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Abdominal Pain in Elderly Persons Clinical Presentation

  • Author: E David Bryan, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Dec 27, 2015
 

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 Examination

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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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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for 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 Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

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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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