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:
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Time of onset and course of the pain
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Sudden or gradual onset
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Location, quality, and severity of pain
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Radiation (eg, to back, groin, shoulder)
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Aggravating or precipitating factors (eg, food, position, medication)
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Palliative factors
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Prior similar episodes
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Ability to pass stool or flatus
Associated symptoms include the following:
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Fever, chills, or sweating
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Urinary symptoms (eg, dysuria, hematuria, hesitancy)
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Anorexia, nausea, vomiting, or diarrhea
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Melena or blood in the stool
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Dyspnea or chest pain
Medical history can provide clues as to the possible etiology of the pain. The following are particularly important to elicit:
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Diabetes
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Cardiovascular disease (hypertension, coronary artery disease, atrial fibrillation, peripheral vascular disease)
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Previous abdominal surgery
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Smoking history
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Alcohol use
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NSAID use
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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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.
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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.
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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.
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Radiograph of a 79-year-old woman with several hours of diffuse abdominal pain. Initial examination of the plain films suggests bowel obstruction.
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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.
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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.
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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.
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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.
