Abdominal pain

Background

• Elderly pts
  • Surgical emergencies are more common in elderly than in any other pt population
  • Viral gastroenteritis is uncommon
  • Conservative admission strategy is strongly advocated
• Pts with immunosuppression often have delayed or atypical presentations
• Fever is not a reliable marker for surgical disease

Workup

• Urine pregnancy
• CBC
  • Note: WBC cannot exclude surgical disease
• Chem
• LFT
• Lipase
  • May be normal early in course of pancreatitis
• UA/UCx
• Guaiac
• ECG (>40 yo)
• ?CXR
• ?Coags
  • GI bleeding, end-stage liver disease, coagulopathy
• ?Lactate
• ?Abd x-ray
  • Consider for r/o obstruction, perforation, or severe constipation
• ?US
• ?CT

DDX

Killers

1. AAA
2. Mesenteric Ischemia
3. Bowel Perforation
4. Small Bowel Obstruction
5. Sigmoid Volvulus
6. Ectopic Pregnancy
7. Placental Abruption
8. ACS

Diffuse

1. Peritonitis
2. Pancreatitis
3. Appendicitis (early)
4. AAA (leaking, ruptured)
5. Aortic Dissection
6. Small Bowel Obstruction
7. Diabetic gastric paresis
8. Mesenteric Ischemia
9. Diabetic Ketoacidosis
10. Bowel perforation
11. Volvulus
12. Sickle Cell Crisis
13. Mesenteric Ischemia
14. Gastroenteritis

Epigastric

1. Gallbladder Disease (Main)
2. GERD
3. PUD
4. Gastritis
5. Pancreatitis
6. Splenic enlargement/rupture/infarction/aneurysm
7. Myocardial Ischemia
8. Pericarditis/Myocarditis
9. Aortic Dissection

RUQ

1. Gallbladder Disease (Main)
2. Appendicitis (retrocecal)
3. Hepatitis
4. Hepatic abscess
5. Fitz-Hugh-Curtis Syndrome
6. Hepatomegaly due to CHF
7. Perforated duodenal ulcer
8. Pancreatitis
9. Herpes zoster
10. Myocardial Ischemia
11. Pneumonia
12. Bowel obstruction
13. Pulmonary Embolism

LUQ

1. Gastritis/gastric ulcer
2. Herpes Zoster
3. Pancreatitis
4. Splenic rupture/distension
5. Myocardial Ischemia
6. Pneumonia
7. Pulmonary Embolism

RLQ

1. Appendicitis
2. Abdominal Aortic Aneurysm (leaking, ruptured)
3. Crohn disease (terminal ileitis)
4. Diverticulitis (cecal)
5. Ectopic
6. Endometriosis
7. Epiploic Appendagitis
8. Herpes zoster
9. Inguinal hernia
10. Ischemic colitis
11. Meckel diverticulum
12. Mittelschmerz
13. Ovarian cyst (ruptured)
14. Ovarian Torsion
15. PID
16. Psoas Abscess
17. Testicular Torsion
18. Kidney Stone

LLQ

1. Abdominal Aortic Aneurysm (leaking, ruptured)
2. Diverticulitis (sigmoid)
3. Ectopic
4. Endometriosis
5. Epiploic Appendagitis
6. Herpes Zoster
7. Inguinal hernia
8. Ischemic colitis
9. Mittelschmerz
10. Ovarian cyst (ruptured)
11. Ovarian torsion
12. PID
13. Psoas Abscess
14. Testicular Torsion
15. Kidney Stone

Pelvic

Abdominal origin

1. Ureteral calculi (Kidney Stone)
2. Psoas abscess
3. Mesenteric adenitis
4. Incarcerated hernia

Pelvic origin

1. Ectopic
2. Adnexal torsion
3. Endometriosis
4. PID
5. Myoma (degenerating)
6. Ovarian cyst (rupture)
7. Tubo-ovarian abscess
8. Mittelschmerz
9. Endometriosis
10. Seminal vesiculitis

Extra-Abdominal

1. MI
2. Aortic Dissection
3. PNA
4. PE
5. Testicular Torsion
6. Herpes zoster
7. Muscle spasm
8. Strep Pharyngitis (peds)
9. Mononucleosis
10. DKA
11. ETOH ketoacidosis
12. Uremia
13. Sickle cell disease
14. SLE
15. Vasculitis
16. Glaucoma
17. Hyperthyroidsim
18. Methanol poisoning
19. Heavy metal toxicity
20. Addison's Disease
21. Porphyria

Elderly

• 60% are surgical
• Acute onset assoc w/ catastrophe
• Med list is important
• Abd exam generally unhelpful/difficult to localize pain
• Misc 25%
  • MI, dissection, mesenteric ischemia
• Biliary Disease - 21%
• Unknown - 20%
• Obstruction - 12%
  • prev surg adhesions, internal/external hernia, malignancy
  • sigmoid/cecal volv - persistant pain, can be subacute, n/v, may not have fever
• Perforated Viscus - 7%
  • nsaids
• Diverticular - 10%
• Appendicitis - 5%
  • 60% perforation in OR, lacking rebound/guarding
• Renal Colic - 4%

Source

• Tintinalli

• ACEP Geriatric lecture series