THE ABDOMEN
| ABDOMINAL PAIN IN THE ELDERLY —Barry C. Simon, MD, Professor of Medicine, University of California, San
Francisco, School of Medicine; Chairman and Program Director, Department of Emergency Medicine, Alameda County
Medical Center, Highland Campus, Oakland, CA
|
| Dangers of nonsteroidal anti-inflammatory drugs (NSAIDs): especially problematic in elderly; speaker cites
recent case of man with gout taking NSAIDs who died from gastrointestinal (GI) bleeding; acetaminophen (Tylenol)
should be used more frequently
|
| Abdominal pain in elderly: difficult to assess; liberal use of computed tomography (CT) recommended; err on side of
admission if unsure
|
| Disease out of proportion to pain: woman 71 yr of age with acute onset of mild-to-moderate but persistent abdominal
pain 4 hr before arrival in emergency department (ED); no fever, nausea, vomiting, or constipation; patient pale and
in mild distress but can hold conversation; heart and lungs fine; abdomen slightly distended and mildly and diffusely tender;
no guarding or rebound; no masses; stool brown; history of hypertension, arthritis, no surgeries; case illustrates how
well patient can appear despite serious disease
|
| Evaluation: chest and abdominal x-rays show problems; free air on x-rays—look at upright chest x-ray; if not helpful,
try left-side down decubitus view to put air up over dome of liver, making it easy to distinguish from bowel gas; ultrasonography
(US)— study shows US as good as or better than plain chest x-ray; if air seen over liver on US, be suspicious
of free air; CT—gold standard
|
| Gastric ulcers in elderly: survey of current literature showed 1) gastric ulcers far more common in elderly than in
younger population; gastric ulcers cause more pain in back, and often cause more air and spillage into abdomen than perforated
duodenum; 2) antacids offer no protection against harmful effects of NSAIDs (proton pump inhibitors [PPIs] offer
some protection); 3) unlike younger patients, older patients present with significant bleeding (76% of those >74 yr of
age) and perforations (many present without pain); 4) incidence of complications 0.5% (ie, 1 in 200 have serious complication;
rate 2.8% in those >70 yr of age); 5) cyclooxygenase (COX)-2 inhibitors being prescribed to avoid complications
of NSAIDs, but if patient taking low-dose aspirin, risk for serious GI complications goes back up to level of patients taking
NSAIDs
|
| Elderly patients: elderly large and growing part of population (20% of population in next 25 yr, with “oldest of old”
[>85 yr] fastest growing segment); diagnosis difficult and mistakes common; patient characteristics—stubbornness
(can prevent patient from fully informing physician) and fear of serious illness and loss of independence combine to delay
seeking care; dementia interferes with history; patients tend to self-diagnose and minimize chronic problems to obscure
acute issues; dangerous to label patient; anatomic differences—abdominal musculature not as robust; previous
surgery (adhesions); poor tissue perfusion due to arthrosclerotic disease (leads to earlier perforation); decreased pain sensitivity;
coexisting disease (eg, glaucoma can cause abdominal pain)
|
| Clinical impact of elderly population: ED time for evaluation of abdominal pain twice as long as in younger patients;
≈20% of ED visits, one third of all ambulance traffic, two thirds of all admissions, and ≈50% of intensive care unit (ICU) admissions
|
| Diagnostic accuracy: high for younger patients with biliary, peptic, or diverticular disease, and abdominal aortic aneurysm
(AAA); poor for elderly, ie, 58% of time correct for peptic ulcer disease, 55% for diverticulitis, and 68% overall;
highlights importance of admitting patients with diagnosis of “abdominal pain of unknown etiology” to avoid labeling
and delay of care; mortality twice as high in elderly patients admitted to medicine service with abdominal pain than in
those admitted to surgical service (patients with comorbidities sent to medical service); indeterminate abdominal
pain—10% of elderly admitted with this diagnosis have malignancy; 40% of those ≥65 yr of age go to operating room
(OR) in next 3 mo; most common admission diagnosis in elderly; phosphate—low sensitivity and specificity, but may
be abnormal earlier in patients with mesenteric ischemia
|
| Case: woman 65 yr of age; ≈24 hr of vague constant abdominal pain that waxes and wanes; no past history of similar pain; history
includes hysterectomy; only slightly febrile, tachypneic, and tachycardic; anxious; regular heart rate and rhythm; decreased
bowel sounds; abdomen mildly and profusely tender (upper more than lower) with no guarding or rebound; stool
negative; US positive for gallstones; diagnosis gallbladder disease
|
| Biliary disease in elderly: differs from younger patients; in this case, small hike in bilirubin but otherwise, laboratory
tests normal; most common diagnosable cause of abdominal pain in elderly; many do not complain of pain; no fever or leukocytosis;
third most common source of sepsis; complications in biliary disease also far more common in elderly; majority
of elderly have gallstones, so unknown whether cause of patient’s problem; unlike younger patients, no female predominance
|
| Acalculous cholecystitis: rare in younger patients, common in elderly; consider when patient confused; US shows no
stones and thick wall around gallbladder; no special diagnostic tools (liver enzymes and bilirubin may help; US helpful
but not as good as hepatobiliary iminodiacetic acid [HIDA] scan, which can show dye uptake in biliary tree); caution—
try to get patient admitted; document attempts in chart
|
| Bowel obstruction: case of man 80 yr of age; nursing home patient with left hemiparesis from old cerebrovascular accident;
complains of abdominal pain over past 12 hr; profuse nausea and vomiting; abdominal distention, no fever; pain initially
waxed and waned but now constant; no known allergies; daily aspirin; slightly tachycardic; abdomen diffusely
tender without guarding or rigidity; stools negative; bowel sounds rare and high-pitched; normal laboratory tests; obstruction
usually diagnosed with plain x-rays; in elderly who need emergency surgery, mortality 44%; hernias in children
most common cause but overlooked as potential cause in elderly; bowel obstructions usually secondary to cancer; also
consider volvulus
|
| Volvulus: population at risk includes sedentary people, patients taking anticholinergic medications, and those with
chronic constipation; high mortality (25%); in elderly, volvulus disease of sigmoid; similar incidence in men and women,
whereas cecal volvulus very different (mostly occurs men and in “younger” age group, ≈50 yr of age); plain films diagnose
volvulus ≈60% of time; sigmoid volvulus appears as distended loop of bowel usually seen on left side, while cecal
volvulus looks like coffee bean
|
| Case: woman 70 yr of age with vague abdominal pain for couple of days; no nausea, vomiting, diarrhea, or fever; informed
staff she “just needed an enema”; history of intermittent constipation, arthritis, diabetes, and complete hysterectomy; medications
include NSAID and glyburide (Micronase); mild-to-moderate crampy pain; vital signs unremarkable; patient appeared
well (reading newspaper); mild but consistent tenderness in right lower quadrant; normal bowel sounds; rectal
examination negative; laboratory tests unremarkable; no guarding or rebound; diagnosed with appendicitis on US; during
surgery, found to have perforation, with major soiling throughout abdomen
|
| Appendicitis in elderly: using US, transverse cut enables physician to see appendix; if distended 7 mm and noncompressible,
significant for appendicitis; almost 100% have pain but usually vague; large percentage do not have traditional
course of starting vague and progressing through lower right quadrant, although most have tenderness; unusual to have
guarding or rebound, and many do not have fever or elevated white blood cell (WBC) count; CT and C-reactive protein
(CRP) may be helpful; appendicitis not anticipated in elderly, but accounts for 5% of all abdominal emergencies in ED;
>50% of patients experience perforation before going to OR, with delay and misdiagnosis major factors; 10% of all appendicitis
occurs in patients >65 yr but accounts for half of all appendicitis deaths; mortality 25%
|
| Pain management: elderly more sensitive to pain medication and tend to experience drop in blood pressure (BP); speaker
advocates fentanyl (Sublimaze; short-acting; reversible; does not cause release of histamine so no problem with BP management)
|
| Mesenteric ischemia: man 76 yr of age; acute onset of severe abdominal pain progressively becoming worse; one episode
of emesis and one large watery stool (no blood in emesis or stool); no fever; pain generalized; complicated history of hypertension,
atrial fibrillation, and congestive heart failure (CHF); no prior surgeries; takes many medications, including aspirin;
no known allergies; looks sick; tachycardic and tachypneic; flow murmur; abdomen not distended, soft, with no guarding or
rebound, no masses or bruits; guaiac-positive stool; laboratory tests unremarkable, slight left shift in WBC count, and phosphate
up; slight anion gap; diagnosis of mesenteric ischemia
|
| Mesenteric ischemia in ED: surgeon may delay past point of patient fitness for surgery; hallmark pain out of proportion
to physical findings; guarding occurs late; digitalis (used in CHF for low–flow state) independent risk factor for bowel
ischemia; presentation varies, depending on cause—nonocclusive 50% (low-flow states; seen more in ICU than ED),
but speaker thinks percentage higher; mesenteric arterial thrombosis 10% (patients have atherosclerotic disease, and when
blood shunted from gut or demand for blood in gut increased, pain [intestinal angina] occurs); thrombosis in mesenteric
vein 10% (deep boring pain, worse after meals; several ED visits before laboratory abnormalities seen; malignancy with
coagulation disorder often present); embolic 30% (patient fine, then abruptly in severe pain with vomiting and diarrhea);
angiography diagnostic and may be therapeutic if performed soon enough
|
| Abdominal aortic aneurysm: case—man 85 yr of age with acute onset of severe diffuse abdominal pain; no nausea,
vomiting, or diarrhea; low BP and rapid heart rate; diaphoretic and in severe distress; hypertension, previous myocardial
infarction (MI) and coronary artery bypass; obese diffusely tender abdomen with rebound and guarding, decreased bowel
sounds, no masses; diagnosis—US and CT; large aorta surrounded by large clot; ≈25% of patients have thrill or bruit;
pulsation in anteroposterior direction normal but if lateral, not normal and provides clue; also “blue toe syndrome” associated
with AAA and with warfarin (Coumadin), caused by plaque that breaks off in aorta when aneurysm starts to distend
and occludes vessels in toes; pain with leak, no pain and asymptomatic if no leak or rupture; present in 1% to 4%
(study suggests ≈6%) of population >50 yr of age
|
| DAMAGE CONTROL AND MANAGEMENT OF THE OPEN ABDOMEN —John A. Morris, Jr, MD, Professor of Surgery,
Vanderbilt University, Nashville, TN
|
| Damage control: speaker’s review 10 to 15 yr ago identified abdominal compartment syndrome as major failure of damage
control (of 16 patients, 4 died immediately on decompression); recognized closing abdomen with towel clips not optimal;
gained better understanding of pathophysiology; began “bumper car” journey toward solutions for managing patients
with open abdomen; “Bogota bag” reported (nonoperative temporary abdominal closure); speaker’s group studied mesh
closure and skin grafting of abdomen and found them not optimal; defects cosmetically unattractive, and managing exposed
bowel for long periods led to high complication rate
|
| Conclusions on damage control: successful 80% of time; 1) lowers mortality; 2) highly expensive; 3) fistula formation
primary driver of expense; 4) time frame to get abdomen closed under low-complication circumstances shorter than
expected
|
| Time factor: complication rate rises dramatically after abdomen open for 8 days; many procedures customarily done in
OR can be done at bedside (eg, in ICU, can do unpacking, wash-outs, orthopedic damage control, tracheostomy, feeding
access, and filter placement)
|
| Principles of management: 1) protect bowel (materials used and pressure applied critical); 2) preserve abdominal domain;
3) biologic closure imperative; close fascia directly or use biologic substitute
|
| Phases of damage control: patient in OR (eg, protruding edematous bowel); first phase—use triple-layer dressing
closure, ie, flexible inert plastic material, surgical towel or gauze over dressing, Ioban dressing on top that expands with
initial resuscitation (goes up and down with patient’s volume status, and appears to expand, so abdominal compartment
syndrome avoided); wrinkling of dressing indicates patient ready for more surgery; second phase—vacuum-assisted closure
(VAC; using K-V.A.C commercial product) that produces negative pressure over abdominal viscera and allows
maintenance of abdominal domain; can now maintain abdominal domain just with K-V.A.C suction and bringing skin
flaps or sides of wound together with Ioban; very effective to maintain and regain domain but requires patience
|
| Synchrony: timing critical; 8-day window; first 24 to 36 hr resuscitation; then first phase of restoration, ie, preparation of
patient for definitive orthopedic or general surgical procedures; most patients need only 2 to 4 days, while worse cases
(lost domain and extensive bowel swelling) require 8 days; third phase—definitive orthopedic procedures; source control
for general surgery patients; start posttraumatic diuresis; reestablish bowel continuity (biologic closure now in same
operation); day 7 or 8, ready for closure; primary (fascia-to-fascia) closure ideal; due to high fistula rate, no longer use
synthetic mesh closure and skin grafting of abdomen; on day 8, patients go to OR for biologic closure or fascia-to-fascia
closure
|
| AlloDerm: speaker notes in group cited earlier with 20% complications, 34% had fistulas; average cost ≈$350,000 per patient
for treatment up to discharge; often took >1 yr; many in United States use AlloDerm (decellularized human cadaveric
dermis); expensive but pliable, strong, and fluid-permeable; in early experience with 9 patients, 3 complications and no fistulas
|
| Technique: AlloDerm on undersurface of fascia, no longer placed on surface; always raise skin flaps in order to cover
with skin; use running polypropylene (Prolene) sutures; put closed drains in place; can close large defects with multiple
pieces of AlloDerm (now available in larger sheets); can use with stomas; experience with ≈100 patients shows relatively
high wound infection rate, but only 8% required AlloDerm, and fistula rate reduced from ≈34% to ≈5%
|
Educational Objectives
| The goal of this program is to educate the listener about abdominal pain in the elderly and recent issues in damage control
and management of the open abdomen. After hearing and assimilating this program, the clinician will be better able to:
|
 | 1. Outline important principles of evaluating abdominal pain in the elderly in the emergency department (ED).
|
| 2. Discuss the unique clinical presentation of appendicitis in elderly patients.
|
| 3. Describe problems and challenges abdominal pain in elderly patients presents to physicians in the ED.
|
| 4. Discuss recent trends in open abdominal wound closure.
|
| 5. Name some key methods for maximizing success in closure of the open abdomen.
|
Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [several trade names]
Aspirin (acetylsalicylic acid; ASA) [several trade names]
Naproxen [Aleve, Anaprox, Anaprox DS, EC-Naprosyn, Naprosyn, Naprelan]
Warfarin sodium [Coumadin]
Suggested Reading
Abou-Nukta F et al: Effects of delaying appendectomy for acut.appendicitis for 12 to 24 hours. Arch Surg 141:504,
2006; Baum SA et al: Old people in the emergency room: age-related differences in emergency department use and care.
J Am Geriatr Soc 35:398, 1987; Cina SJ et al: From emergency room to morgue: deaths due to undiagnosed perforated
peptic ulcers. Report of four cases with review of the literature. Am J Forensic Med Pathol 15:21, 1994; Cotroneo AR
et al: Endovascular abdominal aortic aneurysm repair: how many patients are eligible for endovascular repair? Radiol
Med (Torino) 111:597, 2006; Grossmann EM et al: Sigmoid volvulus in Department of Veterans Affairs Medical
Centers. Dis Colon Rectum 43:414, 2000; Gurleyik G et al: Abdominal surgical emergency in the elderly. Turk J Gastroenterol
13:47, 2002; Habesoglu MA et al: A case of bronchogenic carcinoma presenting with acute abdomen. Tuberk
Toraks 53:280, 2005; Hata J et al: Evaluation of bowel ischemia with contrast-enhanced US: initial experience.
Radiology 236:712, 2005; Hu JC et al: Mesenteric inflammatory veno-occlusive disease as a cause of acute abdomen:
report of five cases. Surg Today35:961, 2005; Irving PM et al: Acute mesenteric infarction: an important cause of abdominal
pain in ulcerative colitis. Eur J Gastroenterol Hepatol 17:1429, 2005; Janzon L et al: Acute abdomen in the
surgical emergency room. Who is taken care of when for what? Acta Chir Scand 148:141, 1982; Kulah B et al: Emergency
bowel surgery in the elderly. Turk J Gastroenterol 14:189, 2003; Lagana D et al: Emergency endovascular treatment
of abdominal aortic aneurysms: feasibility and results. Cardiovasc Intervent Radiol 29:241, 2006; Laurila J et al:
Acute acalculous cholecystitis in critically ill patients. Acta Anaesthesiol Scand 48:986, 2004; Mathis RD et al: An
outcome study of the use of computed tomography for the diagnosis of appendicitis in a community-based emergency department.
South Med J 98:1169, 2005; Nonthasoot B et al: Acute mesenteric ischemia: still high mortality rate in the
era of 24-hour availability of angiography. J Med Assoc Thai 88 Suppl 4:S46, 2005; Owen CC et al: Acute Acalculous
Cholecystitis. Curr Treat Options Gastroenterol 8:99, 2005; Peura DA: Prevention of nonsteroidal anti-inflammatory
drug-associated gastrointestinal symptoms and ulcer complications. Am J Med 117 Suppl 5A:63S, 2004; Riddell AM et
al: Assessment of acute abdominal pain: utility of a second cross-sectional imaging examination. Radiology 238:570,
2006; Suggested Reading Tiah L et al: Sigmoid volvulus: diagnostic twists and turns. Eur J Emerg Med 13:84, 2006;
Yu SH et al: Ultrasonography in the diagnosis of appendicitis: evaluation by meta-analysis. Korean J Radiol 6:267,
2005
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Simon spoke at Topics in Emergency Medicine, presented October 24-27, 2005, in San Francisco, CA, and sponsored
by the University of California, San Francisco, School of Medicine. Dr. Morris spoke at the Detroit Trauma Symposium,
presented November 10-11, 2005, in Dearborn, MI, and sponsored by the Wayne State University School of Medicine, Detroit
Receiving Hospital, and University Health Center. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
|
