Care of geriatric patients with abdominal pain can pose significant diagnostic and therapeutic challenges to emergency physicians. Older adults rarely present with classic signs, symptoms, and laboratory abnormalities. The incidence of life-threatening emergencies, including abdominal aortic aneurysm, mesenteric ischemia, perforated viscus, and other surgical emergencies, is high. This article explores the evaluation and management of several important causes of abdominal pain in geriatric patients with an emphasis on high-risk presentations.
Key points
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Geriatric patients have increased morbidity and mortality compared with younger patients for most abdominal disorders.
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Geriatric patients show atypical signs and symptoms for many common abdominal conditions, contributing to misdiagnosis and worsened outcomes.
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Biliary disease is the most common surgical disease in older adults and often presents with complications.
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Acute mesenteric ischemia and abdominal aortic aneurysm are almost exclusively diseases of older adults and both carry very high mortalities.
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Potentially lethal conditions originating outside of the abdomen, including myocardial infarction, can present with abdominal pain in geriatric patients.
Introduction
Care of geriatric patients with abdominal pain can pose significant diagnostic and therapeutic challenges to emergency physicians. Older adults rarely present with classic signs, symptoms, and laboratory abnormalities. Incidence of life-threatening emergencies, including abdominal aortic aneurysm, mesenteric ischemia, perforated viscus, and other surgical emergencies, is high. This article explores the evaluation and management of several important causes of abdominal pain in geriatric patients, with an emphasis on high-risk presentations.
Epidemiology
Abdominal pain is among the most common presenting complaints in geriatric emergency department (ED) patients. Altered physiology, comorbid conditions, medication side effects, and polypharmacy increase treatment difficulty and risk in this population. Despite widespread use of advanced imaging, diagnostic accuracy is reduced in patients more than 75 years old. The need for surgery or other procedural intervention is high (25%–30%). , Many older adult patients require admission, and those who are discharged should be carefully selected, because the ED recidivism rate is about 10%.
The risk of serious disorder and associated need for admission, morbidity, and mortality are all increased in older patients. In the past, morbidity rates for geriatric patients have been reported to be as high as 45%. With improvements in the understanding of geriatric physiology and the availability of advanced imaging modalities and less invasive surgical techniques, mortalities have improved to approximately 5%. ,
Features of Common Conditions
Biliary and Gallstone Disease
Gallstone disease is a common surgical problem in the geriatric population. Biliary disease, most notably cholecystitis, is the most common abdominal surgical emergency in geriatric patients. Older adult patients are at increased risk for complications, including emphysematous cholecystitis, perforation, and cholangitis ( Fig. 1 ). , Physiologic factors, including atherosclerotic weakening of the gallbladder wall and age-related dilatation of the common bile duct, increase the risk for perforation and choledocholithiasis, respectively. ,
Common symptoms such as nausea, vomiting, and fever are frequently lacking, often leading to delay in care or diagnosis, which contributes to the observed increase in complications. In one series of older adults with acute cholecystitis, fever occurred in only 16% of cases. Similarly, the Charcot triad of cholangitis (fever, jaundice, and right upper quadrant pain) is observed in only 20% to 45% of patients even in the setting of advanced disease. Ultrasonography is the recommended imaging modality for suspected gallbladder disease; however, computed tomography (CT) may offer higher sensitivity, particularly for associated complications and alternative diagnoses. ,
Older adult patients with confirmed acute cholecystitis should be referred for emergent surgical evaluation. Mounting evidence supports early surgical management of acute cholecystitis in geriatric patients because increased rates of morbidity and mortality have been observed with a delayed surgical approach. Antibiotics should be administered in the setting of biliary disease with evidence of infection. The Infectious Diseases Society of America recommends single-agent cephalosporin coverage for most mild to moderate cases but recommends broader, dual-agent coverage for high-risk patients, including those of advanced age.
Pancreatitis
Geriatric patients account for about one-third of cases of acute pancreatitis. Compared with younger patients with acute pancreatitis, older patients develop severe disease more frequently and have higher rates of morbidity. Advanced age does seem to increase mortality risk, particularly after age 80 years. Gallstone disease remains an important cause of pancreatitis in the older adult population, but other causes, including medication-induced pancreatitis and ischemic pancreatitis, should also be carefully considered. , Diagnosis is made more difficult by the frequent absence of common symptoms. In one cohort of patients more than 65 years of age, abdominal pain was absent in almost 25% of patients and vomiting was absent in nearly 60%. The aggressive early fluid resuscitation commonly prescribed to patients with acute pancreatitis may be less tolerated in geriatric patients because of their higher rates of comorbid cardiac disease.
Bowel Obstruction
Small bowel obstruction (SBO) increases in both incidence and associated mortality with advancing age. Reported incidence ranges from around 30 to 40 cases per 100,000 in the 15-year to 44-year age group up to about 400 to 480 per 100,000 in patients more than 65 years old. Large bowel obstructions (LBOs) are also more commonly encountered in the geriatric population. The causes of bowel obstruction differ between the small and large bowel, with adhesions causing most SBOs and malignancy causing as many as 80% of LBOs ( Table 1 ). , The symptoms of LBO can be more insidious in onset compared with SBO, although abdominal pain and decreased passage of stool and flatus are still common. Sigmoid volvulus occurs at a rate 3 to 4 times greater than cecal volvulus, likely a reflection of the chronic dilatation and redundancy observed in the sigmoid colons of geriatric patients. Comorbidities associated with decreased gut motility are significant risk factors for the development of volvulus, with more than 60% of patients having comorbid neurologic or psychiatric conditions. Complications of bowel obstruction can include ischemia, perforation, and intra-abdominal sepsis.
| Small Bowel Obstruction | Large Bowel Obstruction |
|---|---|
|
|
Although plain radiographs have poor sensitivity and specificity for SBO, they can offer rapid evidence of volvulus or free air. CT offers the best diagnostic utility in the investigation of bowel obstruction in older adult patients, because CT can identify important features of an obstruction, including location, severity, presence of a predisposing lesion, and associated complications.
Evidence of bowel obstruction should prompt urgent surgical consultation. Although some bowel obstructions can be managed nonoperatively, nonoperative management is associated with a higher rate of recurrence. Some cases of LBO, specifically volvulus, may be treated nonoperatively with endoscopic reduction and decompression with a rectal tube. Advanced age increases risk of mortality; however, some literature suggests that improvements in supportive care and surgical techniques are narrowing this gap. , Supportive care, including resuscitative fluids, analgesics, and antiemetics, should be administered. Placement of a nasogastric tube can be considered in the setting of severe symptoms from pain, distention, or intractable nausea; however, data regarding their impact on successful nonoperative management are limited. Antibiotics covering gram-negative and anaerobic organisms should be administered to patients with obstructing diverticulitis or evidence of perforation or sepsis ( Table 2 ).
| Diagnosis | Mild Severity/Low Risk a | Moderate to Severe/High Risk b | |
|---|---|---|---|
| Biliary | Cholecystitis | Ceftriaxone Cefazolin | Piperacillin/tazobactam, ciprofloxacin, meropenem, or cefepime Each in combination with metronidazole c |
| Cholangitis | NA | ||
| Extrabiliary | Appendicitis |
|
|
| Diverticulitis |
| ||
| Peritonitis | NA |
a Low risk: age less than 70 years, few medical comorbidities.
b High risk: advanced age, immunocompromise, health care–associated infections.
c May consider early oral therapy in select patients.
d Consider adding methicillin-resistant Staphylococcus aureus coverage with vancomycin for health care–associated infections.
Appendicitis
Geriatric patients account for approximately 10% of appendicitis cases but a significantly greater proportion of deaths from the disease. Complications including necrosis, gangrene, and (most commonly) perforation increase significantly after age 65 years. , The cause of this increased risk is likely multifactorial and includes physiologic changes such as vascular sclerosis and fibrotic narrowing of the appendix and fatty infiltration and weakening of the bowel wall. In addition, older adult patients frequently have a delayed presentation from symptom onset compared with younger patients: 50 hours from symptom onset versus 31 hours in 1 large review.
Presenting symptoms can be notably different in geriatric patients and include absence of fever, migratory pain, rebound tenderness, and nausea. , Right lower quadrant tenderness remains common and can be observed in more than 90% of geriatric patients. , Laboratory studies are of limited benefit because 20% to 25% of patients do not show increased white blood cell count or left shift. Geriatric patients were poorly represented in the derivation of diagnostic scoring systems including the Alvarado and RIPASA scores. , The Alvarado score has been shown to perform poorly in a geriatric population; however, some have suggested that modification of traditional cutoffs may achieve adequate predictive values. , Further study is required to determine what, if any, utility these scores offer in the diagnosis of appendicitis in older adults.
The diagnosis of appendicitis is often aided by diagnostic imaging, and this is even more apparent in older adults. High rates of associated complications, underlying malignancy, and increased diagnostic uncertainty make imaging studies, particularly CT, a valuable diagnostic tool.
Appendectomy remains the recommended treatment strategy for acute appendicitis; however, an approach including an initial trial of antibiotics for uncomplicated cases has shown some efficacy in the overall population. , This treatment strategy is not recommended in older adults because they have been poorly represented in antibiotic-first trials and show high rates of occult perforation and necrosis missed on CT imaging. , Antibiotics are strongly recommended in the setting of perforated appendicitis and preoperatively in uncomplicated cases (see Table 2 ). ,
The World Society of Emergency Surgery recently produced guidelines for the diagnosis and treatment of appendicitis in older adult patients, which highlighted the overall lack of high-quality evidence in this population.
Diverticulitis
Diverticulosis is the most common condition identified on routine colonoscopy. The incidence of diverticulosis increases with age, affecting more than 70% of octogenarians. The rate of development of diverticulitis in the setting of diverticulosis was long quoted in the 10% to 25% range; however, these figures predate routine screening colonoscopy and are thus likely overestimated. , A more recent study of more than 2000 veterans showed an incidence of diverticulitis of approximately 4%.
In Western populations, more than 90% of cases affect the sigmoid and descending colon, producing the hallmark symptom of left lower quadrant pain. The pain of diverticulitis is variable; it may be mild and intermittent or severe and constant. Other reported symptoms, including urinary symptoms, constipation, or diarrhea, can lead to misdiagnosis. Markers of infection, including increased white blood cell count and fever, may be present; however, their absence should not be relied on to rule out disease.
Although diverticulitis can be a clinical diagnosis, caution is warranted in geriatric patients. In a review of more than 400 geriatric patients who were ultimately diagnosed with diverticulitis, CT altered the pre-CT diagnosis in a significant proportion of patients. Although diverticulitis is associated with a more aggressive presentation and higher recurrence rate in younger patients, older patients experience higher perioperative morbidity, prolonged hospitalization, and higher in-hospital mortality.
A variety of treatments are available depending on disease severity and associated complications. Uncomplicated cases have classically been treated with bowel rest and oral antibiotics. Evidence regarding the utility of antibiotics in the treatment of uncomplicated diverticulitis is evolving. At present, the available research suggests that antibiotic use does not reduce time to resolution, but it may reduce rates of recurrence and complications. Antibiotic therapy alone may be used to treat mild to moderate diverticulitis, including patients with early complications such as a phlegmon. Treatment of more severe, complicated diverticulitis ranges from percutaneous drainage to staged resection. Antibiotics, both oral and intravenous preparations, should be selected to cover aerobic and anaerobic gram-negative bacteria (see Table 2 ).
Mesenteric Ischemia
Older adult patients are more commonly affected by acute mesenteric ischemia (AMI), largely because of the concurrent and causative risk factors associated with AMI. Despite advancements in treatment, the mortality from AMI remains as high at 40% to 50%. The challenge of this cannot-miss diagnosis lies in its nonspecific presentation. Abdominal pain is common and is often described as pain out of proportion to the examination. Frequently leading to a misdiagnosis of gastroenteritis, symptoms commonly progress to include vomiting and/or diarrhea, although constipation has also been reported. The duration of symptoms, as well as associated risk factors, are frequently tied to specific past medical comorbidities that the patient may carry.
Mesenteric ischemia is classified into 4 categories based on the cause of injury, with the categories exhibiting subtle differences in precipitating risk factors and clinical presentation ( Table 3 ). , Regardless of cause, the pathologic result is significant bowel ischemia requiring urgent intervention to prevent permanent damage.
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