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What is the leading cause of the acute surgical abdomen in the elderly population?

What is the leading cause of the acute surgical abdomen in the elderly population?. Appendicitis Biliary tract disease Diverticulitis Peptic ulcer disease Pancreatitis.

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What is the leading cause of the acute surgical abdomen in the elderly population?

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  1. What is the leading cause of the acute surgical abdomen in the elderly population? • Appendicitis • Biliary tract disease • Diverticulitis • Peptic ulcer disease • Pancreatitis

  2. A 70-year-old patient with a history of diabetes and hypertension presents to the emergency department with syncope and severe sudden onset of low back pain. Vital signs: BP 80/50,P 120,R24,T37 C. The most appropriate initial diagnostic test is: • Angiogram • Ultrasonography • CAT scan of the abdomen • Magnetic resonance cholangiopancreatography (MRCP) • Supine obstruction series

  3. Which of the following statements is true regarding abdominal pain in the elderly? • White blood cell counts are specifically elevated in the acute abdomen. • Lactate elevations are not an early sign of mesenteric ischemia. • Lipase elevation is a specific test for pancreatitis. • Positive fecal occult blood testing is specifically useful. • Amylase elevation is a non-specific test for pancreatitis.

  4. Acute Geriatric Abdomen Wayne Tamaska, D.O., FACOI, FACOEP

  5. Acute Geriatric Abdomen This Care of the Aging Medical Patient in the Emergency Room(CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

  6. According to the US Census Bureau, one in eight Americans are elderly (over the age of 64). • By the year 2030, one in five Americans will be elderly. U.S. Census Bureau, 2006.

  7. The elderly patient who has abdominal pain consumes more time and resources than any other emergency department patient presentation. • Their length of stay is 20% longer than younger patients. • They require admission half the time. • They require surgical intervention one third of the time. Kizer KW, Vassar MJ. Am J Emerg Med 1998;16(4):357-362. Brewer RJ, Golden GT, Hitch DC, et al. Am J Surg 1976;131(2):219-223.

  8. The overall mortality for elderly emergency department patients with a chief complaint of abdominal pain exceeds 10%, rivaling that of an acute ST elevation MI. Kizer KW, Vassar MJ. Am J Emerg Med 1998;16(4):357-362.

  9. Difficulties In Diagnosing The Elderly • History: dementia, stroke with aphasia, hearing and vision loss. • Altered pain perception. • Medications that interfere with diagnosis. • Lack of fever and leukocytosis. • Co-morbid medical conditions. • Atypical presentations. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

  10. Difficulties In Diagnosing The Elderly • Fever tachycardia and hypotension may be absent even in the seriously ill. • Guarding and rigidity may be lacking because of the laxity in abdominal wall musculature. • 21% of patients older than 70 with a perforated ulcer present with epigastric rigidity. Fenyo G. Am J Surg 1982;143(6):751-754.

  11. Medications That Interfere With Diagnosis • NSAIDs block inflammatory response and decrease the degree of abdominal tenderness and contributes to peptic ulcer disease. • NSAIDs and APAP diminish febrile response. • Narcotics can blunt the pain response. • Beta blockers and negative chronotropes blunt tachycardia. • Normal blood pressure may not reflect the relative hypotension in patients with chronic hypertension. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

  12. Differential Diagnosis Of Abdominal Pain In The Elderly • Cholecystitis • Nonspecific abdominal pain • Obstruction • Hernia • Appendicitis • Diverticular disease • Perforation • Pancreatitis • 12-41% • 9.6-23% • 7.3-14% • 4-9.6% • 2.5-15.2% • 3.4-7% • 2.3-7% • 2-7.3% Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition. Philadelphia, PA: Mosby Elsevier, 2009.

  13. History: High Yield Questions • Age : advanced age means increased risk. • Which came first pain or vomiting: pain first is worse( more likely surgical) • Surgical history: obstruction more likely. • Pain constant or intermittent: constant worse. • Previous episodes: no prior episodes worse. • History: Cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease. All suggest more serious disease. • Alcohol: consider pancreatitis, cirrhosis, hepatitis. Colucciello SA, Lukens TW, Morgan DL. Emergency Medicine Practice 1999;1(1):1-20.

  14. High-Yield Questions • HIV status: drug-related pancreatitis. • Antibiotics or steroids: May mask infection. • Did pain starts centrally and migrate to RLQ: appendicitis. • Vascular , heart disease, hypertension, atrial fibrillation: consider mesenteric ischemia or abdominal aortic aneurysm. Colucciello SA, Lukens TW, Morgan DL. Emergency Medicine Practice 1999;1(1):1-20.

  15. Physical Examination • Ill appearing verses well appearing. • Well appearing patients may still have a serious medical condition. • Fever, tachycardia, and hypotension may be absent in the elderly. • Guarding and rigidity may be absent . • The location of tenderness is generally a reliable guide to the cause of pain.

  16. Physical Examination • Examined the skin for signs of herpes zoster, Cullen’s or Grey Turner’s sign. • Auscultate for bowel sounds and bruits. • Rectal exam may be useful in diagnosing bowel ischemia, GI malignancies and bleeding.

  17. Laboratory Testing • Many tests are nonspecific in the elderly. • White blood cell count may be normal even in the seriously ill. • Lipase level is specific for pancreatitis. • Lactate levels are helpful in diagnosing mesenteric ischemia. Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.

  18. Radiographs • Abdominal radiographs are of limited value. • May identify obstruction, free air, or abdominal aortic calcifications.

  19. Abdominal Ultrasound • Most useful in evaluating gallbladder and pelvic organs. • Bedside ultrasonography is most useful in evaluating for abdominal aortic aneurysm in hypotensive patients.

  20. Computerized Tomography • CT scanning has become one of the most viable tools in diagnosing acute abdomen and the elderly. • CT angiography is replacing traditional angiography in diagnosing mesenteric ischemia. • Limitations include those with contrast allergies and those with renal insufficiency.

  21. Case Number 1 • A 73-year-old female presents with nausea vomiting and progressive abdominal pain over the past two days. • Vital signs: BP 90/60 , P88,R 24,T 38C • PMH: Hypertension, Hyperlipidemia, TIA. • PSH: Appendectomy, hysterectomy, partial colectomy. • Meds: Metoprolol, Atorvastatin, Aspirin.

  22. Physical Exam • Ill appearing 72-year-old with active vomiting. • Heart: RRR 1/6 SEM LSB, Lungs: Diminished breath sounds bases • Abdomen: distended, high pitched bowel sounds, diffuse nonspecific tenderness, no rebound, no bruits, no hernias. • Skin: Dry mucus membranes, no rashes • Neurologic: Awake alert and oriented, nonfocal. • Extremities: +1 edema, symmetric pulses. • Rectal exam: No masses, heme positive brown stool.

  23. Laboratory Values • WBC 12,000 • HB 9.9 • SMA 7: Na 150,K 4.8,CL 105,CO2 18,BUN 33, Creat 2.8 • LFTS: T.Bili 2.0,AST 44,ALT 50 • Amylase 200, Lipase 34 • UA: SG 1.030,20 WBC,10 RBC, Nitrate pos

  24. Differential Diagnosis?

  25. Abdominal Radiograph Image Source: Kennedy Health Systems

  26. Diagnoses?

  27. Small Bowel Obstruction

  28. Discussion • Tachycardia lacking due to beta blockade. • WBC, Amylase, Bilirubin nonspecific in this case. • IV contrast CT scan limited with renal insufficiency. • Elderly may have more extensive past surgical history which predisposes the patient to greater risk of bowel obstruction.

  29. Bowel Obstruction • SBO :The most common cause for emergent surgical intervention in the elderly. • LBO : Less common then SBO. Prevalence increases with age.(Colon cancer, diverticulitis) • Sigmoid and cecal volvulus also cause LBO. • Most cases of LBO must be managed by surgical intervention, but some cases of volvulus may be decompressed by endoscopy.

  30. Case Number 2 • An 85-year-old man presents to the emergency department after syncopal episode. The patient complains of sudden onset of abdominal and back pain. • Vital signs: BP 95/50, P 120, R 24,T 38C. • PMH: Hypertension, diabetes, hyperlipidemia, prostate cancer. • PSH: Prostatectomy, appendectomy. • Medications: Captopril, ASA, Glucophage, Niacin

  31. Physical Exam • Uncomfortable, ill appearing, 85-year-old male writhing in pain. • Heart: Reg 120 no murmur • Lungs: Clear • Abdomen: Distended, obese, mild diffuse tenderness, no rebound. No bruits. • Extremities: No edema, cool with cyanosis and decreased pulses.

  32. Laboratory Testing • WBC 15,000 • HB 8.0 • SMA 7;Na140,K4.8,Cl 100,CO2 18,BUN 22,Creat 1.5 • LFTS: Bili 1.4,AST 55,ALT 60.Amylase 160.Lipase 55

  33. Differential Diagnosis ?

  34. Bedside Ultrasonography Image Source: Cooper Health Systems

  35. Bedside Ultrasonography Image Source: Cooper Health Systems

  36. Diagnosis

  37. Ruptured Abdominal Aortic Aneurysm Image Source: Kennedy Health Systems

  38. Discussion and Management

  39. Abdominal Aortic Aneurysm • Syncope can be an ominous sign in the elderly. • One should always consider aortic aneurysm in any geriatric patient presenting with back pain. • Any patient over the age of 55 with cardiovascular risk factors who presents to the emergency department with a complaint of back pain should have their aorta visualized by ultrasound or CAT scan.* *Emergency Medicine Reports

  40. Abdominal Aortic Aneurysm • Early recognition • Aggressive resuscitation • Early vascular surgical intervention • Utility of bedside ultrasonography • Don’t wait for a CAT scan diagnosis to mobilize vascular surgical intervention

  41. Case Number 3 • An 85-year-old male presents to the emergency department with increasing postprandial abdominal pain. • Vital signs: BP 180/95,P 120,R 26,T 39 C • PMH: A Fib, PVD, HTN, DM • PSH: Fem Pop Bypass, CEA, Appendectomy. • Meds: Digoxin, Warfarin, Metoprolol, Metformin, Aspirin.

  42. Physical Exam • 85 year old ill appearing male in considerable pain. • Heart: irregularly irregular 120 • Lungs: CTA • Abdomen: Diffuse nonspecific tenderness, abdominal bruit present. Guarding present • Neurologic: Confused, non-focal. • Extremities: +1 edema. Diminished pulses.

  43. Laboratory Data • WBC: 18,000 • Hb: 12 • SMA-7: Na148,K 5.0.CL 100,CO2 16,BUN25,Creat 1.6.Glucose 380 • LFTS: Normal • Amylase: 400,Lipase: 60 • Lactate: 6.0 • INR: 1.4 • Digoxin : 1.9

  44. Radiograph Image Source: Kennedy Health Systems

  45. Differential Diagnosis

  46. CAT Scan Findings Image Source: Kennedy Health Systems

  47. Diagnosis: Intestinal Ischemia • Rare disorder: less than 1/1000 hospital admissions. • High mortality: 30% to 90%. • Mortality is dependent on time of diagnosis. • Mortality approaches 100% when the diagnosis is delayed greater than 24 hours. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

  48. Clinical Diagnosis • Pain out of proportion of the exam. • Rebound is initially absent. • When rebound is present the prognosis is poor. • The patients may present with: nausea, vomiting, diarrhea. • The elderly may present with less abdominal pain and other signs such as tachypnea and mental status changes. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

  49. Laboratory Data • Really nonspecific • Leukocytosis, elevated amylase, metabolic acidosis, elevated AST and alkaline phosphatase, hyperphosphatemia. • Elevated lactic acid is helpful but is often a late indicator. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

  50. Radiographic Studies • Plain radiographs are often normal early on. • Thumb printing is a late sign. • Angiography is the gold standard.( 74-100% sensitivity; 100% specificity. • Standard CT has a sensitivity of 64%. • CT Angiography may replace traditional angiography. Some studies show a 96% sensitivity. Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.

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