Prehospital Care
Elderly patients with severe abdominal pain, abnormal vital signs, or altered mental status should undergo the following:
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Large-bore intravenous (IV) access placed with either normal saline or lactated Ringer solution (gauge fluid resuscitation by vital signs)
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Cardiac monitor and pulse oximetry
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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 airway, breathing, circulation (ABCs) and vital signs immediately. Place patients on a monitor and start an intravenous (IV) or heparin lock. Administer oxygen to patients who appear to be seriously ill.
If the diagnosis of abdominal aortic aneurysm (AAA) is suggested, perform a rapid bedside ultrasonography, if available. In a retrospective study (2005-2011) of outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly Dutch patients with rAAA, Raats et al reported equivalent 30-day and 5-year mortality in those who survived eEVAR and OPEN. [19]
Also note the following:
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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.
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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.
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Keep all patients with abdominal pain as nothing by mouth (NPO) until surgical pathology is excluded.
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Place a nasogastric tube in patients in whom bowel obstruction, ileus, or upper gastrointestinal (GI) bleeding is suspected.
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Maintain a low threshold for ordering additional tests such as computed tomography (CT) scanning or ultrasonography.
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If biliary disease is suggested, dicyclomine (Bentyl) or glycopyrrolate (Robinul) may be administered for pain. Nonsteroidal anti-inflammatory (NSAIDs) agents 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. Consider the following:
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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.
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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.
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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.
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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).
Inpatient admission
A systematic review and meta-analysis of 8 studies comprising 592 geriatric patients (age ≥70 years) indicated that early cholecystectomy is feasible for acute cholecystitis in this population. [20] In 316 patients who underwent early laparoscopic cholecystectomy, there was a 23% conversion rate to the open procedure, 24% perioperative morbidity, and 3.5% mortality.
The following applies to patients who are not admitted to the operating room:
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Admit patients with hypotension, altered mental status, persistent tachycardia, or severe pain to the intensive care unit (ICU) for close monitoring.
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All admitted patients should receive serial abdominal examinations.
Discharge
The decision to discharge any elderly patient with abdominal pain should be made very carefully. Discharge of the elderly patient with abdominal pain should be the exception rather than the rule.
All discharged patients should undergo a repeat examination, if possible scheduled within 24 hours. In some venues, a return visit to the ED in 12-24 hours may be the best option for a repeat examination.
A review of the patient's social setting is recommended. Elderly patients who live alone are at high risk, and admission should be considered.
Consultations
In patients in whom ruptured abdominal aortic aneurysm (AAA) or mesenteric ischemia is suspected, consult a surgeon immediately. The surgical consultant should observe the elderly patient with abdominal pain in the emergency department (ED) to determine whether the patient requires operative intervention.
Consult a gastroenterologist immediately for patients with significant gastrointestinal 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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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.
