Acute Abdomen Flashcards
Challenge of dx acute abdomen in elderly - hx and physical?
hx confounded by:
-stoicism
-alterations in pain perception
- memory deficits
- communication problems
- mental status changes
- physical exam unreliable:
80% won’t have rigidity w/ peritonitis (no rebound tenderness)
50% will be afebrile w/ acute cholecystitis
(won’t have elevated WBC either)
- PE must be complete - include all potential hernia sites, abdominal aorta, the rectum and pelvis
- only 5% of female elderly pts had a pelvic exam, 70% of which were abnormal
- dx difficult b/c of unique factors
- less abdominal inflammtory response: less guarding/spasm, lower leukocytes count and lower and delayed temp
Why isn’t ancillary testing reliable?
- 60% of elderly requiring surgery will have WBC less than 10,000
- 40% w/ perforated ulcer will not have free air on x-ray
- ancillary testing may delay dx: other imaging techniques such as CT and US must be used liberally
Why is acute abdomen so common in the elderly?
- diff anatomical factors: poor blood supply to thinner appendix predisposing to perforation and gangrene
- mult abdominal diseases: gallstones, diverticulosis, atherosclerosis
MC cause of abdominal operations in elderly?
- biliary tract disease
- 50% of 80yo and up will have gallstones
- biliary colic is replaced by vague abdominal complaints
- in gallbladder perf (occurring primarily in elderly), only a 1/3 of pts have a hx or prior sx of gallstones
- common bile duct stones are found at time of cholecystectomy in 10% of younger pts, but over 50% of pts over 70
How is biliary tract disease dx in elderly?
- dx of acute cholecystitis usually straightforward but:
- 15% will have no epigastric pain or RUQ pain (neg murphys)
- 5% will have no pain at all (mental status changes?)
- 40% will have normal WBC
- 10% will be afebrile w/ all lab tests normal
- US dx 90%
How common is appendicitis in the elderly? Presentation?
- account for 5-10% of cases but over 50% of deaths from appendicitis
- 1/3 present late (over 72 hrs)
- misdx 50% on admission and 30% at time of surgery
- in a study done:
only 20% presented classically w/: nausea or vomiting, fever (38.6 degrees C), RLQ pain, elevated or shifted WBC - only 60%, 30%, 40% had RLQ pain, N/V and fever of over 37.6 degrees C
- 70% of pts had perforated appendicitis, 30% abscess formation
Presentation of acute pancreatitis?
- in the elderly - gallstones etiology is the most common
- as in young abdominal pain is major sx
- in 5-10% of cases, pain is absent
- pain may be vague, physical exam unremarkable
- non specific signs: tachycardia, hypotension, tachypnea, confusion
Acute diverticulitis presentation? what can this lead to?
- diverticulitis may occur in aggressive form
- phlegmonous inflammation, fistula to adjacent organs or skin, obstruction of colon (may not present w/ a lot of pain)
- many episodes subside, the pt has LLQ pain, tenderness, moderate abdominal distension and moderate temperature elevation
- get a CT scan
Why are peptic ulcers so common in elderly? Presentation?
- have sig higher risk to develop peptic ulcers and complications from NSAIDs ( and sphincter relaxation, less gastric motility, increased risk for H pylori)
- pain is absent in 1/3 of cases
- pain can be vague and poorly localized
- presenting sxs may be systemic and related to blood loss and anemia (falls and syncope)
How common is a AAA in elderly? presentation?
- 6% prevalence in over 80yo group
- typical presentation of rupture includes:
hypotension (70-96%)
abdominal pain (70-80%)
back pain (over 50%) - misdx 30% of time despite classic findings
- key findings is an enlarged tender aorta
- late dx increases mortality from 5% to 50-100%
- beware of:
renal colic sxs
labeling hypotension as vagal (do orthostatics)
atypical location of abdominal pain
Testing for AAA?
- US 98% sensitive for leaking AAA
- CT w/ contrast useful in stable pt
Presentation of an ischemic bowel? Tx?
- severe, visceral pain out of proportion w/ physical exam in pt w/ risk factors
- pain can be absent 25% of time
- hard signs = too late
- early angiography = 90% survival
Causes and RFs for ischemic bowel?
- SMA embolus: RF - a fib, recent MI
- SMA thrombosis: CAD, low flow states
- venous thrombosis: hypercoaguable states
- non-occlusive: low CO (CHF, sepsis, digoxin, hypovolemia )
What could cause a mechanical obstruction?
- may result from adhesions, hernias, appendicitis, malignancy, volvulus, diverticulitis, or AAA
- delayed surgery increases complication rate by 250% in some studies
