Abdominal Pain in Elderly Persons Clinical Presentation

  • Author: E David Bryan, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Apr 21, 2011
 

History

Obtaining a careful history is especially important in elderly patients complaining of abdominal pain. Elderly patients are often less likely to volunteer key points in their symptom development and their medical history. Unfortunately, many elderly patients may be unable to give an adequate history due to predisposing conditions such as dementia or prior stroke.

Key points in the history include the following:

  • Time of onset and course of the pain
  • Sudden or gradual onset
  • Location, quality, and severity of pain
  • Radiation (eg, to back, groin, shoulder)
  • Aggravating or precipitating factors (eg, food, position, medication)
  • Palliative factors
  • Prior similar episodes
  • Ability to pass stool or flatus

Associated symptoms include the following:

  • Fever, chills, or sweating
  • Urinary symptoms (eg, dysuria, hematuria, hesitancy)
  • Anorexia, nausea, vomiting, or diarrhea
  • Melena or blood in the stool
  • Dyspnea or chest pain

Medical history can provide clues as to the possible etiology of the pain. The following are particularly important to elicit:

  • Diabetes
  • Cardiovascular disease (hypertension, coronary artery disease, atrial fibrillation, peripheral vascular disease)
  • Previous abdominal surgery
  • Smoking history
  • Alcohol use
  • NSAID use
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Physical

A thorough physical examination can help to identify the underlying cause of abdominal pain. In general, findings on abdominal examination tend to be less pronounced than in younger patients. Give special attention to the following systems:

Vital signs

Tachycardia or hypotension may be signs of ruptured AAA, septic shock, GI hemorrhage, or volume depletion.

Take a rectal temperature to detect fever or hypothermia.

Pulmonary

Pneumonia occasionally may cause abdominal pain without respiratory symptoms.

Cardiovascular

Acute myocardial infarction can present as epigastric pain with or without nausea and vomiting.

The finding of atrial fibrillation or signs of diminished cardiac output should raise the consideration of mesenteric ischemia.

Hypotension, even if transient, is an ominous sign and should elicit consideration of ruptured AAA, acute myocardial infarction, or septic shock.

Abdominal examination

High-pitched bowel sounds often are associated with bowel obstruction. Absent bowel sounds may indicate adynamic ileus or advanced bowel obstruction.

A tympanitic abdomen may be observed with bowel obstruction.

Elderly patients with peritonitis may lack classic peritoneal signs of rebound and guarding.

A palpable mass may indicate malignancy or phlegmon from ruptured appendix or diverticulitis. A pulsatile mass should raise the consideration of AAA.

Carefully look for the presence of hernia at the umbilicus, in the groin, or near the site of prior surgical incisions.

Genitourinary examination

Perform a rectal examination to identify tenderness, fecal impaction, and the presence of gross or occult blood. Failure to perform a rectal examination in patients with abdominal pain may be associated with an increased rate of misdiagnosis and should be considered a medicolegal pitfall.

Perform a pelvic examination in women regardless of whether the patient may have had a hysterectomy or is postmenopausal.

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Causes

Causes of abdominal pain in elderly patients are as follows (see Pathophysiology for more information):

  • Biliary tract disease
  • Appendicitis
  • Diverticulitis
  • Mesenteric ischemia (risk factors include atrial fibrillation, atherosclerotic disease, and low ejection fraction)
  • Abdominal aortic aneurysm
  • Peptic ulcer disease
  • Malignancy
  • Gastroenteritis

Bowel obstruction

Small bowel obstruction most often is caused by adhesions from previous surgery. In elderly patients, an incarcerated hernia, as shown below, causes approximately 30% of cases, and approximately 20% are caused by gallstone ileus.

CT scan of a 64-year-old woman with vague abdominaCT scan of a 64-year-old woman with vague abdominal pain of 2 days' duration. Physical examination revealed a tender palpable mass in the left lower quadrant. CT scan reveals an incarcerated ventral hernia.

Large bowel obstruction is most often caused by malignancy or volvulus.

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Contributor Information and Disclosures
Author

E David Bryan, MD  Assistant Professor of Emergency Medicine, Texas Tech University Health Science Center at El Paso; Medical Director, Department of Emergency Medicine, Thomason Hospital

E David Bryan, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard Lavely, MD, JD, MS, MPH  Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine

Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Inflammatory mass in the right lower quadrant of an 84-year-old woman with mild abdominal pain of 2 days' duration. A ruptured appendix was found at surgery.
CT scan of a 76-year-old woman with severe abdominal pain of 3 hours' duration. Note the ringlike enhancement of bowel wall in the posterior abdomen. Ischemic small bowel was resected at surgery.
Radiograph of a 90-year-old man with abdominal pain of 4 days' duration. Plain films reveal large bowel dilatation. Sigmoid volvulus with ischemic colon was diagnosed at surgery.
Radiograph of a 79-year-old woman with several hours of diffuse abdominal pain. Initial examination of the plain films suggests bowel obstruction.
Radiograph of a 79-year-old woman with several hours of diffuse abdominal pain. Initial examination of the plain films suggests bowel obstruction. Close-up view reveals pneumatosis intestinalis, indicating mesenteric ischemia.
CT scan of a 64-year-old woman with vague abdominal pain of 2 days' duration. Physical examination revealed a tender palpable mass in the left lower quadrant. CT scan reveals an incarcerated ventral hernia.
CT scan of a 62-year-old man who reported 2 weeks of left lower quadrant abdominal pain. CT scan reveals fat stranding and multiple diverticula around the descending colon. A phlegmon containing bowel and inflammatory tissue has eroded into the left psoas muscle.
A lower CT scan slice from a 62-year-old man who reported 2 weeks of left lower quadrant abdominal pain. Multiple diverticula are observed with an inflammatory mass overlying the left ilium.
 
 
 
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