GENI Program: GI and Abdominal Chief Complaints Kim Macfarlane Clinical Nurse Specialist, Critical Care February 2008
Dehydration Common acute and chronic problem Recognition is critically important to preserve renal function
Dehydration Check for underlying infections including mouth (e.g. thrush), ill-fitting dentures, dysphagia, orthostatic B/P, dry oral mucosa, I&O, urine colour/amount, serum Na+, serum Cr Watch for drug toxicities!!!!!
Malnutrition Multiple risk factors: Denture fit Oral infections/pain Dysphagia Ability to feed self Food intolerances
Malnutrition Drug therapies contributing to constipation and appetite suppression Drugs with extra-pyramidal side effects Living alone Under/overweight Depression Acute covert illness Exacerbation of chronic illness Chemotherapy etc.
Malnutrition Key Assessments: Weight loss Dependent edema Difficulty chewing or swallowing Skin sores, scaly flaky skin Dull brittle hair that easily falls out
Malnutrition Nausea, vomiting Constipation, diarrhea Hydration status Loss of balance and coordination Poor wound healing Eating patterns and sensations (e.g. feeling full after only a few bits)
Malnutrition Drug Effects: Reduced plasma proteins may potentiate the effects of drugs (e.g. more unbound drug) Acid/base disturbances - unpredictability of drug effects Pronounced hypotensive drug effects with reduced colloid osmotic pressure Parkinson s Disease very important to give medications on time so dysphagia does not develop
Malnutrition With slowed peristalsis, ensure that patients don t lie down immediately after meals Consult Dietitian Investigations - CBC (anemia, infection etc), ABGs (acid/base), serum pre-albumin, B vitamin profile, electrolytes, U/Cr etc. Look for worsening heart failure, new onset pneumonia
Abdominal Pain Studies of older adults presenting to ED with abdominal pain suggest that at least 50% require hospitalization 30-40% eventually require surgery for the underlying condition Because of their atypical/subtle presentations, many elderly patients with serious conditions are misdiagnosed with more benign problems such as gastroenteritis or constipation
Abdominal Pain Research suggests that approximately 40% will be misdiagnosed, contributing to an overall mortality rate of approximately 10%
Abdominal Pain Many may be initially referred to the wrong service (e.g. internal medicine when a surgeon may be required) Among elderly patients discharged from the ED with a diagnosis of nonspecific abdominal pain, approximately 10% eventually are diagnosed with an underlying malignancy
Factors Contributing to Muted or Less Pronounced Abdominal Pain in Older Adults Neuropathies especially those associated with DM Chronic use of certain medications corticosteroids, NSAIDs, opioids Less abdominal muscle mass making guarding less apparent or impossible to determine Immunological changes with age
Some Drugs That Can Cause Abdominal Pain Antibiotics Digoxin Colchicine Metformin
Have a High Index of Suspicion!!!!!!!!!! Careful history-taking, determination of risk factors and focused physical examination (including rectal exam) as well as a high index of suspicion are crucial to prevent missed diagnoses
Atypical Signs/Symptoms Elderly patients are more likely than younger patients to present with vague symptoms and have nonspecific findings on examination Many elderly patients have a diminished sensorium, allowing pathology to advance to a dangerous point prior to symptom development. Hence, LATE PRESENATION with HIGH ACUITY
Atypical Signs/Symptoms Their pain is likely to be much less severe than expected for a particular disease Acute peritonitis is without the classic findings of an acute abdomen. May lack classic peritoneal signs: rebound and guarding Rather than severe pain, may present with constipation and decreased appetite Delirium may also be the initial finding with an acute abdomen
Atypical Signs/Symptoms Less likely to have fever or leukocytosis Instead of fever, may present with functional decline, falls and/or generalized weakness Urinary urgency, frequency, incontinence or retention may be a sign of increased intra-abdominal pressure (intra-abdominal compartment syndrome)
Atypical Signs/Symptoms A palpable mass may indicate malignancy or phlegmon from ruptured appendix or diverticulitis. A pulsatile mass should raise the consideration of AAA Pneumonia occasionally may cause abdominal pain without respiratory symptoms
Analgesia for Undiagnosed Abdominal Pain Pain is no longer a primary diagnostic tool It is now advocated that patients with undiagnosed acute abdominal pain should receive analgesic In ED, clinical practice guidelines dating back to the early 1990 s and current research suggest that treating this pain has no impact on diagnostic accuracy and actually enhances the physical examination
Current Research: Do Opiates Affect the Clinical Evaluation of Patients With Acute Abdominal Pain A meta-analysis of placebo-controlled trials indicated that although opiate administration may diminish the perception of abdominal pain, it did not appear to increase management errors, such as delay in surgery or misdiagnosis. The authors conclude that giving opiates to patients with abdominal pain does not result in any major harm [Ranji SR, Goldman LE, Simel DL, Shojania KG (2006) JAMA. 296: 1764-1774]
Pancreatitis Most common non-surgical condition in the older adult Mortality rate for >70yrs is over 40% Higher incidence of necrotizing pancreatitis Presentations: severe pain with N&V, dehydration; SIRS; approximately 10% present with altered mental status and hypotension
Abdominal Aortic Aneurysm Condition almost exclusively found in elderly patients Affects up to 8% of older men and 1.5% of older women Major risk factors include: male, age, smoking, and family history
Abdominal Aortic Aneurysm The US Preventative Services Task Force (USPSTF), now recommends one-time ultrasound screening for men aged 65-75yrs (Annals of Internal Med. Feb. 1, 2005) Older women who smoke (4-fold increased risk) or have a history of heart disease (over 3-fold increased risk) may benefit from screening for abdominal aortic aneurysm (AAA) (J Vasc Surg 2007;46:630-635)
Abdominal Aortic Aneurysm Many AAA s are silent until rupture, at which time only 10% to 25% of affected individuals survive to hospital discharge following repair Many older adults present with a clinical picture suggestive of renal colic (most common misdiagnosis) or musculoskeletal back pain
Abdominal Aortic Aneurysm Approximately 30% with ruptured AAA are initially misdiagnosed If the diagnosis of ruptured AAA is made in the hemodynamically stable patient, the mortality is approximately 25%. In patients presenting in shock, the mortality is 80% Major complication is acute renal failure: ensure adequate volume replacement to prevent hypotension
Biliary Tract Disease Some studies suggest that biliary tract disease is the most common diagnosis among elderly patients presenting with abdominal pain Up to 50% of patients older than 65 years have gallstones Biliary tract diseases include symptomatic cholelithiasis, choledocholithiasis, calculus and acalculous cholecystitis, and ascending cholangitis
Biliary Tract Disease The mortality rate for elderly patients diagnosed with cholecystitis is approximately 10% Cholecystitis is acalculous in approximately 10% of elderly patients with the condition. Classically, the diagnosis requires the presence of right upper quadrant pain associated with fever and leukocytosis. However, 25% of elderly patients may have no significant pain, and less than 50% have fever, vomiting, or leukocytosis
Biliary Tract Disease Complications of biliary tract disease include gallbladder perforation, emphysematous cholecystitis, ascending cholangitis, and gallstone ileus, which accounts for approximately 20% of small bowel obstruction in elderly patients (higher prevalence in women)
Appendicitis Appendicitis is a less common cause of abdominal pain in elderly patients than in younger ones. But the incidence among elderly patients appears to be rising 3 rd most common indication for surgery in the older adult About 10% of cases occur in patients older than 60 years, BUT 50% of all deaths from appendicitis occur in this age group
Appendicitis Estimated initial misdiagnosis is as high as 50% In older adults, the perforation rate is approximately 50%: 5 times higher than in younger adults Delayed presentation is usually associated with increased risk of perforation. Approximately 30-40% of elderly patients with acute appendicitis present more than 48 hours after the onset of abdominal pain
Appendicitis The diagnosis can be extremely difficult to make because about: 50% do not present with fever or leukocytosis 33% do not localize pain to the right lower quadrant 25% do not have appreciable right lower quadrant tenderness Only 20% present with anorexia, fever, right lower quadrant pain, and leukocytosis
Appendicitis Even with minimal lower abdominal pain, consideration should be given to possible perforated diverticulitis or ruptured acute appendicitis
Diverticulitis Risk factors for the development of diverticula in the colon is largely associated with diet and age US data suggest that diverticula are present in approximately 50-80% of patients older than 65 years
Diverticulitis Diverticulitis results when diverticula become obstructed by fecal matter, resulting in lymphatic obstruction, inflammation, and perforation. By definition, diverticulitis involves at least microperforation of the colon
Diverticulitis Approximately 85% of cases involve the left colon. Right-sided diverticulitis is often more difficult to diagnose, but generally more benign Elderly patients with diverticulitis are often afebrile, and an elevated WBC count is observed in less 50% of cases. Only 25% of patients will show a positive result for occult blood in stool
Diverticulitis Subtle signs/symptoms may include diffuse pain and low-grade temperature signaling inflammation, infection or perforation
Bowel Obstruction Accounts for approximately 12% of cases of abdominal pain in elderly patients High-pitched bowel sounds are associated with obstruction. Hypoactive or absent bowel sounds may be a sign of advanced obstruction
Bowel Obstruction GI obstruction may be present with dehydration, cramps, stringy or diarrhea stools and general complaints of feeling unwell
Bowel Obstruction Small bowel obstruction is frequently caused by adhesions from previous surgery. In elderly patients, approximately 30% of cases are caused by an incarcerated hernia, and 20% are caused by gallstone ileus Large bowel obstruction is most commonly caused by malignancy or volvulus
Bowel Obstruction Cecal volvulus is fairly rare and typically presents clinically as small bowel obstruction Sigmoid volvulus is much more common and often can be identified by plain abdominal radiography. Risk factors for sigmoid volvulus include inactivity and laxative use, both of which are common in elderly patients Distension of the colon of more than 9cm can signal impending perforation
Peptic Ulcer Disease The incidence among elderly patients is increasing, which may be in part related to the increasing use of NSAIDs NSAIDs users are 5-10 times more likely to develop PUD than nonusers
Peptic Ulcer Disease Mortality rates in older adults are approximately 100 times higher than that of younger people Diagnosis can be difficult as about 35% have no pain. GI bleeding may present with insidious signs of dehydration and cramping poorly localized abdominal pain. Melena may be present
Peptic Ulcer Disease Complications include hemorrhage and perforation. In elderly patients, perforation is often painless, and free air may be absent on plain radiographs in more than 60% of patients
Gastroenteritis With older adults presenting with nausea and vomiting, consider gastroenteritis as a diagnosis of exclusion. Vomiting and diarrhea can be caused by many illnesses Reviews of cases of missed appendicitis reveal that approximately 50% of patients initially were diagnosed with gastroenteritis Diarrhea may be associated with DM neuropathies
Gastroenteritis Even if other conditions have been excluded, note that gastroenteritis can cause serious morbidity in elderly patients. Of all deaths due to gastroenteritis, approximately 66% occur in patients older than 70 years
Constipation Common problem, but should be considered a diagnosis of exclusion; it may be a symptom of more serious pathology Look at the patient s underlying comorbidities (e.g. hypothyroid), accompanying signs/symptoms and risk factors hydration, diet (e.g. fibre intake), exercise and medication profile Colace is not a drug of choice
Mesenteric Ischemia Although it accounts for less than 1% of cases of abdominal pain in elderly patients, mesenteric ischemia is an important condition to consider Mortality ranges from 70-90%, with any delay in diagnosis increasing the risk of death Risk factors include: cirrhosis, atrial fibrillation, prosthetic valve, abdominal infection, atherosclerotic disease and low ejection fraction
Mesenteric Ischemia Patients classically present with severe abdominal pain despite having little tenderness on examination. Vomiting and diarrhea are often present Sometimes patients may present with recurrent episodes of postprandial abdominal pain, intestinal angina Highly associated with a hypercoagulable state
A closing note: The mortality rates for many intra-abdominal conditions in the elderly rivals that of serious cardiopulmonary diseases. Elderly patients with abdominal pain need to be evaluated just as carefully and admitted just as liberally as those with chest pain. [Burg & Francis (2005, Aug.) Emergency Medicine p.12]