abdominal pain in the elderly

Question 1

Elderly population abdominal pain

Answer 1

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

Question 2

elderly population abd pain physical exam

Answer 2

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

Question 3

abdominal aortic aneurysm clinical findings

Answer 3

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

Question 4

work up of AAA

Answer 4

diagnosis depends
on stability:
consult vascular surgery
unstable patients
direct to OR

Stable patients:
Under open vs endovascular

Question 5

mesenteric anatomy review

Answer 5

Mesentery :
attaches to the intestine and abdominal wall
aides in storing fat
supplies blood vessels, lymphatics and nerves to intestine

Question 6

blood flow to abdominal organs

Answer 6

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

Question 7

mesenteric ischemia

Answer 7

very high mortality
challenging diagnosis and treatment
four types:
superior mesenteric artery embolus
sma thrombosis
mesenteric venous thrombosis
non occlusive mesenteric ischemia (nomi)

Question 8

sma embolus SMA

Answer 8

most common
etiology:
afib
clinical presentation
acute abdominal pain
gut emptying
vomiting a diarrhea
misdiagnoses as gastrentritis
1/3 of hx of embolic event

Question 9

SMA thrombosis

Answer 9

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

Question 10

Acute mesenteric ischemia venous thrombosis

Answer 10

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

Question 11

non occlusive mesenteric ischemia

Answer 11

Low flow state etiology:
sepsis
volume depletion
cardiogenic shock
transient hypoperfusion
dialysis
digoxin use
ICU patients:
abdominal distentipn and gi bleeding

Question 12

workup for mesenteric ishcemia

Answer 12

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

Question 13

mesenteric ischemia treatment

Answer 13

ICU admit
vitals
abdominal pain
urine output
ABG
lactate

medical attention
NPO, NGT
iv fluid
avoid vasopressors
anticoagulation
empiric antibiotics
PPI
supplemental 02

Question 14

mesenteric ischemia surgical plan

Answer 14

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

Question 15

surgical treatment plan for mesenteric ischemia

Answer 15

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

Question 16

intestinal obstrucion

Answer 16

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)

Question 17

extrinsic disease with bowel obstruction

Answer 17

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)

Question 18

intrinsic bowel obstruction

Answer 18

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

Question 19

common insults to colon

Answer 19

2/3 of cases are cancer of the descending colon and rectum
diverticulitis and volvuls
rare for adhesion or hernias obstruct

Question 20

intesintal obstrucion complicaions;

Answer 20

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

Question 21

bowel obstruction clinical findings

Answer 21

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

Question 22

bowel obstruction work up

Answer 22

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

Question 23

large and small bowel obstrucions

Answer 23

Large less common: underlying is an age-dependent common cause of cancer in sigmoid or acute diverticulitis.

small bowel obstucion :

Question 24

bowel obstrucion treatment plan

Answer 24

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