Abdominal Pain in Elderly Persons Workup
- Author: E David Bryan, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Laboratory Studies
Laboratory studies for elderly patients with abdominal pain may include the following:
Complete blood count
Generally perform a complete blood count (CBC).
Although an elevated white blood cell (WBC) count may indicate infection or inflammation, it has poor sensitivity and specificity. Do not make treatment decisions based on a normal WBC count in elderly patients.
Serum chemistries
Comprehensive metabolic panel or basic metabolic panel with liver function tests can be useful in assessing renal function, diabetes, acidosis, biliary tract disease, and liver dysfunction.
An anion gap may be an indication of a serious intra-abdominal process; look for a gap and other signs of acidosis particularly with concern for ischemic bowel.
Again, maintain caution despite the presence of normal results of liver function tests, since elderly patients with acute cholecystitis may not demonstrate elevations.
Serum lipase or amylase
These studies are useful as screening tests for pancreatitis. Little evidence supports obtaining both, and lipase is the superior test.
Urinalysis
Urinalysis is essential to aid in excluding urinary tract infection and detecting the presence of hematuria. Hematuria can have many causes in elderly patients, including ruptured AAA.
In female patients, a catheterized specimen has higher specificity when evaluating for urinary tract infection.
Blood cultures
Blood cultures are recommended for elderly patients presenting with abdominal pain associated with either fever or hypothermia or when sepsis is suspected.
Prothrombin time (PT) and activated partial thromboplastin time (aPTT)
Obtain these in patients in whom liver disease, sepsis, or GI bleeding is suspected and in those expected to require operative intervention.
Arterial blood gases
This is indicated for patients in whom bowel ischemia, diabetic ketoacidosis, or sepsis is suspected.
Arterial blood gas also is a rapid method of determining hematocrit in patients with GI bleeding or if ruptured AAA is suggested.
Serum lactate
This is helpful in sepsis or unexplained high anion gap acidosis.
Type and crossmatch
This is indicated in patients with GI bleeding, ruptured AAA, or in unstable patients.
Imaging Studies
Imaging plays a larger role in the workup of elderly patients with abdominal pain than in younger patients. Preference of imaging modality may vary among institutions according to what is available.
Plain film radiography
Although of limited utility in younger patients, an abdominal series may be helpful in elderly patients because of the wide differential diagnosis.
Plain film radiography can be useful in detecting bowel obstruction, adynamic ileus, nephrolithiasis, and perforation. Occasionally, gallstones may be observed, as well as late findings of mesenteric ischemia (ie, pneumatosis intestinalis). However, the overall sensitivity is very low and a negative abdominal series should not influence management. See the images below.
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. Abdominal ultrasonography
Generally, this is the initial study of choice when evaluating for biliary tract disease because of availability and speed.
Bedside ultrasonography is an excellent rapid screening test for AAA.
Some studies report that it is reasonably sensitive in detecting hydronephrosis and nephrolithiasis, but it is highly operator dependent and not considered the optimal test for urolithiasis.
CT scan
CT plays an increasingly important role in the evaluation of elderly patients with abdominal pain, especially when the diagnosis is unclear.
CT scan is the study of choice for suspected diverticulitis, having a sensitivity of 93%, and is very sensitive in patients with possible appendicitis when the diagnosis is not clear.
When performing CT scan to exclude diverticulitis, allow enough time for the oral contrast to reach the distal colon (usually 2-3 h). One study demonstrated that using CT scan with only water-soluble contrast administered by enema without intravenous (IV) or oral contrast had a sensitivity for diverticulitis of 99% and appeared to be safe. Avoid barium enema in patients with suspected diverticulitis. See the images below.
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. In stable patients with suspected AAA, CT scanning with IV contrast is approximately 100% sensitive.
Noncontrast helical CT scan is reported to be 95-100% sensitive in detecting nephrolithiasis and ureterolithiasis. Unfortunately, many elderly patients have vascular calcifications in the pelvis, making interpretation more difficult. The presence of ureteral dilatation or perinephric stranding can help establish the diagnosis.
CT scanning combined with CT angiography is increasingly used in the evaluation of suspected mesenteric ischemia. In a 2000 position statement by the American Gastrointestinal Society, it was stated that CT was of limited use in the diagnosis of mesenteric ischemia. Subsequent studies have strongly advocated for the use of multidetector-row CT in the evaluation of mesenteric ischemia,[8, 9] including one prospective study that found an overall sensitivity of 96%, with specificity of 94%[10] . Multidetector-row CT scanning had the additional advantage of identifying an alternate diagnosis in 58% of patients without mesenteric ischemia.
Chest radiography
Chest radiography is helpful in excluding pneumonia, which is a cause of abdominal pain.
It may demonstrate free intraperitoneal air under the diaphragm in patients with ruptured viscus. The lateral chest radiography has been demonstrated to be more sensitive in detecting free air.
Angiography
Although this is difficult to obtain on an emergency basis in some institutions, angiography remains the study of choice for mesenteric ischemia.
Nuclear medicine imaging (hepatic 2,6 dimethyliminodiacetic acid [HIDA] scan or diisopropyl iminodiacetic acid [DISIDA] scan)
This is helpful for patients in whom cholecystitis is suspected when the diagnosis is not clear. HIDA and DISIDA scanning both provide a very high negative predictive value.
Other Tests
- Electrocardiogram: Perform an ECG in all elderly patients with upper abdominal pain and in all unstable patients.
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