Nu 735 GI Elderly Abdominal Pain Flashcards
Complicated Abd pain elderly ?
Abdominal pain elderly comples:
* Mortality rate 10%
* Geriatic > 9 fold young
* Longer ER 20%
* Consume more time, resources compare to others
* 33% urgen surgical interventions
Presentation elderly abd pain
- **Present letter **: creats problem
- Vascular Emergency AlWAYs 2nd DX
- **Polypharmacy: mask symptoms , alter VSS, constion, steroids
Vascular ER always 2nd DX
Elderly : Physical Assissment
- PHA : can be benigh at 1st
- VSS less reliable : Normothermi or Hypothermic
- Examine for scars, bruit, bruising
*** Riginity & Muschle tone : **
* due to less abd muschle mass ;
* Absent up to 80% perforated ulcers
Consider ETIOLOGY
- left Lower Lobe PNA
- CHF w hepatic congestion
- Acute MI : female pt abdominal pain
- Afib : RISK Messenteric Ischemia
Ruptured AAA :
**Clinical Findings **
- Leading cause of death :
- Mortality rate 70%
* Misdiagnosed as Renal Colic b/c overlap symtoms: - ** sym: pain radiating go groin, microscopic Hematuria**
- **New onset Kidney STONES after age 50: CT AORTA before D/C **
New onset Kidney STONES after age 50: CT AORTA before D/C
AAA
Majority of Rupture SPace
- Intraperitoneally OR
- Left Retroperioneal Space
*
AAA Rupture
**Clinical Findings **
- Abdominal Pain
- Hypotension
- Pulsatitile Abdominal MASS
- Ecchymosis of TOES: due to EMBOLI from Thrombus
**Rupture: **
**Abdominal pain ; flank pain , Groin Ecchymosis **
Ruptured AAA
< TX Plan >
Depends on Stability
Consult Vascular Surgery
* Unstable Pt: OR
*
*** STable or Suspacted
**CT w Contrast
Avoid Aggressive Volume Repletion
Consider Needs For TRansfusion
- *Surgical Needs: OPEN vs Endovascular repair up to surgen
Acute Mesenteric Ischemia
What is Mesenteric ? +Anatomy
- It Attaches the Intestinve to abdominal wall and Hold it in place
- Aids in Storing FAT
- Supply Blood Vessels, Lymphatics and Nerves to Intenes
* Blood Flow to Abdominal Organs via Splanchinic Perfusion (aka circulation )
**Types: Superior and Inverior **
Superior Messenteric Artery Blood Supply via blood bransches
- Pancreas
- Portion of Stomach
-
Small INtestines (Duodenum, Jejunum, Ilium
* Portion Large Bowel: Cecum, Ascending Colon , Proximal 2/3 of TRansverse Colon - Cecum: begining of Large intestine; connect illium to small intestine
- Ascending “ TRavels upward on RT side of abd
- Transverse: Crosses abdomen horizontally from rt to to left
Inferior Mesenteric Artery (IMA )
Comes off below abdominal Aorta and supply to
* Transvese other 3rd
* Descending (Down on the Left )
* Sigmoid : S shape connect Descending colon to Rectum
* Rectum
Superior Mesenteric Artery
SMA Embolus
- **Most common type **
- AFib : most common Ediology
- Any STATIS of Left Ventrical can lead to this
- MisDX as GAstroenteritis
SMA Embolus S/S
- **Acute Abdominal Pain
- Gut Emptying: V/D
- MisDX as Gasroenteritis **
- **Hx of Embolitic Event (collect hx) **
- OLD pt W > Afib > Diarrhea > Abdominal Pain - DO NOT DX them W GAstroenteritis
SMA/**Arterial THROMBOSIS **
Not Venous
- Similar Pathology to ACS
- Turbulent Flow at SMA Plaque Deposit
- R/F: Hx Smoking & Atherosclerosis
- Limited Blood Flow : due to stenosis > Intestinal Angina > Posrprandial Angina
80% previous Ishemia
- Limited Blood Flow : due to stenosis > Intestinal Angina > Posrprandial Angina
**Postrandial Abdominal Pain : Food fear and wt loss last month or year
- Rupture Plaguq:** Abrump blood flow reductio
s/s similar SMA embolus
Thrombus > Limited Blood Flow b/c Stenosis > Intestinal Angina as post P
Acute Mesenteric Ishemia
Messentieric Venour Thrombosis(MVT)
Not common
Occur younger cohor
HX: Hypercoagulatlable STATE
50% personal of family HX of venous Thromboembolism
Indolent Symptoms:
Symptoms onset days to weeks
Difficult to DX
Nonocclusive Mesenteric Ishcemia
* Low Flow Etiology >
* Sepsis
* Volume Depletion
* Cardiogenic shock
*** Transient Hypoperfusion **
Diallysis
Digoxin use
ICU pt:Abdominal distention pain + GI bleeding
Acute Mesenteric Ishemia
Work UP
Emolitic +Thombus > Out of Proportion Pain
* **Clinical eval & Vascular Imaging **
* Determine Vascular intervantion
* Occlusio Emolic and Thrombolic
* Labs:
* CBC (leukocytosis ) ; BMP, LA, Amylase (elevated )
*
* **Plain Imaging : ** Abdominal XRAY
* Early features show : Thumpring “ : Bowerl edema
* Ischemia Progerssion : Pneumatosis Intestinalis (Air Within a WAll
* Free Intraperitonea Air: Perforated Viscus (ER Exploration)
* **Messenteric Duplex Imaging (GET IT DONe ) **
* 80% possitive Predictive value of Mesenteric Ischemia
* R/O with negative duplex Messenteric Ischemia
* Body Habitus limits imaging . obese pt
*
Thumping on XRAy
Early features show . Bowel edema
Pneumatosis Intestinalis
- Ischemia Progerssion; Air Within a Wall
Perforated Viscus
Free Intraperitonea Air: ER Exploration
Acute Mesenteric Ischemia
Tx
***** ICU Admission
VS, Abdominal EXap, UO, ABG, Lactate
Medical Attention” **
NPO , NGT
IV Fluids (Isotonic Crystalloid IV Solution )
Avod if can Vasopressins
Anticoagulation : Antithrombotic therapy can be given with Antiplatelets
Empiric ABD : Gm negative Anarobs +MRSA
PPI**
O2
I/O
NOMI no caogulation
Acute Mesenteric Ishcemia
Surgical TX plan
- Messeteric ANgiography
- Gold Standard
- Reduce Mortality
- **Goal of Vascular Intevention **
- Reset comppromised Bowel
- Restore INtertinal Blood Flow
- **TX Plan
- **Depends on Clinical Status
- Etiology and location of occlusio
- Open vs Endovascular vs Combined approach determine by vascular surgen **
Acute Mesenteric Ishcemia
Surgical TX plan
Arterial Embolus
-
ARterial Embolus
* Done by small inscion in Artery where clot is restrive - Laparotomy With Assessment of Viability
- Resection of dead Bowel
- Vascular Bypass
- Embolectomy
Surgery
Arterial Thrombosis
- Endarterectomy
- Thrombectomy
- Vascular Bypass
- Thrombolysis
- Angioplasty and Stending usually W Chronic Eschemia most of time
