eMedicine Specialties > Emergency Medicine > Gastrointestinal

Abdominal Pain in Elderly Persons: Treatment & Medication

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
Contributor Information and Disclosures

Updated: Nov 5, 2008

Treatment

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

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).

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.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Antispasmodics

Believed to work centrally by suppressing conduction in the vestibular cerebellar pathways. They may have an inhibitory effect on the parasympathetic nervous system.


Dicyclomine (Bentyl)

Smooth muscle relaxant. Fairly effective in relieving pain from biliary tract disease. May be administered PO/IM. Cannot be administered IV.

Adult

20 mg PO qid
20 mg IM q4-6h

Pediatric

Not established

Effects are weakened when administered with anti-Parkinson drugs, haloperidol, and phenothiazines; toxicity of dicyclomine increases when administered concurrently with amantadine, antihistamines, type-I antiarrhythmics, phenothiazines, TCAs, or narcotic analgesics

Documented hypersensitivity; myasthenia gravis or narrow-angle glaucoma

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution when administering to patients with hepatic or renal insufficiency, cardiovascular disease, urinary tract obstruction, ulcerative colitis, GI obstruction, hyperthyroidism, or hypertension


Glycopyrrolate (Robinul)

Acts in smooth muscle, the CNS, and secretory glands where it blocks action of acetylcholine at parasympathetic sites. Similar to dicyclomine in effects. May be administered IV.

Adult

1-2 mg PO bid/tid
0.1-0.2 mg IV/IM tid/qid

Pediatric

Not established

Levodopa decreases effects; both amantadine and cyclopropane increase glycopyrrolate toxicity

Documented hypersensitivity; narrow-angle glaucoma; tachycardia; ulcerative colitis; paralytic ileus; acute hemorrhage

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May increase chances of developing megacolon, hyperthyroidism, CHF, CAD, hiatal hernia, and BPH

Opioid analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or have sustained injuries.


Morphine sulfate (Duramorph, Astramorph, MS Contin)

Generally safe in low-to-moderate doses in abdominal pain. Not recommended for biliary tract disease because of potential for sphincter of Oddi spasm.

Adult

2-5 mg IV initially; titrate to effect

Pediatric

Not established

Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs, MAOIs, and other CNS depressants may potentiate adverse effects

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate


Meperidine (Demerol)

Generally safe in low-to-moderate doses in abdominal pain. Causes less sphincter of Oddi spasm than morphine but has potential to cause CNS adverse effects.

Adult

50-150 mg PO/IV/IM/SC q3-4h prn

Pediatric

Not established

Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid with protease inhibitors

Documented hypersensitivity; MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with head injuries, since meperidine may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex); substantially increased dose levels due to tolerance may aggravate or cause seizures even if no history of convulsive disorders; monitor closely for morphine-induced seizure activity if seizure history


Fentanyl citrate (Sublimaze)

Potent narcotic analgesic with much shorter half-life than morphine sulfate. Potential advantages in management of abdominal pain include short duration of action and lack of histamine release. Potential disadvantage is potential for sphincter of Oddi spasm.

Adult

0.5-1 mcg/kg/dose IV/IM q30-60min

Pediatric

Not established

Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs may potentiate adverse effects of fentanyl when both drugs are used concurrently

Documented hypersensitivity; hypotension or potentially compromised airway in which establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation

More on Abdominal Pain in Elderly Persons

Overview: Abdominal Pain in Elderly Persons
Differential Diagnoses & Workup: Abdominal Pain in Elderly Persons
Treatment & Medication: Abdominal Pain in Elderly Persons
Follow-up: Abdominal Pain in Elderly Persons
Multimedia: Abdominal Pain in Elderly Persons
References
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Further Reading

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Keywords

abdominal pain, abdominal pain in elderly persons, stomach pain, biliary tract disease, appendicitis, diverticulitis, mesenteric ischemia, bowel obstruction, abdominal aortic aneurysm, peptic ulcer disease, malignancy, gastroenteritis, diabetes, hypertension

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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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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