GENI Program: GI and Abdominal Chief

Complaints

Kim MacfarlaneClinical Nurse Specialist,

Critical CareFebruary 2008

Dehydration

Common acute and chronic problemRecognition is critically important to preserve renal function

Dehydration

Check for underlying infections including mouth (e.g. thrush), ill-fitting dentures, dysphagia, orthostatic B/P, dry oral mucosa, I&O, urine colour/amount, serum Na+, serum CrWatch for drug toxicities!!!!!

Malnutrition

Multiple risk factors:Denture fitOral infections/painDysphagiaAbility to feed selfFood intolerances

MalnutritionDrug therapies contributing to constipation and appetite suppressionDrugs with extra-pyramidal side effectsLiving aloneUnder/overweightDepressionAcute covert illnessExacerbation of chronic illnessChemotherapy etc.

Malnutrition

Key Assessments:Weight lossDependent edemaDifficulty chewing or swallowingSkin sores, scaly flaky skinDull brittle hair that easily falls out

MalnutritionNausea, vomitingConstipation, diarrheaHydration statusLoss of balance and coordinationPoor wound healingEating patterns and sensations (e.g. feeling full after only a few bits)

MalnutritionDrug Effects:

Reduced plasma proteins may potentiate the effects of drugs (e.g. more unbound drug)Acid/base disturbances - unpredictability of drug effectsPronounced hypotensive drug effects with reduced colloid osmotic pressureParkinson’s Disease – very important to give medications on time so dysphagia does not develop

MalnutritionWith slowed peristalsis, ensure that patients don’t lie down immediately after mealsConsult DietitianInvestigations - CBC (anemia, infection etc), ABGs (acid/base), serum pre-albumin, B vitamin profile, electrolytes, U/Cr etc.Look for worsening heart failure, new onset pneumonia

Abdominal PainStudies of older adults presenting to ED with abdominal pain suggest that at least 50% require hospitalization30-40% eventually require surgery for the underlying conditionBecause of their atypical/subtle presentations, many elderly patients with serious conditions are misdiagnosed with more benign problems such as gastroenteritis or constipation

Abdominal Pain

Research suggests that approximately 40% will be misdiagnosed, contributing to an overall mortality rate of approximately 10%

Abdominal Pain

Many may be initially referred to the wrong service (e.g. internal medicine when a surgeon may be required) Among elderly patients discharged from the ED with a diagnosis of nonspecific abdominal pain, approximately 10% eventually are diagnosed with an underlying malignancy

Factors Contributing to Muted or Less Pronounced Abdominal Pain in Older Adults

Neuropathies especially those associated with DMChronic use of certain medications –corticosteroids, NSAIDs, opioidsLess abdominal muscle mass – making guarding less apparent or impossible to determineImmunological changes with age

Some Drugs That Can Cause Abdominal Pain

AntibioticsDigoxinColchicineMetformin

Have a High Index of Suspicion!!!!!!!!!!

Careful history-taking, determination of risk factors and focused physical examination (including rectal exam) as well as a high index of suspicion are crucial to prevent missed diagnoses

Atypical Signs/Symptoms

Elderly patients are more likely than younger patients to present with vague symptoms and have nonspecific findings on examinationMany elderly patients have a diminished sensorium, allowing pathology to advance to a dangerous point prior to symptom development. Hence, LATE PRESENATION with HIGH ACUITY

Atypical Signs/SymptomsTheir pain is likely to be much less severe than expected for a particular diseaseAcute peritonitis is without the classic findings of an acute abdomen. May lack classic peritoneal signs: rebound and guardingRather than severe pain, may present with constipation and decreased appetiteDelirium may also be the initial finding with an acute abdomen

Atypical Signs/SymptomsLess likely to have fever or leukocytosisInstead of fever, may present with functional decline, falls and/or generalized weaknessUrinary urgency, frequency, incontinence or retention may be a sign of increased intra-abdominal pressure (intra-abdominal compartment syndrome)

Atypical Signs/SymptomsA palpable mass may indicate malignancy or phlegmon from ruptured appendix or diverticulitis. A pulsatile mass should raise the consideration of AAAPneumonia occasionally may cause abdominal pain without respiratory symptoms

Analgesia for Undiagnosed Abdominal Pain

Pain is no longer a primary diagnostic toolIt is now advocated that patients with undiagnosed “acute abdominal pain” should receive analgesicIn ED, clinical practice guidelines dating back to the early 1990’s and current research suggest that treating this pain has no impact on diagnostic accuracy and actually enhances the physical examination

Current Research: Do Opiates Affect the Clinical Evaluation of Patients With Acute Abdominal Pain

A meta-analysis of placebo-controlled trials indicated that although opiate administration may diminish the perception of abdominal pain, it did not appear to increase management errors, such as delay in surgery or misdiagnosis. The authors conclude that giving opiates to patients with abdominal pain does not result in any major harm [Ranji SR, Goldman LE, Simel DL, Shojania KG(2006) JAMA. 296: 1764-1774]

Pancreatitis

Most common non-surgical condition in the older adultMortality rate for >70yrs is over 40%Higher incidence of necrotizing pancreatitisPresentations: severe pain with N&V, dehydration; SIRS; approximately 10% present with altered mental status and hypotension

Abdominal Aortic Aneurysm

Condition almost exclusively found in elderly patientsAffects up to 8% of older men and 1.5% of older womenMajor risk factors include: male, age, smoking, and family history

Abdominal Aortic Aneurysm

The US Preventative Services Task Force (USPSTF), now recommends one-time ultrasound screening for men aged 65-75yrs (Annals of Internal Med. Feb. 1, 2005)Older women who smoke (4-fold increased risk) or have a history of heart disease (over 3-fold increased risk) may benefit from screening for abdominal aortic aneurysm (AAA) (J Vasc Surg 2007;46:630-635)

Abdominal Aortic Aneurysm

Many AAA’s are silent until rupture, at which time only 10% to 25% of affected individuals survive to hospital discharge following repairMany older adults present with a clinical picture suggestive of renal colic (most common misdiagnosis) or musculoskeletal back pain

Abdominal Aortic Aneurysm

Approximately 30% with ruptured AAA are initially misdiagnosedIf the diagnosis of ruptured AAA is made in the hemodynamically stable patient, the mortality is approximately 25%. In patients presenting in shock, the mortality is 80%Major complication is acute renal failure: ensure adequate volume replacement to prevent hypotension

Biliary Tract Disease Some studies suggest that biliary tract disease is the most common diagnosis among elderly patients presenting with abdominal pain Up to 50% of patients older than 65 years have gallstonesBiliary tract diseases include symptomatic cholelithiasis, choledocholithiasis, calculus and acalculous cholecystitis, and ascending cholangitis

Biliary Tract DiseaseThe mortality rate for elderly patients diagnosed with cholecystitis is approximately 10%Cholecystitis is acalculous in approximately 10% of elderly patients with the condition. Classically, the diagnosis requires the presence of right upper quadrant pain associated with fever and leukocytosis. However, 25% of elderly patients may have no significant pain, and less than 50% have fever, vomiting, or leukocytosis

Biliary Tract DiseaseComplications of biliary tract disease include gallbladder perforation, emphysematous cholecystitis, ascending cholangitis, and gallstone ileus, which accounts for approximately 20% of small bowel obstruction in elderly patients (higher prevalence in women)

Appendicitis

Appendicitis is a less common cause of abdominal pain in elderly patients than in younger ones. But the incidence among elderly patients appears to be rising3rd most common indication for surgery in the older adultAbout 10% of cases occur in patients older than 60 years, BUT 50% of all deaths from appendicitis occur in this age group

AppendicitisEstimated initial misdiagnosis is as high as 50% In older adults, the perforation rate is approximately 50%: 5 times higher than in younger adultsDelayed presentation is usually associated with increased risk of perforation. Approximately 30-40% of elderly patients with acute appendicitis present more than 48 hours after the onset of abdominal pain

Appendicitis

The diagnosis can be extremely difficult to make because about:

50% do not present with fever or leukocytosis33% do not localize pain to the right lower quadrant25% do not have appreciable right lower quadrant tenderness Only 20% present with anorexia, fever, right lower quadrant pain, and leukocytosis

Appendicitis

Even with minimal lower abdominal pain, consideration should be given to possible perforated diverticulitis or ruptured acute appendicitis

Diverticulitis Risk factors for the development of diverticula in the colon is largely associated with diet and ageUS data suggest that diverticula are present in approximately 50-80% of patients older than 65 years

DiverticulitisDiverticulitis results when diverticula become obstructed by fecal matter, resulting in lymphatic obstruction, inflammation, and perforation. By definition, diverticulitis involves at least microperforation of the colon

Diverticulitis

Approximately 85% of cases involve the left colon. Right-sided diverticulitis is often more difficult to diagnose, but generally more benignElderly patients with diverticulitis are often afebrile, and an elevated WBC count is observed in less 50% of cases. Only 25% of patients will show a positive result for occult blood in stool

Diverticulitis

Subtle signs/symptoms may include diffuse pain and low-grade temperature signaling inflammation, infection or perforation

Bowel Obstruction

Accounts for approximately 12% of cases of abdominal pain in elderly patientsHigh-pitched bowel sounds are associated with obstruction. Hypoactive or absent bowel sounds may be a sign of advanced obstruction

Bowel Obstruction

GI obstruction may be present with dehydration, cramps, stringy or diarrhea stools and general complaints of “feeling unwell”

Bowel Obstruction

Small bowel obstruction is frequently caused by adhesions from previous surgery. In elderly patients, approximately 30% of cases are caused by an incarcerated hernia, and 20% are caused by gallstone ileusLarge bowel obstruction is most commonly caused by malignancy or volvulus

Bowel Obstruction

Cecal volvulus is fairly rare and typically presents clinically as small bowel obstructionSigmoid volvulus is much more common and often can be identified by plain abdominal radiography. Risk factors for sigmoid volvulus include inactivity and laxative use, both of which are common in elderly patientsDistension of the colon of more than 9cm can signal impending perforation

Peptic Ulcer Disease

The incidence among elderly patients is increasing, which may be in part related to the increasing use of NSAIDsNSAIDs users are 5-10 times more likely to develop PUD than nonusers

Peptic Ulcer Disease

Mortality rates in older adults are approximately 100 times higher than that of younger people Diagnosis can be difficult as about 35% have no pain. GI bleeding may present with insidious signs of dehydration and cramping poorly localized abdominal pain. Melena may be present

Peptic Ulcer Disease

Complications include hemorrhage and perforation. In elderly patients, perforation is often painless, and free air may be absent on plain radiographs in more than 60% of patients

Gastroenteritis

With older adults presenting with nausea and vomiting, consider gastroenteritis as a diagnosis of exclusion. Vomiting and diarrhea can be caused by many illnessesReviews of cases of missed appendicitis reveal that approximately 50% of patients initially were diagnosed with gastroenteritisDiarrhea may be associated with DM neuropathies

GastroenteritisEven if other conditions have been excluded, note that gastroenteritis can cause serious morbidity in elderly patients. Of all deaths due to gastroenteritis, approximately 66% occur in patients older than 70 years

Constipation

Common problem, but should be considered a diagnosis of exclusion; it may be a symptom of more serious pathologyLook at the patient’s underlying comorbidities (e.g. hypothyroid), accompanying signs/symptoms and risk factors hydration, diet (e.g. fibre intake), exercise and medication profileColace is not a drug of choice

Mesenteric Ischemia Although it accounts for less than 1% of cases of abdominal pain in elderly patients, mesenteric ischemia is an important condition to considerMortality ranges from 70-90%, with any delay in diagnosis increasing the risk of deathRisk factors include: cirrhosis, atrial fibrillation, prosthetic valve, abdominal infection, atherosclerotic disease and low ejection fraction

Mesenteric IschemiaPatients classically present with severe abdominal pain despite having little tenderness on examination. Vomiting and diarrhea are often present Sometimes patients may present with recurrent episodes of postprandial abdominal pain, “intestinal angina”Highly associated with a hypercoagulable state

A closing note:

“The mortality rates for many intra-abdominal conditions in the elderly rivals that of serious cardiopulmonary diseases. Elderly patients with abdominal pain need to be evaluated just as carefully – and admitted just as liberally – as those with chest pain.” [Burg & Francis (2005, Aug.) Emergency Medicine p.12]