abdominal pain in the elderly Flashcards
Elderly population abdominal pain
acute abdominal pain remains complex
the mortality rate is 10%
remain 20% longer
consume more time and resources
50% need admission
33% need surgical intervention
Presentation:
present later than younger patients
vascular disease is prevalent
polypharmacy
elderly population abd pain physical exam
vitals appear normal
normothermic or hypothermic
examine for surgical scars
rigidity and guarding less seen
less abdominal muscle mass
absent up to 80% perforated ulcers
consider other etiology
lower low pna
CHF with hepatic congetion
Acute MI
1/3 of female with abdominal pain
afib
risk of acute mesentric ischemia
abdominal aortic aneurysm clinical findings
a leading cause of death
mortality 70%
oftern misdiagnosed as renal colic
majority of ruptured space
intraperitoneal of left retroperitoneal space
clinical findings
abdominal pain, hypotension, and pulsatile abdominal mass
ecchymosis of the toe : emboli thrombus
abdominal flank groin ecchymosis
work up of AAA
diagnosis depends
on stability:
consult vascular surgery
unstable patients
direct to OR
Stable patients:
Under open vs endovascular
mesenteric anatomy review
Mesentery :
attaches to the intestine and abdominal wall
aides in storing fat
supplies blood vessels, lymphatics and nerves to intestine
blood flow to abdominal organs
Superior mesenteric artery blood supply:
pancreas
portion of stomach
small intestine ( duodenum< <jejuinum < and ileum
portions of large bowel
inferior mesenteric artery blood supply:
transverse
decending
sigmoid
mesenteric ischemia
very high mortality
challenging diagnosis and treatment
four types:
superior mesenteric artery embolus
sma thrombosis
mesenteric venous thrombosis
non occlusive mesenteric ischemia (nomi)
sma embolus SMA
most common
etiology:
afib
clinical presentation
acute abdominal pain
gut emptying
vomiting a diarrhea
misdiagnoses as gastrentritis
1/3 of hx of embolic event
SMA thrombosis
simular patho of ACS
turbullent flow at SMA
risk factors
hx of athersclerosis and smoking
limiting flow
interstitial angina
80% with previous
post pradial abdomianl pain
food fear and weight loss
ruptured plaque
abrupt blood flow reduction
symptoms comparable to SMA embolus
Acute mesenteric ischemia venous thrombosis
not as common
occur in younger pt
hx of hypercoagulable state
50% personal or family hx of venous thromboembolism
indolent symptoms
onset days to weeks
difficult dianosis
non occlusive mesenteric ischemia
Low flow state etiology:
sepsis
volume depletion
cardiogenic shock
transient hypoperfusion
dialysis
digoxin use
ICU patients:
abdominal distentipn and gi bleeding
workup for mesenteric ishcemia
Pain out of proportion to the physical exam:
clinical evaluation and vascular imaging
determine vascular intervention
occlusion embolic or thrombotic
Labs:
Cbc bmp, lac acid, amylase
leukocytosis, metabolic and lactic acidosis
Plain radiography imaging:
early features show thumbprinting
bowel edema
ischemia progression
pneumonitis intestinal
Mesenteric duplex imaging:
80% positive pred value
rule out neg with duplex
body habitis limits images
mesenteric ischemia treatment
ICU admit
vitals
abdominal pain
urine output
ABG
lactate
medical attention
NPO, NGT
iv fluid
avoid vasopressors
anticoagulation
empiric antibiotics
PPI
supplemental 02
mesenteric ischemia surgical plan
mesenteric angiography
gold standard
reduce mortality
goal of vascular intervention’
resect compromised bowel[
restore the flow of blood
treatment plan
depends on clinical status
etiology and location of occlusion
open vs endovascular vs combined
surgical treatment plan for mesenteric ischemia
Arterial Embolis:
laparotomy with assessment of viability
resection of dead bowel
vascular bypass
embolectomy
Arterial Thrombosis:
endarterectomy
thrombectomy
vascular bypass
angioplasty and stenting
mesenteric venous thrombosis
catheter-directed thrombolysis
non occlusive messentaric ischemia
labarotmomy
intestinal obstrucion
extent of intestional obstrucion:
80% small bowel
1/3 significant ischemia
partial vs. high grade vs complete
simple vs. strangulated ( vascular insufficiency and intestinal ischemia)
mechanical ( blockage or intestinal dysmotility) vs. Functional ( no blockage)
extrinsic disease with bowel obstruction
most common cause of small intestine obstruction
post-operative adhesions
herniations of the anterior abdominal wall
carcinomas ( carcoinmotisis originates in female patients from ovaries, pancreas, or stomach wall)
intrinsic bowel obstruction
congenital
inflammatory
neoplastic
traumatic
volvulus: when the bowel twists on the mesenteric axis: sigmoid affected. Risk factors are psychotropic medication, chronic constipation, and advanced age
common insults to colon
2/3 of cases are cancer of the descending colon and rectum
diverticulitis and volvuls
rare for adhesion or hernias obstruct
intesintal obstrucion complicaions;
Emesis and dehydration:
intravascular volume depletion
loss of gastric potassium hydrogen and chloride
bowel wall hypoxemia
epithelial necrosis;
12 hours of abstruction
full-thickness ischemia necrosis and perforation
compromised arterial blood supply
bowel staisi increases bacterial growth
ecoli strepococcus and klebsiella
closed loop obstuction ;
strangulation
vascular insuffenciy
systematic inflammation
hemodynamic compromise
irreversivle intesinal ishcemia
bowel obstruction clinical findings
cardinal signs:
colicky abdominal pain abd distention emsis and constipation
Classic bowel sounds:
early sbo = high-pitched ada borborygmi
absent or hypoactive is later in the course
partial obstruction:
pass flatus and stool
complete:
evacuate bowel contents downstream
severe pain and peritoneal irritation
strangulation
closed loop obstruction
fever
strangluation or systemic inflammation
bowel obstruction work up
CBC, CMP, and LA
high WBC association
severe volume depletion from ischemic necrosis
hypokalemia, hypochloremia, elevated BUN/Creatine ratio, metabolic alkalosis
hyponatremia
obtain occult stools and Fe+studies
abnormal suggest malignancy
imaging
abdominal x-ray
CT scan PO/IV contrast
identify ischemia
CT post water soulable contrast media
illeus vs pseudo-obstruction
contrast enemas or colonoscopys
identify causes of acute colonic obstruction
large and small bowel obstrucions
Large less common: underlying is an age-dependent common cause of cancer in sigmoid or acute diverticulitis.
small bowel obstucion :
bowel obstrucion treatment plan
fluid rescission and electrolyte repletion
intenstinal decompression
NGT
antibiotics:
controversial
prophlaic adm for surgery
monitor I and O
ileus
peripheral active opioid receptor antagonist ( alvimopan)
accelerates GI recovery
colonic pheudo obstructions:
acetylcholinesterase inhibitor ( neostigmine)
need cardiac monitoring
sigmoid volvulus
decompressed with flex sigmoid
allows definitive correction
cecum volvulus
lapartomy or laparosdcopic correction
