ABDOMINAL PAIN CASE 3
‘An aged male patient with acute abdominal pain’
Gao is an 81 year old male who presents to ED with severe periumbilical abdominal pain. He has a background medical history of long standing hypertension, osteoarthritis and atrial fibrillation but is usually well and living an independent life at home. He takes a regular aspirin regularly and occasional ibuprofen for pain.
On examination, he appears to be in significant discomfort. His vital signs are: HR 90, resp rate 24, BP 100/50 and temperature 37.7 degrees.
Which of the following is a life-threatening diagnosis that should be promptly excluded in this patient?
Choices:
- Mesenteric ischaemia
- Perforated viscus
- Ruptured abdominal aortic aneurysm
- All of the above
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Correct Answer – (4) All of the above
A Take Home Message:
Abdominal pain the elderly can be a challenging presentation. In contrast to younger patients a broad range of life-threatening differentials should be considered.
Further Explanation:
This patient has risk factors for bowel ischaemia (AF), perforation (NSAID use) and AAA (hypertension). It is important to recall that elderly patients may present late with significant pathology. This is because their physiological response is not as marked as in younger patients. For example, this patient’s heart rate may be artificially lowered by rate control agents for the AF such as beta blockers. Furthermore, elderly patients may be hypothermic when presenting with sepsis and physical examination may not be as reliable as younger patients.
Due to the higher risk of significant pathology, these patients require further investigation, most commonly with a contrast CT scan of the abdomen. In the ED we must aim to actively rule-in acute life-threatening diagnoses as soon as possible e.g. AAA rupture using ultrasound, perforated viscus using x-ray and intra-abdominal sepsis using a blood gas lactate. Sepsis is commonly due to cholecystitis, appendicitis and diverticulitis in this age group. In addition, it is also important to consider causes of pain from outside of the abdomen such as acute myocardial infarction and community acquired pneumonia.
The elderly are a high risk group in regards to abdominal pain. Compared with younger patients with similar complaints, the elderly patient with abdominal pain will stay in the ED 20% longer, require admission nearly half the time, and require urgent surgical intervention in nearly one-third of cases.
Links and References:
- Review – www.researchgate.net/publication/7195022_Abdominal_Pain_in_the_Elderly
- UpToDate offers a comprehensive review of the approach to an adult with abdominal pain. This can be accessed through “CIAP” in New South Wales
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