Assessment of elderly patients with

acute abdominal pain

Afif Mufarrij MD, AAEM, CAQSM, RMSK

Emergency Medicine and Primary Care Sports Medicine
Associate Professor of Clinical Emergency Medicine
Program Director - Emergency Medicine Residency Program
Program Director - Primary Care Sports Medicine Fellowship Program
American University of Beirut Medical Center - AUB - Lebanon
 Objectives
1. Identify the causes of abdominal pain that need immediate action

1. Didactic overview of abdominal pain in elderly

2. Illustrate and elaborate on different aspects of abdominal pain in the

elderly through cases

3. Discussion
The ABCs first
 Elderly patients
Mortality of acute abdominal pain (4.5 % of ED visits, 50% admitted ->30% underwent surgery)
in the elderly is around 10 %
Same pathophysiology as the young,
Yet some of the rest is different:
• Vital Signs (less predictable)
• Atypical Presentation –vague symptoms
• Delayed presentation, they wait longer before seeking medical advice
• Higher incidence of asymptomatic pathology (adhesions, cholelithiasis, cancer, diverticulosis,
CVD – aneurysms, ischemia, a. fib…)
• Elderly patients have an altered perception and reporting of pain, Diminished sensorium,
Dementia/CVA
• Altered immunity
• Meds, supplements, and treatments
• Labs may be within normal and non-alarming
Elderly Patients H & ROS & PE
• History is often difficult to obtain • Physical Exam is the same as that
and vague of the normal population:
• Time, location, radiation, intensity, • Vitals (BP HR … - hypothermia 4X)
aggravating factors… • General appearance
• Obesity
• N/V/D flatus/stools • Inspection
• Detailed ROS with meds (NSAIDs, • Auscultation
Blood thinners, anticholinergics, • Palpation (no muscles less guarding)
opioids…) • Rectal, femoral canals
• Previous surgery • Heart and Lungs and others
• Alcohol, Tobacco • POCUS!!
• Co-morbidities
Systemic – Referred – Organ specific
• Systemic: • Organ Specific:
• Metabolic processes: • Organ Specific:
• DKA
• Addisson’s,
• Hyper Calcemia • Acute Mesenteric ischemia
• Porphyria • Cholecystitis • Appendicitis
• FMF
• Pancreatitis • Diverticulitis

• Referred: • COVID • Volvulus

• Gastroenteritis • Bowel Obstruction
• Renal colic
• Pulmonary processes: • Peptic Ulcer
• Cholecystitis
•
•
Lower lobe pneumonia
PE
• UTI • IBD
• Urinary retention • Ischemic colitis
• Cardiac Processes:
• Inferior MI • Constipation/imp • Typhlitis
• Zoster action/stercoral • SBP
• Torsions
colitis
AAFP key recommendations for practice
Am Fam Physician. 2006 Nov 1;74(9):1537-1544.
Case 1
• 75 yo female, diabetic, hypertensive presenting with vomiting and
abdominal/epigastric pain for the past 6 hours, not relieved by
maalox or metoclopramide.
• Vital signs stable
• PE: obese, equivocal tenderness in all quadrants
• Negative rapid covid antigen
• IV in place and paracetamol, esomeprazole and ondansetron given
Case 1- Question
What is the first test that you
would order?

1. ABG with Lactate

2. EKG
3. Point of Care Gallbladder
Ultrasound
4. Portable upright chest X ray
Case 1 - Answer
The correct answer is B – EKG
• It is of utmost importance to rule out immediately life threatening causes as
soon as possible. This patient had an acute inferior MI and went to the cath
lab for stenting

• Answers A, C and D can be right because:

• an ABG may help in establishing a diagnosis of hypoperfusion such as shock and
ischemia
• POCUS may help in establishing a diagnosis of cholecystitis
• an upright X-ray may show air under the diaphragm indicating perforation
• YET an acute MI is the most immediately life threatening cause, and time is
heart tissue.
EKG
Reciprocals
Case 2
• 75 yo female, diabetic, hypertensive presenting with vomiting and
abdominal/epigastric pain for the past 6 hours, not relieved by
maalox or metoclopramide.
• Vital signs stable
• Abdomen Diffusely tender
• Negative rapid covid antigen
• IV in place and paracetamol, esomeprazole and ondansetron given
 Case 2 - Question

You do a bedside ultrasound and see the following What is your next step?
structure, with and without doppler flow:

• A. Consult vascular surgery for

urgent surgery
• B. Start PPIs and consult GI for
urgent endoscopy
• C. Start Antibiotics and consult
general surgery
• D. Reassure and send home
Case 2- Answer
The correct answer is C – Start antibiotics and consult general surgery
• This is acute cholecystitis, the ultrasound image shows a thickened
gallbladder in cross section with pericholecystic fluid

• Answers A, B and D are wrong:

• This is not a vascular structure such as a AAA
• This is not the stomach, necessitating ulcer perforation care
Case 3
• 75 yo healthy female, presenting with vomiting and abdominal/epigastric
pain for the past 2 days, not relieved by maalox or metoclopramide. Has
had a few episodes of diarrhea.
• Vital signs stable
• Abdomen is diffusely tender
• Negative rapid covid antigen
• IV in place and paracetamol, esomeprazole and ondansetron given
• CBC, EKG, troponin, D-Dimer, Chest X ray, liver function tests, Lipase, BUN,
Cr electrolytes, glucose, lactic acid are normal except for 88% PMNs on the
differential. Urine only shows a few white cells.
• Patient feels better after symptomatic management.
Case 3 - Question
What is the most appropriate next step?

• A. Discharge home on antibiotics for UTI and recommendations to

come back if fever, worsening pain, or inability to tolerate PO intake
• B. Admit the patient for symptomatic management and IV antibiotics
• C. Order a CT scan
• D. Consult surgery
• E. Order an ultrasound
Case 3 – Answer
• The correct answer is C – Order a CT scan

• Even though all other answers can be a possible plan of action, consults,
ultrasound, admission, even maybe discharge home with close monitoring yet
CT scan has been shown to alter the diagnosis and management in a
significant proportion of elderly patients with abdominal pain.
CT is your friend!
Case 4
• 75 yo female presenting with abdominal/epigastric pain for the past 6
hours, not relieved by maalox or metoclopramide.
• Vital signs stable
• Negative rapid covid antigen, EKG is normal, dextro as well
• There is diffuse tenderness and rebound more in the upper quadrants
• IV in place and paracetamol, esomeprazole and ondansetron given
• Labs are still not back
• In view of her recent use of NSAIDS you are suspecting a perforated
ulcer and order an Xray which does not show any air under the
diaphragm.
Case 4 - Question
What is the most appropriate next step in the management of this
patient?

• A. Consult General Surgery and perform a rectal exam

• B. Do a Gallbladder ultrasound looking for cholecystitis
• C. Order a CT of the abdomen looking for an abdominal pathology
• D. Consult GI for endoscopy
Case 4 - Answer
• The correct answer is A. Consult General Surgery and perform a rectal
exam
This patient has rebound tenderness, indicating she has peritonitis,
therefore an acute abdomen
A negative x-ray misses a perforation in up to 40 percent of patients
Most patients with a perforated ulcer will have melena.

B. C. and D. will aid in diagnosis, yet this is a surgical emergency in view

of the rebound
Case 5
• 75 yo male, with a. fib , presenting with post-prandial vomiting and
abdominal pain for the past 12 hours, not relieved by maalox or
metoclopramide, has had a few episodes of diarrhea.
• Vital signs stable
• Negative rapid covid antigen, EKG shows normal rate Atrial fibrillation.
It is unchanged compared to the previous one. Dextro is normal.
• Abdomen is soft, no melena, No flank tenderness
• IV in place and paracetamol, esomeprazole and ondansetron given.
Case 5 - Question
You do an ultrasound of the abdomen which is normal, the patient’s
labs show leukocytosis, normal BUN, Creatinine and electrolytes except
for an elevated phosphorus and slightly low bicarb, normal LFTS, lipase,
troponin and the urinalysis shows 2-4 RBCs.
What should you order next?
• A. Non-contrast CT Abd/Pelv
• B. CT Abd/Pelv with IV contrast
• C. CT angiogram of the Abd/Pelv
• D. CT urogram
Case 5 - Answer
• The correct answer is C. CT angiogram of the Abd/Pelv
• This patient has a major risk factor for embolic mesenteric ischemia;
atrial fibrillation. He has no flank or abdominal tenderness to suggest
a renal colic despite the hematuria. The high phosphorus and low
bicarb are additional findings in mesenteric ischemia.
Case 6
• 75 yo male, diabetic, hypertensive • You perform an ultrasound looking for
presenting with vomiting and hydronephrosis and you find this
abdominal/flank pain for the past 6 structure in the abomen
hours, and an episode of hypoension
at home. Not relieved by maalox or
metoclopramide,.
• Vital signs stable
• Negative rapid covid antigen. EKG
normal.
• IV in place and paracetamol,
esomeprazole and ondansetron given
• Blood tests are ordered and urine
dipstick is positive for blood
Case 6 - Question
Which of the below is/are the most important test(s) for the
management of the patient?

A. Lactic Acid
B. PT/PTT
C. Type and Crossmatch
D. D-Dimer
Case 6 -Answer
• The correct answer is C. Type and Crossmatch
• This patient has a AAA contained rupture and will need urgent
transfusion and surgery.
• All the other tests are adequate, but not the most important.
Acute Cholcystitis
• Most common surgical emergency in the elderly with abdominal pain
• Classic indicator’s – Murphy and RUQ tenderness only in ½, 40 percent do not have nausea
• An ultrasound can be extremely helpful when evaluating the gallbladder as it is the gold standard
• You will see GB wall thickening, pericholecystic fluid and have a positive sonographic murphy, a sometimes a
stone at the GB neck
• LFTS are sometimes normal, WBC count as well. Sometimes they don’t have fever.
• More than 50 percent will have complications such as ascending cholangitis, perforation, or a gall stone
ileus, acalculous cholecystitis is seen in 10 percent
Case 7
• 75 yo Male, previously healthy presenting with left flank and severe
abdominal pain for the past 7 days, not relieved by acetaminophen or
advil, has had a fever and malaise recently. He was seen in our ED 3
days ago and was discharged after a complete evaluation. He was
seen yesterday for the same complaint and had a full septic workup
that was done including CT chest abd pelvis which were normal.
• All of his blood work was normal as well. Urine as well.
• Today patient’s pain is unchanged and he wants an answer
Case 7 - Question
Your next step is to:

A. Repeat a CBC and if normal discharge to follow up awaiting blood

urine and stool cultures
B. Consult infectious diseases
C. Re-examine the patient and repeat some tests if needed
D. Consider admission for oncological workup
Case 7 - Answer
• The correct answer is C. Re-
examine the patient and repeat
some tests if needed.
Case 8
• 75 yo female, presenting with vomiting and abdominal/epigastric pain for
the past 6 hours, not relieved by maalox or metoclopramide, she also
reports chills.
• Vital signs 38.2 HR 110 BP 123/78, 98 percent sat, in pain
• Negative rapid covid antigen
• IV in place and paracetamol, esomeprazole and ondansetron given
• You do a bedside ultrasound and find sludge in the gallbladder but no
sonographic Murphy or gallbladder wall thickening
• labs show leukocytosis, elevated LFTs, gamma GT and Alk phos, as well as
an elevated Amylase and Lipase. Her lactate is 6 and bicarb is 12.
Case 8 -Question
• What is the most appropriate next step?

• A. Order a HIDA scan

• B. Consult GI for ERCP
• C. Order an official ultrasound of the gallbladder
• D. Order a CT scan of the Abdomen
• E. Fluid resuscitation and antibiotics
Case 8 - Answer
• The correct answer is E. Fluid resuscitation and antibiotics

• This is a case of cholangitis/pancreatitis and the patient is in shock

• Shock can be due to either third spacing secondary to the pancreatitis or
sepsis secondary to the cholangitis.
• Most patients with acute ascending cholangitis present with Charcot’s triad
(i.e., fever, jaundice, and right upper quadrant pain).
• The majority of patients have an elevated G-GT and alkaline phosphatase
level
• 40 percent have hyperbilirubinemia
• Reynold’s pentad (i.e., Charcot’s triad plus shock and mental status
changes) is reported to occur in only 14 percent of cases
Case 9
• You are sitting in your office and the security officer asks you if you
can check the CT scan of his mom. It is not reported. You decide to go
over the images of the abdomino/pelvic CT scan with IV contrast
done a few hours ago.
• She is a 72 yo female with a PMHx of IBS and hysterectomy. She had
been complaining of persistent abdominal pain and loose stools for
the past 12 days and her physician ordered imaging after noting
diffuse tenderness. She is currently feeling better.
Case 9
Case 9 - Question
• What are your recommendations regarding the findings on the chest
and pelvis?

• A. Recommend antibiotics and later on a colonoscopy

• B. Discuss possibility of malignancy with metastasis
• C. Send the son do a PCR and get all contacts evaluated
• D. Recommend admission for workup and antibiotics
Case 9 - Answer
• The correct answer is C. Send the son do a PCR and get all contacts
evaluated
• These slices show diverticulosis, (not -itis) and pulmonary changes
typical of covid; crazy paving in RLL (ground glass plus interlobar
thickening)
Diverticulitis
• Most elderly have diverticulosis, mostly in sigmoid,
diverticulitis, 20 percent of these will have diverticulitis
(obstruction of diverticulus/i)
• 50 percent are afebrile and have a normal wbc count
• 30 percent have no abdominal tenderness
• 50 percent are initially misdiagnosed
• 15 percent have a rectal bleed
• common cause or blood per rectum in elderly, stops alone
Case 10
• 75 yo male, diabetic, hypertensive, obese presenting with vomiting and
abdominal/epigastric pain for the past 12 hours, not relieved by PPIs or
antiemetics. She has a dry mouth and is thirsty but vomits every thing she
drinks.
• Vital signs: afebrile, HR 105, BP 110/69, pulse ox 98%
• Negative rapid covid antigen
• Abdomen is diffusely tender, some high pitched sounds, and no rebound
• IV in place and paracetamol, esomeprazole and ondansetron given
• Labs sent (CBC, BUN, CR Electrolytes, LFTs, Lipase, troponin, lactic acid, D-
Dimer, BNP)
• EKG is normal, Chest X ray as well
Case 10 - Question
• You do an x-ray of the abdomen
and find this
What is your next plan of action?
• A. Order a CT of the abdomen and
start fluid resuscitation
• B. Consult surgery and start fluid
resuscitation
• C. Do one additional blood test
and start fluid resuscitation
• D. Start broad spectrum antibiotics
and fluid resuscitation
Case 10 - Answer
• This correct answer is C. Do one additional blood test and start fluid
resuscitation
• This patient’s dextro reading ended up being 670. She does have SBO
features on the X-ray, yet one needs to always make sure DKA is not
missed.
Disposition?
• Unless you are sure of your
diagnosis after extensive testing
for catastrophes, do not send
elderly patients home
Conclusion
• Gastroenteritis is still the most common acute cause of abdominal pain in our community, yet beware of red herrings
• Targeted labs:
• Lactic acid
• Troponin
• D-Dimer
• Lipase, gamma GT
• Pro-calcitonin
• Beware of a normal Abdominal Xray
• CT is your friend, even plain CT
• Use a bedside ultrasound (Gallbladder, Bladder/kidneys, air, AAA…)
• Beware of the vascular catastrophes: (lactic, troponin, D-dimer)
• Mesenteric
• Aortic
• Dissection
• MI
• Better to be safe than sorry: extensive workup with low threshold to call for surgeons, if in doubt admit for observation
• Hi Georges
•
• This is a brief bio (I added my cv for reference if you want to add or remove things)
•
• Dr Afif Mufarrij is one of the founders of the department of Emergency Medicine at AUBMC in 2007. He is board certified in both
Emergency Medicine and Primary Care Sports Medicine. Dr Mufarrij is an associate professor and currently the program director for
the Emergency Medicine Residency Program at AUBMC. Prior to assuming this position, he had established the first Primary Care
Sports Medicine Fellowship at AUBMC in 2019. Dr Mufarrij is also the founding chief of service of the ED at KMC in 2015, and was the
first director of Professional Practice Development for the ED at AUBMC in 2012. Dr Mufarrij loves research and teaching and has
been heavily involved in medical student and resident education since joining AUB. He has a special interest in point of care
ultrasound (POCUS), traumatic brain injuries and regenerative medicine.
•
• Regarding the photo can you use the one on the CV I sent?
•
• Topic: Assessment of elderly patients with acute abdominal pain
•
• Objectives:
1. Identify the causes of abdominal pain that need immediate treatment and stabilization (referral to the emergency department
(identify true emergencies quickly: ABCs/MIs/acute abdomen/DKA/SBP/)
2. Quick didactic overview of abdominal pain in elderly
3. Illustrate and elaborate on (diagnosis/management/consultation/disposition) different aspects of abdominal pain in the elderly
through multiple cases AAA, Zoster, inferior MI, renal stone, diverticulitis, cholecystitis, pancreatitis, DKA, covid gastroenteritis,
mesenteric infarction, volvulus, peptic ulcer perforation, neutropenic colitis,
4. Discussion with the audience