The evaluation of elderly patients presenting with abdominal pain poses a difficult challenge for the emergency physician. It will become an increasingly common problem because the elderly population in the India is growing rapidly. The definition of elderly varies among authors, but for the purpose of this subject, age 60 years is a reasonable starting point.
Studies published in the 1980s and 1990s demonstrated that, among elderly patients presenting to the ED with abdominal pain, at least 50% were hospitalized and 30-40% eventually had surgery for the underlying condition. These studies also showed that approximately 40% of these patients were misdiagnosed, contributing to an overall mortality rate of approximately 10%. The image below illustrates an inflammatory mass of an elderly woman with a ruptured appendix.
A careful history and physical examination as well as a high index of suspicion are crucial to prevent missed diagnoses.
Mortality varies greatly depending on the underlying pathology. Approximately 30-40% of patients require surgery, and overall mortality is approximately 10%.
Abdominal pain may be the presenting symptom in a wide range of diseases in elderly patients. Note that elderly patients with intra-abdominal pathology are more likely to present with symptoms other than abdominal pain, such as fever, fatigue, chest pain, or altered mental status.
Biliary tract disease includes symptomatic cholelithiasis, choledocholithiasis, calculus and acalculous cholecystitis, and ascending cholangitis.
Appendicitis is a less common cause of abdominal pain in elderly patients than in younger patients, but the incidence among elderly patients appears to be rising.
The formation of diverticula in the colon is largely a product of diet and age and is relatively rare in those younger than 40 years.
Including mesenteric ischemia (see the image below) in the differential is important, even though it accounts for less than 1% of cases of abdominal pain in elderly patients. Mortality ranges from 70-90%, and any delay in diagnosis increases the risk of death.
Bowel obstruction accounts for approximately 12% of cases of abdominal pain in elderly patients.
AAA is observed almost exclusively in elderly patients. Approximately 5% of men older than 65 years have AAA. The male-to-female ratio is 7:1.
Peptic ulcer disease (PUD) deserves special mention, since the incidence among elderly patients is increasing. This may be due in part to the increasing availability and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Users of NSAIDs are 5-10 times more likely to develop PUD than nonusers.
Among elderly patients discharged from the ED with a diagnosis of nonspecific abdominal pain, approximately 10% eventually are diagnosed with an underlying malignancy.
Consider gastroenteritis a diagnosis of exclusion in elderly patients with vomiting and diarrhoea. Vomiting and diarrhoea can be caused by many illnesses. Reviews of cases of missed appendicitis reveal that approximately one half of patients initially were diagnosed with gastroenteritis.
Elderly patients with urinary tract infection are much less likely to have symptoms of dysuria, frequency, or urgency than younger patients
Myocardial infarction and pneumonia also commonly present as vague abdominal complaints in elderly patients.
Therefore, its not just abdominal pain. When it happens to an elderly person, he/she should be taken to a medical professional immediately to diagnose the Etiology correctly and differentiate the fatal outcomes promptly and start treatment immediately.
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