Abdominal Pain in Elderly Persons Clinical Presentation
- Author: E David Bryan, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
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)
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:
Cardiovascular disease (hypertension, coronary artery disease, atrial fibrillation, peripheral vascular disease)
Previous abdominal surgery
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:
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.
Pneumonia occasionally may cause abdominal pain without respiratory symptoms.
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.
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.
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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