Abdominal pain is often misdiagnosed in the ED: Take steps to protect patients
Complaint may be much more serious than it seems
Gastrointestinal (GI) bleed. Cancer. Myocardial infarction (MI). Constipation. These are just some of the conditions that could present as abdominal pain in ED patients.
Acute abdominal pain often is overlooked or misdiagnosed in ED patients, says a new study.1 Researchers compared two groups of patients with abdominal pain: 832 patients ages 65 to 80 years and 1,458 patients ages 20 to 64 years. They found that older patients were misdiagnosed 52% of the time, compared with 45% of the control group.
In addition, elderly patients more often had specific organic disease and arrived at the ED after a longer history of abdominal pain compared to younger patients. "ED nurses need to be aware that the presentation of the elderly patient with abdominal pain may be much more serious than it seems," says Karen Hayes, PhD, ARNP, assistant professor at the School of Nursing at Wichita (KS) State University.
Elderly patients also have a higher incidence of asymptomatic underlying pathology for aortic aneurysm, MI, and pneumonia, warns Hayes.2 "All of these can present as vague abdominal pain, so maintain a high level of suspicion."
Pain among older adults is complicated by multiple, concomitant causes and locations of pain, which makes it difficult to distinguish acute pain caused by a new illness from that of an old condition, adds Hayes. For instance, a patient with a history of diverticulosis presenting with a new onset of pain related to a bowel adhesion may believe the pain is from the old problem and delay presenting to the ED for the new, urgent problem, she explains.
The challenges for this patient population include multiple comorbidities, sensory losses, and dementia, says Joyce A. Dixon, RN, MSN, assistant nurse manager at the ED at University of California-San Diego Medical Center. "This complaint should be taken very seriously at triage," she says.
Patients with acute abdominal pain account for approximately 5%-10% of ED visits, and geriatric populations have a higher frequency of this complaint.2 "They are typically more acutely ill than younger populations and therefore have a higher admission rate, as well as higher mortality and morbidity," says Sam Shartar, RN, CEN, nurse manager of the ED at Emory University Hospital in Atlanta.
To improve care of patients with acute abdominal pain, consider the following:
• Rule out a cardiac event.
"Atypical cardiac presentations are common in the elderly," says Dixon. "An electrocardiogram should be done sooner rather than later, to rule out cardiac ischemia."
Elderly and female patients present with atypical patterns of pain when having an MI, says Shartar. "Presentation with epigastric pain may be their only symptom," he says. "Patients typically present with a complaint of abdominal pain without differentiating between abdominal and epigastric pain on initial presentation."
• Obtain a thorough medication history.
Elderly patients may unknowingly be taking duplicate medications, such as Tylenol and generic acetaminophen or Motrin and generic ibuprofen, says Dixon. "That can exacerbate or compound the search for a diagnosis," she says. "Obtaining a thorough medication history is essential, including over-the-counter medications. This is so important that the [Joint Commission on Accreditation of Healthcare Organizations] has declared it a National Patient Safety Goal."
• Perform an accurate pain assessment.
Elderly people do feel pain as intensely as younger patients, but they are less likely than younger people to report it, says Hayes. Assessment of pain in elderly cognitively impaired patients may be difficult, she adds.
You'll need multiple assessment tools and approaches, including the verbal descriptor scale, visual analog scale, the Wong-Baker FACES pain rating scale, the pain thermometer, and observing the patient for increasing agitation, moaning, or pain on movement, says Hayes.
• Don't assume that constipation is the cause.
A common misconception is that constipation is the cause of most abdominal pain in elders, says Hayes. "This is a frequent problem, but the patient should also be asked about rectal bleeding or narrowed stool caliber," she says. "The elderly patient with abdominal pain and any of these symptoms should be evaluated for mass lesions or other organic problems."
• Be aware of the differences in how elderly patients present.
The study's researchers found that rebound tenderness, local rigidity, and rectal tenderness were less common in older patients with peritonitis. Elderly patients with acute peritonitis are much less likely to have the classic findings of an acute abdomen, says Hayes. "They are less likely to have fever or leukocytosis. In addition, their pain is likely to be much less severe than expected for a particular disease," says Hayes.
Older patients often wait several days before they seek care, even in the presence of significant disease, says Shartar. "The nurse must practice diligence in identifying the often subtle signs that serious pathology exists," he says. You must do a thorough physical examination and history, look for changes in mental status, look for changes in functionality with regard to activities of daily living, and monitor trends with vital signs, he says.
• Remember that there still may be acute pathology, even if findings from the physical examination are negative.
This misconception is common, Shartar says. "For example, the presence of bowel sounds doesn't rule out peritonitis or small bowel obstruction," Shartar says. "Because of the increased frequency of significant problems such as neoplasm, ischemic bowel, and small bowel obstruction, this patient population is at extreme risk for increased complications and mortality."
Because of the difficulty in reliably diagnosing patients with abdominal pain, any patient with hypothermia, fever, hypotension, leukocytosis, or abnormal bowel sounds should be considered for admission, says Shartar. "In our ED, we use cross-sectional radiological studies to assist with the identification of serious disease," he says.
• Ask the right questions at triage.
When patients report abdominal pain, ask the following questions, says Jeanette A. Trotman, RN, BSN, CEN, co-director of emergency services at Albert Einstein Medical Center in Philadelphia:
— Where on the abdomen does it hurt? "This helps narrow down possible sources and etiology of the pain," says Trotman.
— What makes it better and/or worse?
— Is the pain associated with eating or moving?
— When did it start?
— Describe the quality and characteristics of the pain. Is the pain constant, intermittent, stabbing or dull and aching?
— Is there tenderness? Is the abdomen firm?
— When was the last bowel movement? Was it normal? "This helps determine if you might be dealing with possible obstruction," says Trotman. "Color may indicate a GI bleed."
— Is there any history of trauma, such as recent falls, blunt force or penetrating injuries? For example, a bicycle fall a few days ago may be forgotten or thought not to be relevant by the patient, but that could be the reason for the pain, says Trotman.
For females of childbearing age, also ask:
— When was your last menstrual period? Do you have any vaginal discharge or bleeding? "Pain in pregnancy puts two patients potentially at risk: mom and baby. Ectopic pregnancies are potentially surgical emergencies," says Trotman.
For men, also ask:
— Does the pain radiate into the scrotum? Is there any penile discharge? "For males, testicular torsion is a surgical emergency," says Trotman. "Flank pain could be related to kidney stones, disease, or infection."
References
- Laurell H, Hansson LE, Gunnarsson U. Acute abdominal pain among elderly patients. Gerontology 2006; 52:339-344.
- American College of Emergency Physicians. Clinical Policy: Critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000; 36:406-415.
Sources
For more information on abdominal pain in the ED, contact:
- Joyce A. Dixon, RN, MSN, Assistant Nurse Manager, Emergency Department, University of California-San Diego Medical Center, 200 W. Arbor Drive, San Diego, CA 92103. Phone: (619) 543-7155. E-mail: [email protected].
- Karen Hayes, PhD, ARNP, Assistant Professor, School of Nursing, Wichita State University, 1845 Fairmount, Wichita, KS 67260. Phone: (316) 978-5721. E-mail: [email protected].
- Sam Shartar, RN, CEN, Nurse Manager, Emergency Department, Emory University Hospital, 1364 Clifton Road N.E., B-177, Atlanta, GA 30322. Phone: (404) 712-7576. E-mail: Samuel. [email protected].
- Jeanette A. Trotman, RN, BSN, CEN, Co-Director, Emergency Services, Albert Einstein Medical Center, Philadelphia. Phone: (215) 456-6677. E-mail: [email protected].
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