the intestines.

Another risk factor for mesenteric ischemia is smoking.

There is a form called mesenteric venous thrombosis. If patients have venous problems, they can have symptoms for a long time — 1 or 2 weeks — some people's radar goes down for this.

Medscape: What sort of imaging is helpful for mesenteric ischemia?

Dr. Martinez: You can diagnose it fairly readily with a CT scan. Once you have taken a history, you can stratify the patient as high, medium, or low risk of mesenteric ischemia. Angiography is appropriate for the high-risk patients. For medium- and low-risk patients, you can do a CT angiogram.

Medscape: What are the tricks to detecting ruptured abdominal aortic aneurysms?

Dr. Martinez: We can all make the diagnosis in the cases that are pretty classic: abdominal pain, hypovolemic shock, and a pulsatile mass.

But it's very rare that you have the classic symptoms. Hypotension is often absent. The most common misdiagnosis is renal colic. The condition can also be mistaken for a kidney stone. Any elderly patient with symptoms of nephrolithiasis should have an evaluation of the aorta to detect abdominal aortic aneurysms.

For almost any elderly patient who comes in presenting with abdominal pain, throwing on an ultrasound to look at the size of the aorta will help catch some of these cases and reduce the mortality.

Medscape: What's tricky about appendicitis in the elderly?

Dr. Martinez: You usually think about this occurring in kids. Only 14% or 15% occur in the elderly, but they account for about half of all deaths from appendicitis.

Medscape: Do elderly patients have different signs and symptoms than younger patients with appendicitis?

Dr. Martinez: They often don't present with fever and vomiting. Nearly a quarter have no right lower quadrant pain. Nor do they don't present as early. Up to a fifth of elderly patients with appendicitis don't present until they have had symptoms for 3 days.

A recent study at one institution found that the admitting diagnosis was incorrect in 54% of elderly patients with appendicitis. The perforation rate was nearly 70%. By the time they present to the ED, they may already have a ruptured appendix.

The important thing is to have a high index of suspicion for this disease. If they have their appendix, you really have to look for this diagnosis. Get a CT scan. Consider a surgical consultation. Several studies have shown decreased morbidity and mortality with rapid diagnostic laparotomy as opposed to watchful waiting.

Medscape: Overall, it sounds like you have to react quickly to abdominal pain in this population.

Dr. Martinez: Elderly patients with abdominal pain are a very high-risk population. They have a pretty high mortality rate and a high morbidity rate. No matter how well they look when they hit the door, you should look at them as ticking time bombs.

Dr. Martinez has disclosed no relevant financial relationships.

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