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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, December 4, 2017

Acute Abdomen in Elderly


Working up an elderly population presenting with abdominal pain is always a challenging task. Almost always there are chances of potential mishaps due to delayed or missed diagnosis. Data suggests that abdominal pain is the most common ED presentation and the fourth most common complaint among elderly and nearly half of elderly patients with abdominal pain will require admission, and 1/3 will require  a surgical intervention. This makes it an important topic for us to be familiar with. Usual issues related to geriatric population (pharmacologic, social, cognitive) make evaluation extremely difficult. Click here to read more about how is elderly population different.
 

Key Issues:


  • Present later in their disease course
  • Present with vague symptoms (Only 1/6 present with textbook appendicitis presentation)
  • Difficult Communication (hearing, visual, cognitive)
  • Underreport symptoms (Poor pain perception, fear of hospitals and medical interventions)
  • Physical exam has limited utility - Atrophy of abdominal wall musculature diminishes rebound and guarding
  • Medications blunt or alter their response to disease
  • Less likely to develop fever or leukocytosis
In A&E, we should have a low threshold to image elderly due to high likelihood of surgical illness and unreliable physical examination. Ideally, CT is the imaging of choice. Plain films are of limited utility. Due to unreliable history, misleading examination findings and unpredictable nature and course of the illness, admission for observation should be considered if no confusion is reached after ED work up. . 

Common Geriatric Abdomen Pathologies

Mesenteric Ischemia
  • Risk factors include Atrial Fibrillation, Heart Failure. 
  • Pain out of proportion to examination. Perform a quick assessment and come up with a plan. Involve your Surgical colleagues and Radiologists ASAP.
  • May present with normal vital signs and laboratory values. Do not overly on White cell count and lactate. Lactate and EBC both are non-specific. 
  • Imaging of choice is CT with IV contrast.
  •  Rx them with Pain Relief, Fluids and electrolytes, NG Tube for gut decompression, Foleys Catheterisation , Broad Spectrum Antibiotics and immediate surgical consultation. 



Aortic Diseases (AAA, Dissection)

  • Be cautious whenever you attribute flank/abdo pain to Renal Stones in elderly.
  • AAA May present with weakness, dizziness, uneasiness or syncope
  • Classic presentation is pain abdomen, pulsalitle mass and hypotension
  • Use bedside USG to measure aorta and also look for a dissecting flap
  • Maintain BP enough to perfuse brain and do not give too much fluids
  • Arrange blood for transfusion and involve vascular surgeons ASAP


Gall Bladder Disease and Pacreatitis


  • Perforation, gangrene, emphysematous cholecystitis, ascending cholangitis, gallstone ileus, choledocholiathisis, and gallstone-induced pancreatitis are all more prevalent 
  • More than 50% with acute cholecystitis will lack nausea, vomiting, or fever. Leukocytosis may be absent in 30% to 40% of those with acute cholecystitis.31 Evaluation by ultrasound may be less helpful given the increased prevalence of acalculous cholecystitis as well as cholodocolithiasis and delay in surgery may result in an increased mortality.
  • More than 50% cases pancreatitis and elderly are due to Gall Stones. 


Small Bowel Obstruction


  • Classical symptoms are not seen early in the course of disease
  • May present with diarrhoea due to hyperperistalsis distal to the obstruction point
  • Gallstone disease may contribute to 25% of bowel obstructions in elderly


Diverticulitis


  • Diverticular bleeding is one of the most common causes of lower GI bleeds
  • Acute diverticulitis occurs when the diverticula become obstructed by fecal matter, resulting in lymphatic obstruction, inflammation, and perforation. 
  • Usually presents with LLQ pain, with or without bloody stools, nausea, and fever but 1/3rd of the geriatric presentations of acute diverticulitis do not have abdominal tenderness on examination. Once the acute phase resolves, endoscopy should be performed to rule out carcinoma after an acute episode of diverticulitis. 
  • Most can be managed medically, with antibiotics, intravenous fluids, and bowel rest. If there are larger perforations or abscess formation, surgery or percutaneous drainage may be indicated.

Large Bowel Obstruction

  • Common causes are diverticulosis and malignancy. 
  • Classically present with abdominal pain, vomiting, and constipation/obstipation, 
  • Often diagnosed late in their course 
  • Sigmoid and cecal volvulus account for a smaller subset of large-bowel obstructions, but more often requires emergent surgical intervention. 
  • Sigmoid volvulus, causing close to 80% of volvuli, causes a more gradual onset of pain, whereas cecal volvulus presents more acutely.
  • Sigmoid volvulus can often be decompressed with a rectal tube, sigmoidoscope, or barium enema, whereas cecal volvulus requires surgical repair. Volvulus of either site is at risk for perforation and should be decompressed urgently. 
  • Functional impairment and decreased motility of the GI tract can lead to acute colonic pseudo-obstruction, or Ogilvie syndrome i.e. functional obstruction of the GI tract. This is more commonly seen in elderly and debilitated patients. Treatment is conservative medical management. Neostigmine can be very effective but requires careful monitoring due to potential of bradycardia. 


Constipation


  • May be associated with fecal impaction and fecal incontinence. Fecal impaction can cause mucosal ulceration, bleeding, and anemia. 
  • Often caused by Medications, comorbidities, inactivity, and decreased gastric-emptying time and GI malignancies 
  • Perform a rectal examination should be performed on all patients with constipation to rule out mechanical obstruction of stool.
  • Treat chronic constipation with dietary and activity changes, followed by bulk laxatives and warm water enema


Malignancy


  • Ask for h/o unintentional weight loss, night sweats, and fatigue, hematuria, hematochezia. 
  • May also present with peritonitis, ascites, perforation, obstruction, or abdominal mass

Appendicitis
  • Difficult to diagnose in elderly patient and missed in more than 50% cases. The classic presentation is rarely seen. Literature now supports the use of non-contrast CT imaging for suspected appendicitis.
  • Elderly have a higher risk for mortality and morbidity following appendectomy. 


Extra-Abdominal Causes


  • Congestive heart failure
  • Acute Coronary Syndromes
  • Pneumonia, Pulmonary embolism
  • Prostatitis 
  • Urinary retention/infection (antihistamines, anticholinergics, technical obstruction, Pyelonephritis)
  • Herpes zoster involving thoracic dermatomes 
  • Rectus sheath hepatomas if they are on anticoagulants

Take Home

  • Think of Vascular causes of pain abdomen in elderly (AAA, Dissection, Bowel Ischemia)
  • GB disease (Cholecystitis, Cholangitis, Pancreatitis) and Bowel Obstruction are common in geriatric population
  • Do a rectal exam to assess prostate, look for blood/malena
  • Do a broad work up including lab tests and have a low threshold for imaging and admission for observation


Further Raeding: 
Leuthauser A, McVane B. Abdominal pain in the geriatric patient. Emergency Medicine Clinics. 2016 May 1;34(2):363-75.


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic


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