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EMERGENCY CARE FOR THE ELDER WITH ABDOMINAL PAIN Module # 3

EMERGENCY CARE FOR THE ELDER WITH ABDOMINAL PAIN Module # 3. Ed Vandenberg MD CMD Geriatric section OVAMC & Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512 updated 11-20-06 Adapted from Bill Lyons, M.D. &

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EMERGENCY CARE FOR THE ELDER WITH ABDOMINAL PAIN Module # 3

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  1. EMERGENCY CARE FOR THE ELDER WITH ABDOMINAL PAINModule # 3 Ed Vandenberg MD CMD Geriatric section OVAMC & Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512 updated 11-20-06 Adapted from Bill Lyons, M.D. & (from R. M. McNamara, M.D. for SAEM)

  2. PROCESS Series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

  3. OBJECTIVES Module 3 • Describe the presentations and diagnostic approach to: • Other diagnostic possibilities of acute abdominal pain in this population

  4. REVIEW OF CASE 70 yo male with Diffuse Abdominal pain X 4 d and syncope today. Appearance: pale, diaphoretic, VS BP 96/70 HR 110 RR 22 T 37.6, SaO2 95% RA Aorta not enlarged or tender NEW DATA ON CASE After IVF, supine BP 118/72 HR 100 ECG  borderline sinus tach, but no acute process apparent EXAM Decreased bowel sounds Mild tenderness throughout, somewhat greater in lower abdomen Not rigid; mild increased muscle tone in lower abdomen Aorta non-tender and normal in size Jar bed &/or rock pelvis mild discomfort Normal femoral pulses, back, skin, heart, lungs, rectal; no hernias CASE UPDATEFrom last module

  5. DIFFERENTIAL DIAGNOSIS • What diagnostic possibilities should be considered for this patient?

  6. DIFFERENTIAL DIAGNOSIS *Major life threats • Ruptured AAA* • Acute mesenteric ischemia* • Myocardial ischemia/MI (ACS)* • Dissecting aneurysm*

  7. DIFFERENTIAL DIAGNOSIS ADDITIONAL Ddx • Appendicitis • Diverticulitis • Cholecystitis • Perforated PUD • Obstruction (SBO, LBO) • Pancreatitis • Abscess

  8. Lab CBC w diff UA BMP LFT Amylase/lipase Cardiac enzymes Results WBC 7.5, Segs 70% (43-77%) Bands 11% (0-10%) Lymphs 17% (15-45%) Hgb (12.5), Platelets: 180,000 U/A: nitrite neg 2-5 WBC/hpf, no bld Electrolytes ( N), BUN (55),Cr (1.2) Glu (101), Osm ( 289) Normal Normal CK 150, Trop; < 0.3 What lab tests do you want now?

  9. Bedside Abd. Ultrsd CXR/Abd series CT abdomen Sorry, your radiology dept or the hospital won’t let you have it ( you do it anyway) Result; Normal aorta Neg CXR, Abdominal film: distended loops of SB with AFL, No free air Sorry, radiology can’t do it until ?????– “backed up” What imaging tests do you want now?

  10. CASE UPDATE • Diagnosis: SBO • Treatment: NG suction and IVF • Next day: • Temp 40C, WBC 16, 000, bands 16% • Abdominal exam more rigid • CT scan  abscess in lower abdomen

  11. CASE DEVELOPMENT • Findings at surgery were? ruptured gangrenous appendix • Prolonged post-op course • Discharged to SNF after a 22 days hospital stay.

  12. Appendicitis and the Aged (1), (2), (3) • Classic symptoms……….20% • PE: • Rebound tenderness…. < 50% • Lab : • Leukocytosis…………..< 42.9% •  T. Bilirubin…………… 16% • Xray. • Ileus, SBO, Gallstones or renal calculi • 25%

  13. Perforation is present in: 42-62% of patients despite operations within? 6 hours  12 hours  24 hours  36 hours  48 hours  End of question  Appendicitis and the Aged (It gets worse!!)(4)

  14. Why early perforation 4), (5), (6) ? (1) Atrophy of intraluminal lymphioid tissue 2) Thinning of the appendiceal wall 3) ASCVD reducing blood supply 4) Narrowed lumen 5) Immune dysregulation 6) Late presentation 7)Atypical symptoms that delay diagnosis Or could it be? We elders like to “harass” youngers The real answer: Lack of reserve gives us less time to reactThe BAD NEWS: Mortality: 2-32% Morbidity 48% Appendicitis and the Aged

  15. How to make the diagnosis sooner Ultrasound: sensitivity 80% specificity 95% CT(particularly useful in mentally confused, obese or immunosuppressed who lack localized symptoms) Education of referring health care practitioners to consult sooner on non-specific abdominal pain or sepsis without origin in the elderly. Best outcomes in Acute abdominal pain elderly: Early CT abd. and experienced surgeon consulted

  16. How to make the diagnosis sooner High index of suspicion in situations with less impressive symptoms than in younger patients. Rely more on clinical impression and knowledge of aging physiology than on laboratory tests.

  17. INSTRUCTIONS ON E.D. DISCHARGE for Abdominal pain with negative work up • Return if pain worsening • Return if pain or vomiting > 6-8 hours • Return if cannot take in or keep down PO • Share instructions with another person

  18. Diverticulitis and Age Incidence: Diverticula: in 25% of 60-70 y.o. In 40% of > 70 y.o. Morbidity: -more frequent perforations than in younger patients -shorter more rapid course of disease Mortality: with perforation age > 65 y.o. = 17%

  19. What percent of those age > 70 have gallstones? 40%  50%  70%  85%  ✔ Cholecystitis and Cholangitis

  20. Cholecystitis and Cholangitis Biliary tract disease is the most common abdominal problem leading to surgery in the aged Symptoms of acute cholecystitis in the aged: Afebrile 33% Nontender 25% Without leukocytosis 33%

  21. Cholecystitis and Cholangitis Difficulties in judging severity: When surgeon perceived a decrease in severity of illness: 40 % of the patients had: -empyema of gallbladder or gangrenous cholecystitis or perforation

  22. The classic “Charcot’sTriad” (fever, jaundice and abdominal pain) found in what percent of patients?) 1) 30-50% 2) 55-70% 3) 70-90% Answer: 55-70% Sooner than classic triad the elderly will present with: -Mental confusion -Hypo tension Creating: Reynold’s pentad: fever, jaundice and abdominal pain plus -Mental confusion -Hypotension Acute Cholangitis

  23. SUMMARY • Acute abdominal pain more often serious in elders – greater mortality and need for surgery • Red flags: -upper abdominal pain, ill appearance, abnormal VS • Syncope, hypotension, back or flank pain should alert you to possible AAA rupture

  24. SUMMARY, cont. • History often confounded, ask other informants • Look for subtleties on PE • Consider mesenteric ischemia: in a. fib, atherosclerotic disease, CHF and other low output states, hypercoag states • Appendicitis can be very atypical in elders • Low threshold to obtain abdominal CT

  25. Thank you for Your kind Attention !! Ed Vandenberg MD CMD Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu

  26. Post test • A 70-year-old white woman with a history of hypertension and obesity presents to her primary care physician for follow-up care. During her visit, she reports that approximately 1 month ago she had two episodes of severe, sharp, localized, right upper quadrant pain that lasted for 1 hour and spontaneously resolved. The pain was associated with nausea, vomiting, and a decreased appetite. There was no fever, chills, jaundice, or change in bowel habits. She has had no other similar episodes. • Physical examination is significant for blood pressure 120/84 mm Hg, regular heart rate, anicteric sclera, clear lungs, benign abdomen without guarding, tenderness, or rebound, and guaiac-negative stool. Laboratory studies show normal hematocrit, leukocyte count, electrolytes, and liver enzymes. Ultrasound examination demonstrates a gallbladder with two small gallstones, a partially calcified gallbladder wall, and no biliary ductal dilatation. • What is the most appropriate management for this patient? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

  27. What is the most appropriate management for this patient? • Observation • Administration of ursodiol • Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy • Cholecystectomy

  28. Answer; D. Cholecystectomy Cancer of the gallbladder has the greatest incidence in persons who are aged 65 years and older. It is three times more common in women than in men, and it is more common in white than in black Americans. In the United States, gallbladder cancer is the most common malignancy in Native Americans. Factors associated with gallbladder malignancy include genetics, gallstone disease, calcification of the gallbladder wall, bile composition, environmental carcinogens, infections (Salmonella

  29. The signs and symptoms of gallbladder cancer are nonspecific and can resemble biliary cholic or cholecystitis. The lack of specific indicators for cancer may result in a delay in diagnosis and treatment. Pain is the most common initial complaint. However, the pattern of pain is variable. Other associated symptoms include nausea, vomiting, anorexia, and weight loss. Patients may also present with jaundice, hepatomegaly, a palpable mass, or ascites. • Laboratory findings are not diagnostic. When there is local extension of the malignancy into the biliary tree, there can be increased alkaline phosphatase and bilirubin levels. Tumor markers (ie, CEA, CA 19-9) may be elevated but are not diagnostic.

  30. A number of imaging studies (eg, ultrasonography, computed tomography scan, magnetic resonance imaging scan) have been used to diagnose gallbladder malignancy. The most widely used diagnostic study is the ultrasound. Findings on ultrasonography can include thickening of the gallbladder wall, gallbladder mass, and calcification of the gallbladder. Partial or complete calcification of the gallbladder wall (“porcelain gallbladder”), as in the patient in this case, is associated with malignancy.

  31. Surgical intervention, the most appropriate management for this patient, is the only treatment that can result in a cure. However, 80% of the patients with gallbladder cancer are found to have unresectable disease at the time of cholecystectomy. Age should not deter referral for surgical intervention. Chemotherapy remains experimental and does not improve survival. Radiotherapy provides little benefit for survival. • The other listed management options represent inadequate interventions for a potential malignancy: observation with treatment for recurrent symptoms, administration of ursodiol (ursodeoxycholic acid), and ERCP with sphincterotomy. end

  32. References • Horattas MC, Guyon DP, Wu D. A reappraisal of appendicitis in the elderly. Am J Surg 1990 Sep;160(3):291-293. • Owens BJ, Hamit HF. Appendicitis in the elderly. Ann Surg 1978 Apr;187(4):392-396. • Watters JM, Blakslee JM, March RJ, et.al. Can J Surg. 1996 Apr;39(2):142-146. • Kraemer M, Franke C, Ohmann C, et.al. Acute appendicitis in late adulthood: incidence, presentation, and outcome. Results of a prospective multicenter acute abdominal pain study and a review of the literature. Langenbecks Arch Surg. 2000 Nov;385(7):470-481. • Burns RP, Cochran JL, Russell WL. et.al. Ann Surg 1985 Jun;201(6): 695-704. • Morrow DJ, Thompson J, Wilson SE. Acute cholecystitis in the elderly: a surgical emergency. Arch Surg 1978 Oct;113(10):1149-1152.

  33. References -Balsano N, Cayten CG. Surgical emergencies of the abdomen. Emerg Med Clin North Am 1990 May;8(2):399-410. -Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Engl J Med 2003 Jan16;348(3):236-242. -Singal BM, Hedges JR, Rousseau EW, et.al. Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients. Ann Emerg Med 1992 Jul;21(7):802-807. -Elangovan SE. Clinical and laboratory findings in acute appendicitis in the elderly. J Am Board Fam Pract 1996 Mar-Apr;9(2):75-78. -Hall A, Wright TM. Acute appendicitis in the geriatric patient. Am Surg. 1976 Gebp;42(2):147-150. -Lau WY, Fan ST, Yiu TF. Acute appendicitis in the elderly. Surg Gynecol Obstet 1985 Aug;161(2):157-160. -Rosenthal RA, Zenilman ME, Katlic MR. Principles and Practice of Geriatric Surgery, 2000. Springer-Verlag NY, Inc.

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