Abdominal Pain in Elderly Persons Clinical Presentation

Updated: Jul 17, 2018
  • Author: E David Bryan, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Presentation

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

Next:

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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