Acute Abdomen

Question 1

Challenge of dx acute abdomen in elderly - hx and physical?

Answer 1

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

Question 2

Why isn’t ancillary testing reliable?

Answer 2

• 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

Question 3

Why is acute abdomen so common in the elderly?

Answer 3

• diff anatomical factors: poor blood supply to thinner appendix predisposing to perforation and gangrene
• mult abdominal diseases: gallstones, diverticulosis, atherosclerosis

Question 4

MC cause of abdominal operations in elderly?

Answer 4

• 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

Question 5

How is biliary tract disease dx in elderly?

Answer 5

• 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%

Question 6

How common is appendicitis in the elderly? Presentation?

Answer 6

• 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

Question 7

Presentation of acute pancreatitis?

Answer 7

• 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

Question 8

Acute diverticulitis presentation? what can this lead to?

Answer 8

• 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

Question 9

Why are peptic ulcers so common in elderly? Presentation?

Answer 9

• 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)

Question 10

How common is a AAA in elderly? presentation?

Answer 10

• 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

Question 11

Testing for AAA?

Answer 11

• US 98% sensitive for leaking AAA

- CT w/ contrast useful in stable pt

Question 12

Presentation of an ischemic bowel? Tx?

Answer 12

• 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

Question 13

Causes and RFs for ischemic bowel?

Answer 13

• 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 )

Question 14

What could cause a mechanical obstruction?

Answer 14

• may result from adhesions, hernias, appendicitis, malignancy, volvulus, diverticulitis, or AAA
• delayed surgery increases complication rate by 250% in some studies