Beware Abdominal Pain in the Elderly
ABSTRACT & COMMENTARY
Source: Marco CA, et al. Abdominal pain in geriatric emergency patients: Variables associated with adverse outcomes. Acad Emerg Med 1998;5:1163-1168.
In an attempt to determine final diagnoses and outcomes of elderly emergency department (ED) patients with abdominal pain, along with clinical predictors of surgery and death in the ensuing two months post evaluation, Marco and colleagues performed a longitudinal case series study of all such patients presenting to their ED over a 12-month period. Patients older than age 64 who presented with a chief complaint or final ED diagnosis of abdominal pain were eligible for study. Telephone follow-up of discharged patients occurred at two-week intervals until resolution of symptoms or establishment of definitive diagnosis. Discharge diagnosis was used as the final diagnosis for admitted patients. Chart review was used to collect the following data: patient demographics, vital signs, physical exam findings, laboratory values, abdominal x-ray findings, disposition, length of hospital stay, procedures, treatment, repeat ED visits, repeat hospital admissions, final diagnosis, and final outcome.
Follow-up information was available for 375 of 380 eligible patients. Fifty-two percent of eligible patients were admitted to the hospital; 22% underwent surgery or other nonspecified procedures, and 5% died within two months of initial presentation. Variables independently associated with death included free air on abdominal x-ray, age older than 84 years, "other significant" x-ray findings, and bandemia. Variables independently associated with need for surgery included hypotension, abnormal bowel sounds, "other significant" x-ray findings, dilated loops of bowel on abdominal x-ray, and leukocytosis.
Marco et al conclude that the need for hospitalization in elderly patients with abdominal pain is high, along with morbidity and mortality. Though specific variables are strong predictors of adverse outcome, their absence does not rule out significant disease. Finally, they recommend consideration of hospital admission for elderly patients with abdominal pain, especially when presentation includes fever, hypotension, leukocytosis, or abnormal bowel sounds.
Comment by Frederic Kauffman, MD, FACEP
There are many technical limitations in this study. The study suffers from the potential flaws of any retrospective chart review in that it relies upon accuracy and completeness of chart documentation. The terms "other inpatient procedures" and "other significant radiographic abnormalities" are not defined by Marco et al. Most importantly, I was appalled that, at least per chart documentation, 5% of patients lacked a full set of vital signs, 37% had no rectal exam performed, and 95% of females had no pelvic exam performed. And, while dogmatic approaches in medicine are rarely justified, I dare say that every elderly patient with abdominal pain must have a rectal exam performed and documented, along with a pelvic exam in female patients.
Despite these flaws, Marco et al emphasize many essential take-home points. The differential diagnosis of abdominal pain in the elderly is voluminous, filled with etiologies capable of producing major morbidity and mortality. Presentations of common diseases often are atypical in this age group and, in and of themselves, present a major diagnostic challenge for the emergency physician. Marco et al found a two-month death rate of more than 5%, and only 66% of patients were improved or recovered two months after their presenting condition.
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