Clin Geriatr Med 23 (2007) 255270

Abdominal Pain
Ernest L. Yeh, MD, FAAEMa,*, Robert M. McNamara, MD, FAAEMb
Department of Emergency Medicine, Temple University School of Medicine, Temple University Hospital, 3401 North Broad Street, 1011, 10th Floor Jones Hall, Philadelphia, PA 19140, USA b Department of Emergency Medicine, Temple University School of Medicine, Temple University Hospital, 3401 North Broad Street, 1002, 10th Floor Jones Hall, Philadelphia, PA 19140, USA
a

The population of the United States is rapidly getting older. According to the US Census Bureau, approximately one in eight Americans were elderly (age O64) in 1994, and about one in ve will be elderly by the year 2030. The number of persons aged 65 years old and older will more than double by the middle of the next century, to 80 million [1]. Obviously, the growth of this segment of the population will be accompanied by an increase in the number of patients who seek a medical evaluation for abdominal pain. This complaint must be considered seriously, because nearly half the patients older than 65 years who present to the emergency department (ED) with abdominal pain are admitted, and as many as one third require surgical intervention at some time during their admission [2,3]. The overall mortality for elderly ED patients with a chief complaint of abdominal pain exceeds 10%, rivaling that of an acute ST-segment elevation MI [2]. Elderly patients may initially present to outpatient oces but frequently need additional evaluation in a more acute setting, either an ED or an inpatient unit. Elderly patients with abdominal pain who present to the ED typically require more resources (diagnostic tests, medications, and length of stay in the ED) and are more often admitted than younger patients [4]. This complaint is frequent: a recent study of 10 northern New Jersey EDs reported that 4.2% of the visits for those 65 and older were for abdominal pain [5]. In considering the older patient who has abdominal pain, clinicians should remember

* Corresponding author. E-mail address: ernest.yeh@temple.edu (E.L. Yeh). 0749-0690/07/$ - see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cger.2007.01.006 geriatric.theclinics.com

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that the chronologic age may not fully reect the patients physiologic age and should consider the overall health condition [6].

Diculties in diagnosis Many factors make diagnosis dicult in elderly patients [7]. These include diculty in obtaining history from the patient, lack of consistent physiologic responses (including fever and leukocytosis), and confusing clinical presentations due to other comorbid conditions [8]. The patients ability to provide a history is frequently compromised by an altered ability to communicate. These communication diculties may result from hearing and vision loss, cerebrovascular accidents leading to receptive or expressive aphasias, Alzheimers disease, and other age-related dementias. Other barriers to obtaining an adequate history include the patients fear of loss of independence and stoicism. Altered pain perception in the elderly may inuence the patients ability adequately to describe and report pain [9,10]. A number of medications can interfere with the diagnostic process or may be contributing causes of the presenting abdominal condition. Nonsteroidal anti-inammatory drugs (NSAIDs), for example, are frequently used by elderly patients. NSAIDs may block the expected inammatory response to peritonitis and thereby decrease the degree of abdominal tenderness for a given pathologic condition, or they may be a contributing source of a perforated peptic ulcer. Narcotic use for chronic conditions may also blunt the pain response that normally signies an intra-abdominal catastrophe. This eect can cause a delay in the patients presentation or lead the clinician to underestimate the severity of the condition. However, the patient whose signicant abdominal pain has been identied should receive adequate analgesia. Judicious use of narcotic analgesia has not been found to aect the reliability of the physical examination or interfere with the diagnostic process in patients who have severe abdominal pain [1113]. NSAIDs and acetaminophen may also diminish the fever response normally associated with infection or sepsis. Beta blockers and other negative chronotropes may blunt the tachycardia that is associated with a stressed physiologic state resulting from increased metabolic demands, fever, or hypovolemia. Normal blood pressure may not reect relative hypotension in patients who are chronically hypertensive. Age-related physiologic changes have been hypothesized as the reason for which elderly patients have more frequent atypical presentations of abdominal pain than their younger counterparts. These atypical features include longer time until presentation, normothermia or even hypothermia, and lower leukocyte counts in the face of serious intra-abdominal infections [14,15]. It is accepted that other medical conditions, such as myocardial

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ischemia, tend to present in the elderly with atypical symptoms [16], and this principle may be extended to abdominal pathologic conditions.

History Although history taking may be less reliable in older patients who have abdominal pain, the clinician should try to obtain as complete a history as possible. This should typically include  Character: Clinicians should seek to distinguish between the dull, aching, or gnawing pain suggestive of visceral pain and the characteristically sharp, more dened and localized somatic pain associated with peritonitis [17].  Location: Embryologic origins of abdominal organs determine where a patient will feel visceral pain. Foregut structures include the stomach, pancreas, liver, biliary system, and proximal duodenum, with pain typically localized to the epigastric region. The rest of the small intestines and the proximal third of the colon (including the appendix) are midgut structures, and the visceral pain associated with injury to these organs is referred to the periumbilical region. Hindgut structures such as the bladder, uterus, and distal two thirds of the colon usually cause pain in the left lower quadrant or suprapubic region. Pain is usually reported in the back for retroperitoneal structures such as the aorta and kidneys [17].  Onset: Acute-onset pain should alert the clinician to the possibility of an intra-abdominal catastrophe, especially a perforated viscus, a ruptured abdominal aortic aneurysm, or another vascular emergency. Unfortunately, as mentioned previously, elderly patients may not present as expected; in one series of patients older than 70 years who had perforated ulcers, only 47% reported sudden-onset pain [7]. Pain that has a gradual onset is possible with a serious vascular issue, such as mesenteric ischemia.  Radiation: Radiation may be characteristic of a given disease (eg, radiation from epigastrium to back in pancreatitis) or may reect the progression of disease (eg, continued aortic dissection or migration of ureteral calculi).  Intensity: Severe pain should raise concerns about a serious underlying cause; however, descriptions of more mild pain should not dissuade the clinician from further evaluation.  Duration and progression: Persistent, worsening pain is worrisome, whereas pain that grows less severe is typically favorable. Serious entities generally present early, but delays may occur.  Associated events: Anorexia, vomiting, diarrhea, and urinary symptoms should be investigated. Pain frequently precedes vomiting in surgical conditions [3].

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 Provocative and palliative factors: Pain with movement usually signies peritoneal irritation; this is a key feature to discern during the interview. Questions about how the trip to the oce/ED went will often prompt the patient with peritoneal irritation to remark on an increase in pain that occurred when hitting a bump. Pain after eating may reect peptic ulcer disease, biliary disease, or mesenteric ischemia. The patient should also be questioned about any self-treatments.  Previous episodes: Recurrent episodes generally point to a medical cause, with the exceptions of mesenteric ischemia (intestinal angina), biliary disease, and partial bowel obstruction.

Physical examination The general appearance of the patient is always important. An ill-appearing elderly patient is cause for great concern, given the high mortality associated with abdominal pain in this patient population [2,3]. Conversely, the clinician must not be misled by the well-appearing patient who has serious underlying disease [8]. As noted earlier, vital sign abnormalities such as fever, hypotension, and tachycardia may be absent even in seriously ill patients. However, clinical suspicion should be elevated when any of these abnormalities is noted, because elderly patients frequently have a diminished reserve capacity. Tachypnea may be noted secondary to pain, or it may be attributed to a metabolic acidosis from sepsis or ischemic bowel. Inspection may reveal distension in bowel obstructions. Auscultation may reveal high-pitched sounds in small bowel obstruction. Fortunately, the location of tenderness is generally a reliable guide to the underlying cause of the pain [18]. Guarding and rigidity may be lacking because of laxity in the abdominal wall musculature [6]. A disturbing nding is that only 21% of patients older than 70 with a perforated ulcer presented with epigastric rigidity [7]. Although the diagnostic value of a rectal examination is minimal for most acute conditions, it may be of use in mesenteric ischemia or in raising suspicion for colon cancer. Further examination should include inspection for hernias, pulsatile masses, and the quality of femoral pulses. Thorough skin assessment may identify herpes zoster or signs of retroperitoneal hemorrhage, such Cullens sign or Grey Turners sign [19].

Diagnostic studies Laboratory and ancillary tests The signicant limitations of laboratory studies must be appreciated in the evaluation of acute abdominal pain in the elderly. Many tests are nonspecic and, as previously discussed, may give a false sense of security when

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they are normal. For example, the total leukocyte count may be normal in the face of serious infection, such as appendicitis or cholecystitis. Specic testing may be helpful in certain diagnoses, such as those of pancreatitis (lipase) or mesenteric ischemia (lactate), or in select circumstances, such as a prothrombin time for a patient who is taking warfarin. Radiographs Plain abdominal radiographs are of limited utility in the evaluation of acute abdominal pain. Although they may be helpful (eg, in identifying free intraperitoneal air, calcied aortic aneurysm, air uid levels in obstruction), other diagnostic studies are almost always indicated or are preferable as initial testing. Ultrasound Ultrasound is particularly useful in evaluating the gallbladder and pelvic organs. Additionally, bedside ultrasound in the ED is useful in the older patient who presents with abdominal pain and hypotension. It can quickly reveal an abdominal aortic aneurysm, prompting early mobilization of the surgical team. Ultrasound is limited by operator skill, bowel gas, and body habitus. Computed tomography CT is frequently used in evaluation of the patient who has abdominal pain [20]. Recent advances in the technology have allowed for improved image resolution and shorter acquisition times. Coronal and three-dimensional reconstruction signicantly enhance the detail of examinations. CT angiography has become more widespread and may be able to replace traditional angiography as a means of evaluating mesenteric vessels [21]. The major limitations of CT scanning are associated with intravenous contrast administration and include allergy and impaired renal function. CT scanning without contrast can provide signicant information in a more expeditious fashion. Judgment must be exercised in transporting an acutely ill patient away from the resuscitation area. Angiography Angiography has long been the gold standard for evaluation of the abdominal aorta and mesenteric vascular structures. Although alternative imaging modalities such as MRI and CT have an increasing role [22], institutional and clinician preferences for angiography still exist. Additionally, angiography plays a signicant role in therapy for certain diagnoses.

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Specic diagnoses Bowel obstruction Small bowel obstruction (SBO) is one of the most common reasons for surgical intervention in patients who have abdominal pain. The most common risk factor, namely previous abdominal surgery resulting in adhesions, is patient specic and not necessarily age related [23]. Surgical intervention may be necessary for lysis of adhesions, repair of incarcerated hernias, and bowel resection [24]. Abdominal pain, distension, and vomiting are typically present, and the diagnosis is usually straightforward. Delayed diagnosis is associated with increased mortality and morbidity in patients requiring surgical management [25]. CT will typically reveal dilated loops of bowel and air uid levels (Fig. 1). On occasion, a transition point may be seen, where there is evidence of distended bowel followed by normal bowel. Large bowel obstruction (LBO) is less common than SBO, but its prevalence rises with aging along with that of its most common causes (colon cancer and diverticulitis) (Fig. 2) [6]. Sigmoid and cecal volvulus are other entities associated with LBOs. Although vomiting and constipation are typically expected in LBO, they are not always present [23]. Most causes of LBOs require surgical intervention. However, some cases of sigmoid volvulus may be decompressed initially by sigmoidoscopy to allow for medical resuscitation as needed before denitive operative intervention [26]. Biliary tract disease The incidence of cholelithiasis increases with age; studies report a prevalence ranging from 3% to 18% of the population. It is hypothesized that

Fig. 1. CT showing dilated loops of small bowel with air uid levels suggestive of small bowel obstruction.

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Fig. 2. Large bowel obstruction (arrow) due to a colon mass.

decreased responsiveness to cholecystokinin and depressed gallbladder motility predispose the older patient to stone formation [27]. Symptomatic diseases typically require surgery or endoscopic intervention and include biliary colic (calculous or acalculous), cholecystitis, gallstone pancreatitis, and choledocolithiasis. In the setting of acute cholecystitis in an elderly patient, it is highly recommended that one initiate the operative procedure with minimal delay, because delays are associated with signicantly increased morbidity [28]. Nonoperative management in patients older than 80 can result in mortality as high as 17% [29]. Elderly patients tend to have the typical right upper quadrant or epigastric pain, but more than half of elderly patients with acute cholecystitis do not have nausea and vomiting, and a significant proportion do not have fever [30]. Ultrasound is frequently used in the evaluation of right upper quadrant pain (Fig. 3). But if no gallbladder stones are found and clinical suspicion for cholecystitis is still high, radionuclide scanning/cholescintigraphy should be performed. Appendicitis Appendicitis accounts for approximately 5% of all cases of acute abdomen in the elderly [31]. Less than one third of elderly patients have the classic presentation, dened as including all of the following: fever, elevated white blood cell count, anorexia, and right lower quadrant pain. The dicult nature of this disease in the elderly is reected in the literature. For example, in one series, 54% of older patients who had appendicitis had an incorrect initial admitting diagnosis, which contributed to the high perforation rate (51%) found at the time of surgery [32]. The delay in presentation

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Fig. 3. Ultrasound of gallbladder with acoustic shadowing from gallstones.

of the patients was also reported as a factor contributing to increased complication rates. Many factors may deect attention from appendicitis as the cause of the patients pain, including lack of the classic symptoms, absence of fever and leukocytosis (in as many as 20% of patients), and clinical features suggesting an alternative diagnosis, such as urinary tract infection (frequency, pyuria) or gastroenteritis (diarrhea). Importantly, right lower quadrant pain and tenderness are usually present, and appendicitis must remain high on the list of diagnostic possibilities when these symptoms are discovered. Although CT scanning (Fig. 4) has aided in the diagnosis of appendicitis in patients who have abdominal pain [33], its sensitivity is

Fig. 4. CT showing inamed appendix and periappendiceal fat stranding (arrow).

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not 100%, and admission for observation is prudent when the cause of lower abdominal pain is unclear. Abdominal aortic aneurysm The diagnosis of ruptured abdominal aortic aneurysm (AAA) should be the rst consideration in an older patient who has abdominal, back, ank, or groin pain and hypotension. The presence of a pulsatile abdominal mass on examination or bedside ultrasound will clinch the diagnosis. Unfortunately, the clinical features sometimes lead clinicians astray, especially when hypotension is absent. The most common misdiagnoses include renal colic and diverticulitis [34,35]. It is prudent to consider investigation for AAA whenever renal colic is suspected in elderly patients. Ruptured AAA carries mortalities from 15% to 50%, with rates approaching 90% when patients are in shock [35]. Early diagnosis and an aggressive approach represent the patients best chance for survival. The need to have diagnostic certainty before operation should be tempered by the potentially serious consequences of delay. It should also be considered that most patients who are operated on for suspicion of this condition and turn out not to have a ruptured AAA do have another disease that requires laparotomy [36]. CT angiography is the test of choice in stable patients because of its ability to detect aneurysm as well as rupture or leak (Fig. 5). Given that approximately 90% of AAAs are infrarenal, the CT angiogram can assist the surgeons in their operative approach [37]. Non-contrast CT may be considered in patients who have contrast allergies or renal insuciency. In unstable patients, bedside ultrasound examination may also be used to

Fig. 5. Contrast CT showing proximal abdominal aortic aneurysm with mural thrombus.

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identify AAA rapidly [38]. Emergent operative intervention should occur as soon as possible when a ruptured AAA is identied [34,35]. Bowel perforations Peptic ulcers are one of the most common causes of bowel perforations [6]. The expected presentation begins with a report of the sudden onset of severe epigastric pain, with subsequent development of evidence of peritonitis on physical examination. However, this pattern is less common in the elderly. The atypical presentation in the elderly frequently leads to delays or failures in making the diagnosis. Many elderly patients present with minimal abdominal pain [7], and the presence of an underlying peptic ulcer is frequently obscured by the lack of pain in such patients [39]. Often the patient reports no history of peptic ulcer disease [40]. Although the nding of free air on plain radiographs (usually an upright or lateral chest radiograph) aids in the diagnosis, its absence should not be used to exclude one; these studies do not show pneumoperitoneum in as many as 40% of patients who have perforated ulcers [40]. CT is highly sensitive for free air (Fig. 6). Although nonoperative management is sometimes considered in younger patients, patients older than 70 are less likely to have a favorable outcome with a nonsurgical approach [41]. Colon cancer and diverticular disease are responsible for most other bowel perforations in the elderly, especially because the incidence of these entities increases with age [42]. The presentation of such perforations varies with the location, extent of leakage, and response of the patient. The diagnosis is often not clear until CT or operative intervention is employed in a patient who has suspected peritonitis.

Fig. 6. Perforated gastric ulcer with free air and massive ascites.

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Diverticular disease Diverticular disease may present as abdominal pain, lower gastrointestinal bleeding, an acute abdomen from perforated diverticula, or a large bowel obstruction. Pain usually begins in the hypogastric region and localizes to the left lower quadrant. Diarrhea and constipation have both been reported as alterations in bowel habits. Although diverticulitis may often be diagnosed clinically in patients who have a history of diverticulosis, elderly patients should typically undergo imaging (Fig. 7). Contrast CT of the abdomen and pelvis is usually the test of choice, because colonoscopy and rectal contrast enemas may carry a risk for perforation during the acute phase. Mild cases may be treated with oral antibiotics and a clear liquids diet in patients who have close follow-up. However, it has been suggested that it is appropriate to admit elderly patients for intravenous antibiotics and close observation, because of the potential for rapid progression of gram-negative sepsis [43]. Peridiverticular abscesses may be treated by means of CT-guided drainage, whereas laparotomy for colonic resection should still be performed in cases of frank perforation. Surgical consultation should also be considered for patients who do not improve with medical management. Pancreatitis In the elderly, pancreatitis is less often caused by alcohol abuse than in younger patients; gallstones are responsible in as many as 70% of patients older than 80 years. No cause of pancreatitis can be identied in as many as 15% to 30% of cases in older patients [44]. Classic symptoms are a steady,

Fig. 7. Coronal CT showing multiple diverticulae in descending colon.

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boring pain radiating to the back, associated with nausea, vomiting, and dehydration. Progression of pancreatitis may mimic systemic inammatory response syndrome and is believed to be triggered by a variety of inammatory mediators [45]. As a result, elderly patients frequently present in shock, and necrotizing pancreatitis represents the most lethal complication, especially in patients older than 80 [46]. Serum amylase and lipase may aid in the diagnosis of acute pancreatitis, but CT (Fig. 8) should almost always be considered in the work-up, because other diagnoses may need to be excluded. Endoscopic or surgical therapy may be considered in gallstone pancreatitis, whereas CT-guided drainage may be performed in cases of abscess or limited necrosis. Surgical debridement is usually only considered in refractory or severe cases. Mesenteric ischemia Delayed diagnosis of mesenteric ischemia (MI) is frequent and carries a high mortality, with rates of 45% to 90% depending on causation of the event [47]. MI may be caused by either nonocclusive infarction or occlusion from an embolus or thrombus. The superior mesenteric artery is most frequently involved in acute and chronic occlusions, but the inferior mesenteric artery and the mesenteric vein can be aected [47]. Risk factors include cardiac dysrhythmias (particularly atrial brillation), myocardial infarction, congestive heart failure, peripheral vascular disease, embolic disease, and hypotensive states. Typical symptoms include the gradual onset of abdominal pain (though an embolus may present with sudden pain), which progresses in severity over time and is refractory to narcotic analgesics. The early abdominal

Fig. 8. CT with complex pancreatic mass (arrow).

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examination is usually benign despite the severity of the pain, and this association is a key diagnostic clue. Nausea, vomiting, and diarrhea are common, and the clinician must be careful not to attribute those symptoms reexively to gastroenteritis. Late ndings of peritonitis and shock are ominous signs. Nonocclusive ischemia develops from hypoperfusion [48] and can occur in patients hospitalized for other reasons, including sepsis, dehydration, and heart failure [49]. Leukocytosis and lactic acidosis are generally present and may increase suspicion for MI. Plain lms are generally nonspecic. Use of CT (Figs. 9 and 10) and CT angiography is more common and may also provide insight into other disease states. Angiography can provide both a diagnostic option for identifying the extent of vessel involvement and a therapeutic option for the infusion of vasodilatory agents or thrombolytics [50]. Treatment is primarily surgical but may involve a combination of angiography and laparotomy [51]. Even with intervention, MI carries a high mortality in the setting of multisystem organ failure [52]. Other conditions and causes In addition to the conditions reviewed in this section, numerous other surgical and nonsurgical entities can cause abdominal pain in the elderly. Aortic dissection, intussusception, gastric volvulus, and ischemic colitis are on the list of conditions that may require surgical intervention. Important nonsurgical diseases may also present with abdominal pain. First and foremost on this list is acute myocardial ischemia, which should always be considered in the elderly patient who has upper abdominal pain. Virtually

Fig. 9. Pneumatosis, free air, and air in portal vein in a patient with ischemic colon.

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Fig. 10. Air in liver from portal system.

every other chest disease can present with abdominal pain, including pneumonia, pulmonary embolism, empyema, and congestive heart failure. The genitourinary system should not be overlooked: renal colic, pyelonephritis, epididymitis, testicular torsion, ovarian cancer, and Fourniers gangrene are important causes in the elderly. Diabetic ketoacidosis, herpes zoster, hypercalcemia, Addisonian crisis, hemochromatosis, and hematomas of the rectus sheath or retroperitoneum in anticoagulated patients are some medical causes of abdominal pain in the elderly. Summary Abdominal pain in the elderly has numerous causes. A prudent approach involves routine and early consideration of the life-threatening pathologic conditions and recognition that serious disease may be very dicult to diagnose. Atypical presentations of abdominal diseases are common in the elderly. This problem contributes to delays in diagnosis and treatment and thus, unfortunately, to increased mortality and morbidity. The complaint of abdominal pain in an elderly patient must be considered seriously. It may require referral to an ED, extensive diagnostic testing, surgical consultation, and consideration of admission for observation until the patients condition is claried. References
[1] U.S. Census Bureau. The elderly population. Available at: http://www.census.gov/ population/www/pop-prole/elderpop.html. Accessed July 20, 2006.