--- title: "Abdominal pain in elderly" canonical: "https://clinicaldecisions.refined.site/space/EM/13141760/Abdominal%20pain%20in%20elderly" format: markdown --- ### See also [Abdominal pain - facts](https://clinicaldecisions.atlassian.net/wiki/spaces/EM/pages/13207337) [Abdominal pain pathway](http://staffnet/QualityDocs/Clinical%20Forms/Medicine%20and%20Health%20of%20Older%20People/Emergency%20Medicine%20-%20ECC/%5bF%5d%20Adult%20Acute%20Abdominal%20Pain%20Pathway%20May26.pdf) *restricted* ### In this section --- ### Epidemiology> Macro (anchor) - Approximately 4% of ED visits are for abdo pain in those over 65 years. This will increase with the increasing proportion of elderly patients in the population. - 40% are initially misdiagnosed. - 25 – 33% eventually require surgery (at some point during their hospital stay). - 10% - 14% overall mortality rate. This rate can double if the diagnosis in the ED is incorrect. - More than 60% of the causes of abdominal pain in elderly patients are surgical in nature, a rate nearly double that of younger patients. ### Presentation> Macro (anchor) - More likely to present with vague symptoms and have non-specific findings upon examination. - Many elderly have altered mental status, which allows the condition to present at a more advanced stage. - Acute peritonitis is less likely to present with the classic findings of an acute abdomen. Patients are less able to exhibit guarding and rebound. - The patient is less likely to have fever or leukocytosis. - Their pain may be much less severe than expected for a particular disease. - Co-morbid diseases and their therapy contribute to the complexity of care. ### > Macro (anchor) History red flags Sudden severe pain suggests serious disease – ruptured AAA, aortic dissection ruptured viscus, volvulus, mesenteric embolus, MI. However these disorders may present without a sudden onset. For example only 47% of patients over the age of 70 with perforated ulcers reported sudden onset of pain. Generally severe pain = serious disease. Pain awaking the patient from sleep should always be considered significant. However, patients with serious pathology may report little or no pain. ### > Macro (anchor) Examination findings and red flags - Up to 30% of elderly patients with a serious infection present with a blunted or absent fever response. When fever is present, elderly patients are much more likely to have a serious (nonviral) infection than younger patients. - Vital signs may be normal despite serious disease (eg absent tachycardia as patient on beta-blockers). - Patients are less able to manifest guarding and rebound. - A hypotensive elderly patient with abdo pain has a ruptured AAA until proven otherwise. ### > Macro (anchor) Investigations - All elderly patients with abdo pain should have an ECG. - WBC may be normal even with significant pathology. The average white blood cell (WBC) count in elderly patients who have a surgical abdomen was only 12,400 cells/mm3. - U + Es, LFTs and amylase should be done as routine. - Consider urine (but do not write off flank pain as ureteric colic because of the presence of blood). - Consider ABG (lactate if metabolic acidosis is present). - Erect CXR should be done to exclude intrapulmonary process. Note that 10 – 50% of perforations may not show free air on the erect CXR.3 - Consider AXR/ KUB. Have a low threshold for requesting abdominal ultrasound (note high incidence of gallbladder disease) and CT abdomen (which has been shown to alter diagnosis and disposition in 50% and 25% respectively in elderly patients with abdominal pain) in consultation with general surgical registrar. At that point patient should be referred to general surgical team who can follow up US/CT scan report. ### > Macro (anchor) Diagnosis | | | | --- | --- | | **Indeterminant** | 24%. Note that up to 10% of these are later diagnosed with cancer. | | **Biliary disease** | 5-20%. Most common diagnosable cause of abdominal pain in the elderly. 10% of cholecystitis is acalculous. Fever and leucocytosis only seen in 60%. Mortality rate is nearly 10%. | | **Bowel obstruction** | 12%. Post surgical most common cause. Hernias second most common with mortality up to 40% in those requiring emergency surgery. Malignancy most common cause for large bowel obstruction and volvulus second most common cause (sigmoid 80%, caecal 15%, transverse 5%). Mortality 25-40%. | | **Perforated viscus** | 7%. Up to 40% of patients do not have free air on initial X/R. First presentation in up to 10% of elderly with PUD. | | **Diverticulitis** | 6%. In people over 60 yrs - 30% have diverticulosis and 30% will develop diverticulitis. | | **Appendicitis** | 4%. Misdiagnosed pre-operatively in 40-50%. Mortality up to 25% in those over 75 yrs. Less than 50% have guarding or rebound. Only 35% have typical pain migration. Perforation is common. Patients are often not febrile (rates range from 21-7% presenting with fever). | | **Incarcerated hernia** | 4%. See above. | | **Renal colic** | 4%. Beware of AAA. | | **Aortic aneurysm** | 1%. Incidence rises after age 55 and peaks at 6% at age 80 yrs. Mortality rate with rupture > 50%. Initial misdiagnosis common – 30% in one series. Most common symptom is abdo pain (not back pain) and occurs in 70 – 80%. Size of aorta is extremely difficult to determine on physical examination. | | **Mesenteric ischemia** | 1%. Classically pain out of proportion to physical exam (and history of cardiac disease). AF, recent MI, low CO states, hypercoagulability, atherosclerosis all risk factors. May be a history of prior episodes. Nausea, anorexia and vomiting are common and up to half will have diarrhoea (so consider mesenteric ischaemia in any elderly patient that you diagnose with "gastroenteritis"). Confusion develops in 30% which makes diagnosis more difficult. Mortality with delayed diagnosis is over 85%. | | **Others eg UTI, constipation, PE ** | ### > Macro (anchor) Management points and disposition - If the patient looks unwell then move them to resus or monitored (if not already there). Oxygen, monitoring, large bore IV lines, IV fluid resuscitation, crossmatch blood as appropriate. Early surgical review and ICU input. If the patient appears unwell then cover with broad spectrum antibiotics. - **Suspected ruptured AAA should be discussed immediately with Auckland Hospital**. - **If they are unstable they must not go to CT.** - **Ultrasound in resus** may be helpful but should not delay transfer. - Given the high incidence of morbidity and mortality and the high incidence of requirement for surgery the elderly patient with abdominal pain should generally be admitted by the surgical team. ### References McNamara R. Abdominal Pain in the Elderly.  In: Tintinalli JE. Emergency Medicine – A Comprehensive Study Guide. McGraw Hill 6th ED Hendrickson M, Naparst T. Abdominal surgical Emergencies in the Elderly. Emerg Med Clin North Am - 01-Nov -2003; 21(4): 937-69 Birmbaumer D. The aging abdomen. The Eleventh Annual Stanford Symposium on Emergency medicine and acute care (Lecture notes) Birmbaumer D. The Elder Patient. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., 2002 Mosby, Inc. Bugliosi TF, Meloy TD, Vukov LF. Acute abdominal pain in the elderly. Ann Emerg Med 1990;19(12):1383-6. --- Reviewed February 2025. [Send feedback](https://clinicaldecisionsupport.atlassian.net/wiki/spaces/EM/pages/3014657) to page coordinator