Abdominal Pain in Elderly Persons Treatment & Management

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

Prehospital Care

Elderly patients with severe abdominal pain, abnormal vital signs, or altered mental status should undergo the following:

  • Large-bore IV placed with either normal saline or lactated Ringer solution (gauge fluid resuscitation by vital signs)
  • Cardiac monitor and pulse oximetry
  • Oxygen by nasal cannula or 100% face mask, depending on vital signs and pulse oximetry
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Emergency Department Care

Care in the emergency department is dictated by the severity of presentation. Assess ABCs and vital signs immediately. Place patients on a monitor and start an IV or heparin lock. Administer oxygen to patients who appear to be seriously ill.

If the diagnosis of AAA is suggested, perform a rapid bedside ultrasound, if available.

Administer IV boluses of normal saline or lactated Ringer solution to patients with suspected volume loss. Carefully hydrate patients with a history of renal disease or congestive heart failure to avoid volume overload.

A Foley catheter may be helpful as a guide for volume resuscitation in patients who are sicker. Incontinence is not an indication for a Foley catheter.

Keep all patients with abdominal pain as nothing by mouth (NPO) until surgical pathology is excluded.

Place a nasogastric tube in patients in whom bowel obstruction, ileus, or upper GI bleeding is suspected.

Maintain a low threshold for ordering additional tests such as CT scan or ultrasound.

If biliary disease is suggested, dicyclomine (Bentyl) or glycopyrrolate (Robinul) may be administered for pain. NSAIDs are very effective for biliary colic but should be administered with caution to elderly patients.

In patients with undifferentiated abdominal pain, administering small doses of opioids is reasonable. Several studies have demonstrated this to be safe and effective without decreasing diagnostic accuracy.

  • Morphine administered IV in doses of 2-4 mg is inexpensive and effective. Morphine, like all opioid analgesics, has been demonstrated to cause spasm of the sphincter of Oddi. This side effect should be taken into account when treating patients in whom biliary disease is suspected.
  • Fentanyl has distinct advantages for use in the emergency department. Its short half-life allows for frequent reevaluations between doses. It also causes almost no increase in histamine release and minimal drop in blood pressure.
  • Meperidine (Demerol) has been the traditional opioid of choice in biliary tract disease because it causes less sphincter of Oddi spasm. However, the incidence of adverse central nervous system effects, including seizures, have led many to caution against its use under any circumstance.
  • Depending on the practice environment, contacting the on-call surgeon prior to administering opioids may be reasonable.

Initiate appropriate antibiotic coverage for patients in whom sepsis, cholecystitis, appendicitis, diverticulitis, or perforated viscus is suspected. Please refer to the article on the specific diagnosis for choice of antibiotics for a specific disease process (see Differentials).

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Consultations

In patients in whom ruptured AAA or mesenteric ischemia is suspected, consult a surgeon immediately.

Consult a gastroenterologist immediately for patients with significant GI bleeding.

When the diagnosis is uncertain, obtain surgical consultation. Discharge of an elderly patient with abdominal pain should be the exception rather than the rule.

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Proceed to Medication
 
 
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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