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Contributor Information

Author

Nicole Cimino-Fiallos, MD
Resident
University of Maryland
Department of Emergency Medicine
Baltimore, Maryland

Disclosure: Nicole Cimino-Fiallos, MD, has disclosed no relevant financial relationships.

Editor

Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York

Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.

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10 Causes of Abdominal Pain in the Elderly

Nicole Cimino-Fiallos, MD  |  November 16, 2016

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Slide 1

Acute, atraumatic abdominal pain is a common complaint in elderly patients presenting to the emergency department (ED).[1,2] As the US population ages, the number of these presentations is expected to continue to rise. In 2014, the life expectancy of a 65 year old in the United States was 19.3 years, and that of a 75 year old was 12.2 years.[3]

Older patients with abdominal pain are more likely than their younger counterparts to require hospitalization and/or surgery or other invasive procedures, and they are also more likely to suffer complications, including death. A prospective study of 360 patients aged 60 years and older who presented to an ED with atraumatic abdominal pain found that 58% of these patients were admitted and an additional 18% required operative intervention or an invasive procedure; overall, 5% of the patients died within 2 weeks.[4]

NOTE: The pathologies highlighted in this slideshow represent only a few of the causes of abdominal pain in the elderly. Nonetheless, these few underscore the need to maintain an especially high degree of clinical suspicion in the geriatric population.

The left lateral decubitus radiograph reveals small bowel obstruction (SBO) in an elderly patient. Air-fluid levels as well as incidental surgical clips from a previous bowel resection can be seen.

Image courtesy of Spangler R, Van Pham T, Khoujah D, Martinez JP. Int J Emerg Med. 2014;7:43. [Open access.] PMID: 25635203, PMCID: PMC4306086.

Slide 2

Outcomes and the Elderly

Many factors contribute to worse outcomes in the elderly, including physiologic changes associated with aging, comorbid conditions, and polypharmacy.[5,6]

An important and possibly modifiable risk factor associated with worse outcomes in elderly patients with acute abdominal pain is delayed recognition of severe pathology. In a retrospective study of 132 patients older than 80 years who presented with atraumatic abdominal pain, 20% had a discrepancy between their ED diagnosis and their final diagnosis.[7] Even more concerning, those whose diagnosis was initially missed had a 59% mortality.[7] Another study with 360 seniors demonstrated that the older the patient, the greater the risk of misdiagnosis and mortality.[4] Thus, by heightening clinical suspicion and awareness, physicians may be able to identify significant disease early as well as minimize delays in management.

Although there has been much focus in recent years on the differences in presentation and outcomes between men and women with chest pain, such differences do not seem to be present in older patients with abdominal pain. An observational study of abdominal pain in 131 geriatric patients revealed no disparity between men and women in the use of imaging studies and antibiotics, pain control, or diagnosis, although older males with abdominal pain had higher mortality rates at 3 months.[8]

Sonogram diagnostic for an abdominal aortic aneurysm (AAA) courtesy of Spangler R, Van Pham T, Khoujah D, Martinez JP. Int J Emerg Med. 2014;7:43. [Open access.] PMID: 25635203, PMCID: PMC4306086.

Slide 3

Vital Signs in the Elderly

As people age, they experience physiologic changes that contribute to atypical presentations of illness. A well-studied physiologic change in the older population is an increase in tonic sympathetic nervous system activity which, in turn, not only accelerates cardiovascular disease but has also been implicated in heart failure.[9] Conversely, adrenal responses to acute stress are blunted with age, which may lead to paradoxically normal vital signs in those with serious illness.[9]

Older patients have also been shown to have a lower basal temperature[10,11] as well as generate a smaller degree of leukocytosis when ill than younger patients.[10] A retrospective review of 231 patients with a median age of 64 years and abdominal pain found that temperature and laboratory values were not useful for distinguishing between surgical and nonsurgical disease.[12]

Physiologic changes of aging also affect how and when older patients present. A review of how geriatric patients perceive pain concluded that "differences in the neuroanatomy, physiology, and biochemistry of the nociceptive pathways may cause alterations in pain perception."[13] Such differences in pain perception may, in turn, result in delays in older patients seeking care as well as decreased clinical suspicion of severe pathology on the part of healthcare providers.

Tables courtesy of Nicole Cimino-Fiallos, MD. Image content sources: (1) Chester JG, Rudolph JL. J Am Med Dir Assoc. 2011;12(5):337-43. PMID: 21450180[10]; and (2) Gadde S, Omar B. J Am Soc Hypertens. 2015;9(4)(suppl):e64-e65.

Slide 4

History and Physical Evaluation of the Elderly Patient with Abdominal Pain

Eliciting a history from the older patient with abdominal pain can be challenging. This group is more likely to not only have dementia but also to present with alteration of their mental status as part of their constellation of syndromes.[11] When obtainable, the circumstances surrounding the chief complaint may be helpful. Acute onset of abdominal symptoms may suggest a vascular cause, but older people tend to have later presentations which often complicates those details.[6] Fever, chills, and other systemic symptoms may suggest infection.

When possible, it is important to obtain collateral information from the patient's family/caregiver and/or medical records. For example, a history of coronary artery/cardiovascular disease, renal disease, malignancy, immunosuppression, and/or recent surgery (eg, abdominal, vascular) or other procedural intervention all convey additional risk and help to build a more complete differential diagnosis. Establishing the patient's baseline mental status as well as their living situation and functional status may aid in the evaluation of their presenting condition in the appropriate context. Reviewing medications (eg, anticoagulants, beta-blockers, chemotherapy agents, opioids) may also help reveal comorbidities when patients are unable to provide information or do not know their own histories.

Sonogram of a gallstone courtesy of Wikimedia Commons/Nevit Dilmen.

Slide 5

The physical examination in elderly patients may be atypical. For example, in cases of peritonitis, they may not manifest classic signs such as rebound and guarding.[2]

The initial evaluation should focus on the ABCs (airway, breathing, circulation), but geriatric patients may have blunted vital sign responses.[11] When ill, older patients are also more likely to have altered mentation and be unable to cooperate with the examination. Nonetheless, a thorough physical evaluation has the potential to help clinicians form a differential diagnosis and, thus, should not be overlooked.

The abdominal assessment should always include an evaluation of the bowel sounds and palpation for tenderness and masses.[6] The skin should be inspected for rashes, cellulitis, and/or scars that may give clues to the past surgical history. In males presenting with abdominal pain, a testicular examination is an important part of the evaluation. A rectal examination may determine the presence of impacted feces or frank or occult blood.[2,6]

The image shows ecchymosis of the abdominal wall (Cullen sign) in a patient with acute pancreatitis.

Image courtesy of OpenStax CNX, Rice University/Herbert L Fred, MD, Hendrik A van Dijk.

Slide 6

Workup of the Elderly Patient with Abdominal Pain

Owing to the high morbidity and mortality associated with missed or delayed diagnoses in the senior population, it is appropriate to have a low threshold for obtaining laboratory and imaging studies. Basic laboratory results may be useful when abnormal, but they should not reassure the clinician if the findings are normal in the presence of a clinical scenario that is otherwise concerning.[1] Some causes of abdominal pain that are not attributable to intraabdominal pathology may be identified via blood work. Examples include metabolic derangements such as diabetic ketoacidosis and hypercalcemia, as well as myocardial infarction.[1]

Infectious processes, including Clostridium difficile infection, pelvic inflammatory disease, and herpes zoster, must also be considered. Extraabdominal disease processes may also present with abdominal pain, including acute coronary syndromes and pulmonary processes (eg, pneumonia, pulmonary embolism). Many medications may also cause abdominal discomfort.

Image courtesy of Medscape/Sam Shlomo Spaeth.

Slide 7

In the past 2 decades, there has much investigation regarding the utility of different imaging modalities in abdominal pain generally, as well as in the elderly population specifically. A 2014 study showed strong agreement between the preoperative ED diagnosis by computed tomography (CT) scanning and the final postoperative diagnosis in elderly patients with nontraumatic acute abdominal pain who underwent surgery.[14] Magnetic resonance imaging (MRI) and ultrasonography also have proven utility in evaluating abdominal pain, but plain radiography has had a lower yield.

Radiography may best be considered a screening test for free air or obvious obstruction, but a normal plain film cannot rule out serious pathology, as upright chest x-rays do not show intraperitoneal air in 40% of geriatric patients with perforation.[15]

The plain abdominal radiographs demonstrate nonocclusive mesenteric ischemia. The early phase reveals ischemia due to vasoconstriction of the splanchnic vessels leading to spastic reflex ileus (A). The intermediate phase shows thinning of the bowel walls of the small and large intestines (B).

Images courtesy of Reginelli A, Iacobellis F, Berritto D, et al. BMC Surg. 2013;13 suppl 2:S51. [Open access.] PMID: 24267670, PMCID: PMC3850956.

Slide 8

Management of the Elderly Patient with Abdominal Pain

Management of the elderly patient with abdominal pain is often initiated along with the diagnostic workup, before a firm diagnosis has been reached. Patients presenting with vital sign abnormalities or obtundation may require resuscitation before much additional information is available.

Fluid resuscitation may pose a clinical dilemma in older patients, as this population is more likely to have congestive heart failure or hepatorenal issues, thereby making them more susceptible to volume overload than younger patients. In the setting of hypotension, it is prudent to give small fluid boluses more frequently rather than aggressive fluid administration, and then reassess volume status by examination as well as imaging with chest x-rays or ultrasonography.

In the stable patient, pain control has previously been a source of controversy. Traditionally, clinicians were reluctant to use opioids to treat patients with abdominal pain, for fear of masking symptoms. However, a meta-analysis of randomized controlled trials found that opioids may offer pain relief without adversely affecting clinical decision making.[17]

Image courtesy of Marjorie Kamys Cotera/Bob Daemmrich Photography / Alamy Stock Photo.

Slide 9

A significant percentage of elderly patients presenting with abdominal pain require surgery. The most common operative indications in 456 seniors with abdominal pain in one study were cholecystitis, incarcerated hernia, malignancy-related issues, and appendicitis.[18] The same study found that the following factors were all associated with increased mortality[18]:

  • Older age
  • American Society of Anesthesiologists (ASA) physical status score of 3 or higher
  • Atrial fibrillation
  • Decreased body mass index (BMI)
  • Open surgery
  • History of cancer

As noted earlier, the differential diagnosis for abdominal pain is quite wide. For elderly patients in particular, it includes several "can't miss" diagnoses, 10 of which are reviewed in the following slides.

The intraoperative image was obtained in a patient with cholecystitis of the incarcerated gallbladder. The 10-mL syringe is used for size comparison.

Image courtesy of To H, Brough S, Pande G. BMC Surg. 2015;15:72. [Open access.] PMID: 26063048, PMCID: PMC4464702.

Slide 10

Abdominal Aortic Aneurysm

Both the incidence and the mortality associated with AAA increase with age. A 2014 study showed 30% mortality among patients with ruptured AAA that was repaired—the mortality rate was the same whether the repair was surgical or endovascular.[19]

Ruptured AAAs present differently on the basis of their location and how they rupture.[20] Intraperitoneal rupture (20%) almost always results in rapid exsanguination and death. Fortunately, approximately 80% of ruptured AAAs are retroperitoneal, with a small percentage resulting in an aortocaval or aortoduodenal fistula. Retroperitoneal bleeds may temporarily tamponade, or "seal off," for hours, days, or even weeks. This further clouds the presentation, as a patient may complain of several days or weeks of symptoms rather than an acute onset just prior to arrival as classically expected. Instead of pain or syncope, presenting complaints in patients with a sealed-off retroperitoneal rupture may range from neurologic to dependent hematoma and/or pain in the groin or testes, or as obstructive jaundice.[20]

The CT scan with contrast reveals an AAA in an asymptomatic elderly male. There is calcified atherosclerotic plaque on the aneurysm wall and in the distal aorta (a).

Image courtesy of Duggirala A, Delogu F, Angelini TG, et al. Front Genet. 2015;6:125. [Open access.] PMID: 25883602, PMCID: PMC4381652.

Slide 11

The "classic triad" of hypotension, back pain, and a pulsatile abdominal mass in AAA is only seen in 25%-50% of patients.[20] Thus, it is important to maintain a high index of suspicion for AAA, as the physical examination is notoriously unreliable, and mortality rises sharply with diagnostic delay.

An unstable patient with a suspected ruptured AAA requires emergent surgical consultation, large-bore vascular access, and readily available blood products. Preoperative permissive hypotension may result in better outcomes, as there is less pressure on the rupture itself.[21]

Because the presentation of AAA may be so variable and its risk increases with age, it is appropriate to obtain imaging studies in a stable elderly patient with suspected AAA. Bedside ultrasonography has sensitivity and specificity for the evaluation of AAA and may improve time to diagnosis[22]; however, this modality does not always detect retroperitoneal rupture. CT angiography (CTA) may be used to evaluate for AAA rupture in a stable patient.[21]

The three-dimensional (3-D) reconstruction of a CT scan reveals an infrarenal AAA.

Image courtesy of Wikimedia Commons/Bakerstmd.

Slide 12

Acute Mesenteric Ischemia

Acute mesenteric ischemia is another vascular emergency that typically presents with abdominal pain and requires quick recognition and treatment to reduce morbidity and mortality.[1] The mesentery suffers a sudden loss of perfusion, leading to ischemia or infarction, usually due to embolism or thrombosis but sometimes owing to global hypoperfusion, as in shock states. This condition is rare but has a high mortality rate, greater than 50% in some case series.[1] Acute mesenteric ischemia is largely seen in the elderly.[1,23] A large systematic review consisting of more than 1100 patients found that the mean age of presentation was 66.2 years.[23]

The classic presentation of acute mesenteric ischemia is acute onset of abdominal pain in a person at risk of thromboembolism (eg, a patient with atrial fibrillation or an artificial heart valve), but in the same systematic review as above, only 35.2% of patients had a history of atrial fibrillation and only 3.1% had a history of valvular heart disease.[23] Abdominal pain, nausea, and vomiting are fairly nonspecific complaints, as is the classic feature of pain out of proportion to the examination findings.[1]

The images show the preoperative 2-D multidetector CT reconstruction on the coronal plane (A) and intraoperative image (B) of mesenteric venous thrombosis in a patient with acute mesenteric ischemia.

Images courtesy of Reginelli A, Iacobellis F, Berritto D, et al. BMC Surg. 2013;13 suppl 2:S51. [Open access.] PMID: 24267670, PMCID: PMC3850956.

Slide 13

Without a pathognomonic historical or physical finding, acute mesenteric ischemia is a diagnostic challenge, particularly in the elderly.[1] One study suggests that the true incidence in geriatric patients may be underestimated.[24] Elevated lactate levels is another classic association, but it is a late finding in mesenteric ischemia.

CTA is the study of choice in most cases[1] and requires both arterial and venous phase contrast media for optimal evaluation for mesenteric ischemia. Clinical suspicion as written in imaging orders has been shown to improve radiographic diagnosis; therefore, it is critical for the referring clinician to not only include mesenteric ischemia in the differential diagnosis but also communicate such concern to the radiologists.[25]

Management of mesenteric ischemia is always interventional. As with any ischemic process, time to definitive therapy is critical. Consult a surgeon as soon as the diagnosis of acute mesenteric ischemia is suspected. There is ongoing debate about whether open surgery or percutaneous transluminal angioplasty with stenting is optimal treatment, but the consensus at this time appears to be that surgery is preferable when bowel ischemia is suspected.[23]

The CT scan depicts an ischemic bowel due to thrombosis of the superior mesenteric vein. Thickened bowel wall (arrow) can be seen with the dilated bowel.

Image courtesy of Wikimedia Commons/James Heilman, MD.

Slide 14

Appendicitis

Appendicitis is a well-studied example of a disease that has a different presentation in the elderly, often leading to diagnostic and treatment delay.[1,6,26] Although this disease is more common in younger patients, it is not rare in the older population, representing approximately 10% of surgical disease found in geriatric patients presenting with abdominal pain.[18] Indeed, appendicitis is the third most common surgical indication in this population.[1,6]

Elderly patients with appendicitis have higher rates of perforation and mortality than their younger counterparts,[27] even within senior age groups.[28] A retrospective study that compared outcomes between octogenarian patients and those 60-79 years old ("young old") found worse postoperative morbidity and mortality in the older group.[26] Older patients are also more likely to present not only later in the disease process but also with complicated appendicitis, including abscess or phlegmon, which is independently associated with higher mortality. In one study, 18% of patients older than 60 years presented with complicated appendicitis, a 12-fold increased risk compared to younger patients.[29]

The intraoperative image reveals a large appendiceal perforation at the base of the cecum.

Image courtesy of Wong CS, Naqvi SA. World J Emerg Surg. 2011;6:36. [Open access.] PMID: 22053953, PMCID: PMC3253676.

Slide 15

The classic presentation of appendicitis is familiar: anorexia and abdominal pain that begins periumbilically and migrates to the right lower quadrant.[30] Frequently associated symptoms include nausea, vomiting, and fever. Unfortunately, not all patients with appendicitis present with these classic symptoms; some single-center studies suggest that the elderly present later and more atypically than younger patients.[1,6,26]

Obtaining imaging studies is reasonable in the evaluation of elderly patients when there is any suspicion for appendicitis, because the history and physical examination cannot safely rule out this condition and laboratory results may be normal, especially in the early stages. Although ultrasonography may be a useful tool in the assessment of suspected appendicitis, CT scanning is more sensitive and specific and has been shown to result in a greater reduction in negative appendectomies.[31]

In terms of the initial management, all patients with acute appendicitis should have nothing by mouth (NPO) and undergo evaluation by a surgeon. Research is ongoing regarding the utility of antibiotics alone in the treatment of uncomplicated appendicitis, but many such studies exclude older patients.[32] Until further data are available, acute appendicitis in most patients and in the elderly specifically is usually managed surgically (open or laparoscopic).

CT scan revealing an inflamed appendix (arrow) courtesy of Spangler R, Van Pham T, Khoujah D, Martinez JP. Int J Emerg Med. 2014;7:43. [Open access.] PMID: 25635203, PMCID: PMC4306086.

Slide 16

Pancreaticobiliary Disease

Pancreatitis

Acute pancreatitis is more common (200-fold increase[1,6]) and causes greater morbidity in geriatric patients than in the overall population, with about one third of cases presenting in patients older than 65 years and mortality rates as high as 25% (vs 5%-10%).[33] The causes of pancreatitis in older patients also differ from those of the general population, with fewer cases directly attributable to alcohol use and more due to gallstones, medications, cancer, and hyperlipidemia.

Although the classic presentation is that of epigastric pain radiating to the back accompanied by nausea, vomiting, and dehydration, an estimated 10% of geriatric patients may instead exhibit hypotension and altered mental status.[1,6]

Image of the pancreas and gallbladder courtesy of Wikimedia Commons/Bruce Blaus.

Slide 17

This admission CT scan was obtained from a patient with severe acute pancreatitis and a history of excessive alcohol use over a period of 6 months. Note the presence of peripancreatic edema and thickening of the Gerota fascia on the left side.

Image courtesy of Leppaniemi A, Mentula P, Hienonen P, Kemppainen E. World J Emerg Surg. 2008 Jan 30;3:6. [Open access.] PMID: 18234076, PMCID: PMC2266717.

Slide 18

Biliary disease

Biliary disease, specifically acute cholecystitis, is the principal surgical emergency in seniors.[1,6] Biliary disease is generally more common with aging due to many physiologic changes. Older people have more gallstones, a greater proportion of pigmented stones, larger common bile duct diameter and dilatation of the main pancreatic duct, reduced gallbladder motility, and greater lithogenicity of bile, as well as elevated levels of amylase and lipase.[34] These changes and others predispose the elderly to cholecystitis, cholangitis, and gallstone pancreatitis.

The patient's history may point toward biliary disease if there is a known history of cholelithiasis, previous episodes of pancreatitis, or recent endoscopic retrograde cholangiopancreatography (ERCP) or other procedures. Gallstone disease is common in the elderly, with frequency estimates of 14% to 27%.[33,34]

Image courtesy of Wikimedia Commons/Bruce Blaus.

Slide 19

An elderly patient with calculous cholecystitis (obstructive cholecystitis caused by gallstones) may or may not exhibit the classic findings of fever, vomiting, and Murphy sign (increased pain with inspiration during right upper quadrant palpation).[1,6] Indeed, up to 40% of affected patients are afebrile and without nausea/vomiting.[1,6] Moreover, older patients are also less likely to exhibit right upper quadrant pain, with 27% of those older than 70 years in one study presenting without pain in this region.[35]

Acalculous cholecystitis primarily affects critically ill elderly patients, typically in the setting of splanchnic vasoconstriction, fasting state, and hemodynamic instability.[34]

The sonogram reveals a very large gallstone with significant surrounding edema in a patient with acute cholecystitis.

Image courtesy of Spangler R, Van Pham T, Khoujah D, Martinez JP. Int J Emerg Med. 2014;7:43. [Open access.] PMID: 25635203, PMCID: PMC4306086.

Slide 20

Acute cholangitis is a bacterial infection most often caused by choledocholithiasis that may occur as a complication of acute cholecystitis, particularly in older patients.[1,6,36] The classic presentation of acute ascending cholangitis is fever, jaundice, and right upper quadrant pain (Charcot triad). However, elderly patients may present with sepsis and mental status changes, with or without the Charcot triad (the Reynolds pentad consists of the Charcot triad plus altered mental status and hypotension).[36]

The top CT scan demonstrates occlusion of the common bile duct by a stone. The bottom CT scan reveals a 1-cm dilated common bile duct at the portal triad.

Images courtesy of David Schwartz, MD, New York University Hospital.

Slide 21

The laboratory evaluation of suspected biliary disease should include liver function tests and pancreatic enzyme levels. Elevated levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin suggest cholestasis and obstruction.[36]

Imaging studies are also a key consideration in the assessment of biliary disease. Noninvasive modalities such as ultrasonography, CT scanning, and MRI may limit the use of more invasive procedures (eg, ERCP) to confirm the diagnosis. Ultrasonography has traditionally been considered the first-line imaging study for suspected cholecystitis. However, a 2015 study suggested that CT scanning is more sensitive than ultrasonography in the diagnosis of cholecystitis, whereas ultrasonography is more sensitive for detecting cholelithiasis.[37] CT scanning has additional benefits to consider in the elderly population: it is faster and less operator dependent than ultrasonography and may be used to simultaneously evaluate for pathology outside the biliary tree.

The diagnostic sonogram (left) demonstrates a gallbladder with a thickened wall but no gallstones. The intraoperative laparoscopic image (right) in the same patient shows a necrotic gallbladder.

Images courtesy of Sahebally SM, Burke JP, Nolan N, Latif A. J Med Case Rep. 2011;5:551. [Open access.] PMID: 22081944, PMCID: PMC3227694.

Slide 22

Whether cholecystitis is calculous or acalculous, the definitive management is cholecystostomy or cholecystectomy. As discussed earlier, cholecystitis is the most common operative condition found in elderly patients presenting with abdominal pain, comprising 32% of surgical disease in one study.[18] It is also associated with higher perioperative morbidity and mortality (≤19%) in this population than in young individuals, including greater rates of sepsis and gangrenous changes.[33]

In the elderly, cholangitis is often amenable to ERCP, as in younger patients. Endoscopic treatment has been associated with lower morbidity and mortality than with percutaneous or surgical treatment; morbidity has been as high as 88% with open surgical repair, compared to 6% with endoscopy.[38]

Intraoperative laparoscopic cholecystectomy view of the cystic duct and cystic artery courtesy of Medscape.

Slide 23

Bowel Emergencies

Older adults have higher rates of intestinal obstruction in both the small and large bowel than younger people.[1] Part of this is attributable to the greater likelihood of older patients having a history of abdominal surgery, which predisposes to SBO (adhesions, hernias), and higher rates of colon cancer and volvulus, which predispose to large bowel obstruction (LBO).[1,2,6] The elderly also have higher rates of diverticulosis, increasing their risk of diverticulitis. Consequently, bowel pathology must be on the differential diagnosis for any elderly patient presenting with abdominal pain.

Radiography is often used as a screening test for bowel obstruction, but it is neither sensitive nor specific. In a study of 142 patients with intestinal obstruction, plain radiography detected only 62.5% of obstructions and was unable to localize the obstructions in any patients.[39] CT scanning, however, is effective for identifying and localizing obstructions as well as revealing any associated pathology (eg, large tumors, abscesses, diverticulitis).[40,41]

The intraoperative image in a patient with bowel obstruction shows multiple giant diverticula arising at the mesenteric border of the jejunum.

Image courtesy of Falidas E, Vlachos K, Mathioulakis S, Archontovasilis F, Villias C. World J Emerg Surg. 2011;6(1):8. [Open access.] PMID: 21385440, PMCID: PMC3061903.

Slide 24

Small bowel obstruction

SBO is significantly more common than LBO, in the elderly and in the general population. In older people, SBO is the second most frequently missed surgical emergency, after appendicitis.[1,6]

SBO classically presents as abdominal pain and distention in a patient with a history of abdominal surgery, often associated with nausea, vomiting, and constipation.[1,6] However, even patients without a history of abdominal surgery are at risk, especially older patients, as fecal impaction, diverticular disease, and malignancy may also cause SBO.[42]

Typical physical examination findings are high-pitched or absent bowel sounds and abdominal distention,[43] but these are not conclusive features, and the diagnosis is usually made by imaging studies.

The images are from the same patient as discussed in the previous slide. The abdominal x-ray on the left reveals distended small bowel loops and gas-fluid levels. The CT enteroclysis on the right shows multiple and dilated jejunal diverticula.

Images courtesy of Falidas E, Vlachos K, Mathioulakis S, Archontovasilis F, Villias C. World J Emerg Surg. 2011;6(1):8. [Open access.] PMID: 21385440, PMCID: PMC3061903.

Slide 25

Large bowel obstruction

Obstruction of the large bowel is far less common than that of the small bowel, comprising about 20% of intestinal obstructions in the general population. The top three causes of LBO—malignancy, diverticulitis, and volvulus—are more common in the elderly.[42] Up to 50% of older patients do not manifest vomiting or constipation,[1] but about 20% have diarrhea.[6]

The evaluation and initial management of LBO are very similar to that for SBO, although the definitive treatment is dependent on the underlying etiology. In general, the clinical approach consists of rapid assessment and prompt surgical consultation, accompanied by volume resuscitation as well as administration of preoperative broad-spectrum antibiotics (selected on the basis of the suspected cause).[41]

The upright abdominal radiograph on the left reveals multiple air-fluid levels and dilated loops of bowel in a patient with LBO. The flat abdominal radiograph on the right demonstrates dilated loops of bowel in the same patient.

Images courtesy of Wikimedia Commons/James Heilman, MD.

Slide 26

Volvulus

Volvulus is twisting of the bowel around its mesentery.[44] This condition most often affects the sigmoid colon (80%),[6] especially in the elderly, but volvulus may also involve the cecum or transverse colon. Volvulus is thought to cause about 31% of all bowel obstructions in the United States but occurs more frequently in other parts of the world.[45]

Sigmoid volvulus (shown) is characterized by a gradual onset of abdominal pain, generally in a chronically ill, debilitated patient, whereas cecal volvulus typically has an acute onset and requires urgent surgical intervention.[1,6] Left untreated, volvulus may lead to bowel ischemia and perforation.

Image courtesy of Spangler R, Van Pham T, Khoujah D, Martinez JP. Int J Emerg Med. 2014;7:43. [Open access.] PMID: 25635203, PMCID: PMC4306086.

Slide 27

Diverticular disease

Diverticulosis consists of outpouchings of colonic mucosa through weaknesses in the intestinal wall.[46] It is often seen in Western countries and affects older people (age >70 years: >60%; age >80 years: about 80%).[1,47] An estimated 10%-20% of patients with diverticulosis develops diverticulitis, in which one or more diverticula become inflamed and may lead to fecal peritonitis.[1,48]

Diverticulosis and, therefore, diverticulitis, most commonly affect the sigmoid colon, but any site in the colon may be involved. Asymptomatic diverticulosis is frequently noted on routine colonoscopy. CT scanning is appropriate to evaluate suspected diverticulitis, confirm the diagnosis, and classify the condition.[48]

Diverticulitis is traditionally classified as either uncomplicated, which may generally be treated conservatively (eg, bowel rest, antibiotics), or complicated.[48] Complicated diverticulitis is associated with abscess or perforation and is almost universally managed surgically.[48,49]

The CT scan on the left demonstrates diverticular disease, colonic wall thickening, fat stranding, and pericolic fluid and air bubbles. The endoscopic image on the right reveals diverticulosis in a different patient.

Images courtesy of (1) Sartelli M, Moore FA, Ansaloni L, et al. World J Emerg Surg. 2015;10:3. [Open access.] PMID: 25972914, PMCID: PMC4429354 (left); and (2) Wikimedia Commons/Samir (right).

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