Acute Abdominal Disease in the Aged

Difficult Diagnoses

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Acute Abdominal Disease in the Aged Steven L. Phillips, MD, * and Gerard P. Burns, MCh, FRCS, FACSt

The diagnosis of acute abdominal diseases in the aged often presents considerable difficulty. At a time when accurate historical data as to initial onset of symptoms, origin and radiation of pain are crucial, the physician often is hindered by the patient's fading memory. Associated degenerative or disease processes in the elderly also can suppress the classical physical signs of acute abdominal diseases. Tenderness, pain, muscle rigidity, and guarding can be difficult to evaluate and often are absent in the elderlv patient with dulled senses. The fact that the aging body often does na't develop muscle splinting or guarding, febrile response, or leukocytosis to the same degree as a younger one also complicates the evaluation. The common use of nonsteroidal anti-inflammatory drugs, both prescribed and over the counter, for chronic diseases in the elderly population may impair the body's ability to respond further and may even predispose to some acute abdominal diseases. Because of a fear of being hospitalized with possible institutionalization and further loss of independence, many elderly patients avoid seeking medical attention early in the course of their disease. In 1985 there were 36,155,000 major operations in the United States. Nearly 33 per cent (10,612,000) were on patients over the age of 65. 61 Elderly patients do poorly when an emergency surgical procedure is required. It is extremely important that physicians become more responsive to vague abdominal complaints in the geriatric population. Acute abdominal disease in the geriatric patient presents special problems in diagnosis because of some unique factors in this age group: 1. The clinical features of acute abdominal inflammatory conditions frequently are less pronounced in the geriatric patient. The abdominal muscles often are thin, with some degree of atrophy, and react with less splinting, muscle guarding, or spasm. The white cell count tends to be lower for a given degree of inflammation or may show no elevation. *Acting Chief, Division of Geriatrics. Veterans Administration Medical Center. Martinez. C,~lifornia tProfessor of Surgery. State University of New York at Stony Brook; and Senior Attending Surgeon. Long Island Jewish ~1edical Center, New Hyde Park, ;\Jew York

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Temperature elevations in older patients frequently are delayed and often raised to a lesser degree than in younger patients. 2. Anatomical factors may be different. For example, the omentum may be reduced in size, with loss of fat, and less likely to seal off an acute abdominal process. The blood supply to the appendix is poor and the wall thin, predisposing to perforation and gangrene. 3. Multiple abdominal disease processes already may exist and lead to diagnostic confusion. For example, gallstones frequently are present in the elderly and increase in frequency with increasing age. Diverticulosis and hiatal hernia are common in the American geriatric patient. Atherosclerosis of the abdominal vessels with calcification of the arteries frequently is seen. Some degree of megacolon from chronic constipation occurs in many elderly patients. 4. Communication problems with the patient may result from mental confusion, aphasia from a previous stroke, or Alzheimer's disease. An adequate history, so crucial in making the correct diagnosis in acute abdominal disease, often is unobtainable. Some of the more common disease entities now will be considered. ACUTE MESENTERIC ISCHEMIA

The initial symptom of acute mesenteric ischemia is abdominal pain, frequently severe but poorly localized. Characteristically, the pain appears disproportionately greater than the physical signs would suggest. In patients with visceral artery stenosis, there may be a long history of previous attacks of abdominal pain, often related to eating and accompanied by weight loss. The abdomen usually is not tender to palpation and is without muscle spasm. With the onset of intestinal infarction, muscular rigidity may develop, with areas of localized tenderness. Nausea, vomiting, and abdominal distension occur, with the passage of a loose or bloody stool. However, a study of patients admitted to an acute medical service with suspected bowel infarction showed no physical or laboratory findings that distinguishecl those with infarction from those without. 14 The diagnosis of superior mesenteric artery thrombosis may be suspected when there is a prior history of intestinal angina. Patients with existing mitral stenosis, atrial fibrillation, or recent myocardial infarction with mural thrombus are prone to embolization, and the clinical picture of infarction develops rapidly, often within 6 hours. Nonocclusive ischemia occurs in patients with severe congestive heart failure, cardiac arrhythmias, digitalis therapy, hypotension, and sepsis with a low flow state. Mesenteric venous thrombosis may be suspected in patients with pre-existing malignant disease, migrating thrombophlebitis, and coagulation disorders. The diagnosis of mesenteric ischemia can be strengthened by the demonstration of a leukocytosis, elevated aspartate aminotransferase, lactate dehydrogenase, and creatine phosphokinase. The phosphate level may be elevated in blood, urine, and peritoneal fluid. 26 With the onset of bowel infarction, lactic acidosis may develop. When the diagnosis is suspected, plain x-ray films of the abdomen should be taken, with the patient in the

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erect position if possible, mainly to exclude a perforated viscus or intestinal obstruction. The films may reveal intestinal distention from ileus; thumb printing of the bowel wall, particularly in the colon, indicative of intramural hematoma; separation of bowel loops from edema of the wall; and streaks of gas in the thickened bowel wall or in the portal vein. When mesenteric ischemia is suspected, abdominal angiography should be performed, first using flush aortography to show aneurysm, dissections, or major visceral artery occlusions and collateral circulation, followed by selective superior mesenteric arteriography. 5 The appearance of thrombotic occlusion or embolus and of nonocclusive ischemia often is diagnostic. Therapeutic administration of intra-arterial papaverine will result in increased mesenteric flow and relief of symptoms if infarction has not yet occurred.

INTESTINAL OBSTRUCTION The cardinal clinical features of intestinal obstruction, pain, vomiting, distention, and obstipation frequently are masked in the elderly. A clear history of pain may not be obtained until the disease is advanced. Constipation and fecal impaction are frequent findings in the geriatric patient and may lead to the early clinical features being ignored. Clinical examination of the elderly patient with a distended abdomen may show visible peristalsis through a thin abdominal wall. This, in itself, is not diagnostic of intestinal obstruction and simply may be a reflection of the atrophied abdominal muscles. Although umbilical and inguinal hernias generally are obvious, a small femoral hernia, particularly in the obese patient, easily may be missed. The rectal examination may reveal fecal impaction; this should be treated by enemas, with digital disimpaction if necessary, because there may be another source of intestinal obstruction higher in the bowel. A serious threat in the aged is the incarceration or strangulation of an asymptomatic external hernia. External hernias account for nearly 30 per cent of acute intestinal obstructions, with a mortality rate of 44 per cent in those undergoing emergency surgery.9 The remainder of obstructions primarily are caused by adhesions, inflammation, gallstones, or tumors. IO . 46 The pain associated with obstruction usually is cramping in nature and, frequently, periumbilical or hypogastric. In small bowel obstruction, the pain waves occur closer together than in large bowel obstruction. Abdominal distension, tenderness, vomiting, and absent bowel sounds are not always evident. A careful search for old abdominal scars and external hernias is required. Rectal examination may detect a mass when a tumor involving the rectosigmoid area is causing large bowel obstruction. Plain radiographs of the abdomen show dilated intestine, with air fluid levels. Prompt recognition and management of complicating situations can mean the difference between success and failure. 10 Although the early diagnosis of intestinal obstruction is difficult, attempts must be made to make the diagnosis before bowel strangulation occurs. The mortality of operations for acute intestinal obstruction in the

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elderly is high and rises when bowel resection is required. Several studies have emphasized the difficulty in distinguishing simple obstruction from strangulation clinically. 37. 47 The classical features of strangulation, namely, constant rather than colicky pain, leukocytosis, fever, and tachycardia, are unreliable. Intestinal obstruction in the elderly usually is caused by either adhesions from previous surgery or carcinoma of the colon. If there is a previous history of gallstones and the patient has had a recent attack of biliary colic or acute cholecystitis followed by the development of intestinal obstruction, gallstone ileus should be suspected. This may be confirmed on the plain xray of the abdomen by the characteristic picture of ileus of the small bowel with air-fluid levels, a radio-opaque density in the right lower quadrant, and the presence of air in the biliary tree from the biliary-enteric fistula. In elderly patients with systemic illnesses and poor mobility, massive gaseous distension of the large bowel may occur even in the absence of distal mechanical obstruction. 18. 19.24 This colonic pseudo-obstruction sometimes is known as Ogilvie's syndrome. 41 The patient generally presents with varying degrees of abdominal pain and vomiting, associated with either diarrhea or constipation. The physical findings are a distended abdomen that is tympanitic but not tender. The bowel sounds are normal or decreased and rectal examination may reveal constipation or a markedly dilated, cavernous rectum. 24. 41 Plain abdominal radiography shows massive, gaseous dilation of the cecum, ascending, and transverse colon, with few, if any, air fluid levels and, frequently, gas or feces in the rectum. The exclusion of an organic obstruction can be achieved by sigmoidoscopy and barium enema. 19 The colonoscope can be used to decompress the colon effectively, with subsequent placement of a drainage tube in the proximal colon for more prolonged decompression. 4, 39, 40 The accurate diagnosis of colonic pseudo-obstruction can negate the need for a laparotomy in a sick elderly patient. 24 ACUTE BILIARY PANCREATIC PROBLEMS

Gallstones are common in the geriatric population. The overall incidence in women above the age of 60 is 25 per cent, and above the age of 80, is 35 per cent ..32 Abdominal pain occurring in the patient with gallstones may, of course, be caused by some other condition, such as peptic ulcer disease, gastric or pancreatic cancer, or intestinal obstruction. Acute cholecystitis frequently occurs in the patient with gallstones and is characterized by epigastric or right subcostal pain that may radiate to the back or to the right shoulder. When the pain subsides after several hours, the diagnosis presumably is biliary colic without cholecystitis. Persistent pain, tenderness, and fever, often accompanied by nausea and vomiting, indicate the onset of acute cholecystitis. Abdominal tenderness over the tip of the ninth costal cartilage and a positive M urphy' s sign indicate the presence of an inflamed gallbladder. If a tender gallbladder is palpable, the diagnosis is confirmed and no further special studies are necessary. In one study, however, abdominal tenderness

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was absent in 26 per cent and peritoneal signs were absent in 50 per cent of elderly patients with acute cholecystitis. 36 Empyema and possible gangrene of the gallbladder should be suspected, particularly if the whole blood count and temperature are elevated, although these may be normal in the elderly. In the absence of a palpable gallbladder, further studies will be necessary. The simplest test is ultrasonography, which is highly sensitive in showing stones (95 to 100 per cent). The demonstration of stones in the gallbladder by ultrasound does not necessarily imply that they are responsible for the symptoms. Ultrasonographic signs consistent with acute cholecystitis include a thickened gallbladder wall, a pericholecystic fluid collection, and a gallbladder that is tender to pressure by the ultrasound probe on deep inspiration (positive ultrasonic Murphy's sign). To confirm acute cholecystitits, a HIDA or PIPIDA scan should be performed. In 95 per cent of patients with acute cholecystitis, the test will be positive, with no opacification of the gallbladder caused by cystic duct obstruction. Patients with biliary colic may show gallbladder filling. Acute suppurative cholangitis is a life-threatening complication of stones in the common bile duct or common bile duct obstruction. It should be diagnosed in the presence of Charcot's triad, namely, fever and chills, pain, and jaundice. Elderly patients with cholangitis subsequently may develop mental confusion and hypotension as a result of septic shock, and this combination (referred to as Reynold's pentad) indicates a very serious prognosis and a high mortality in the absence of urgent decompression of the common bile duct. 11 Acute pancreatitis in the elderly usually is caused by the passage of small gallstones, with temporary occlusion of the ampulla of Vater. The condition is characterized by abdominal pain, jaundice, elevated serum bilirubin, and serum amylase.

PEPTIC ULCER DISEASE Peptic ulcer disease may present in the elderly without pain in onethird of patients but with symptoms of gastrointestinal bleeding, anemia, nausea, vomiting, or weight 10ss.13 Upper gastrointestinal endoscopy is highly efficacious in showing peptic ulcer disease and acute gastric mucosal lesions and is well tolerated by elderly patients. Barium studies usually are not required. Even perforated peptic ulcer may be painless in the elderly. In a group of 31 patients in whom perforated peptic ulcer was not diagnosed until autopsy, 24 (77 per cent) were aged 60 or over. 17 The lack of pain has been attributed to the frequent use of steroids and nonsteroidal antiinflammatory medications in the elderly, which modify the clinical picture. Neuropsychiatric disturbances also may play a role. 17 When perforated peptic ulcer is suspected, an upright chest film will show subphrenic air in 80 per cent of patients. Elderly patients often are suitable for a lateral decubitus film only. When the diagnosis is strongly suspected and free air is absent, 200 ml of air may be injected through a nasogastric tube into the

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stomach and a second film obtained. This frequently will demonstrate a leak.

GASTRIC VOLVULUS For gastric volvulus to occur, the peritoneal supports must be elongated or absent, allowing the stomach to rotate more than 180 degrees with subsequent closed loop obstruction and possible strangulation. There are multiple initiating factors, including congenital or acquired adhesions, extrinsic pressure from adjoining masses or organs, intrinsic lesions such as an ulcer or neoplasm, intractable vomiting, acute gastric dilatation, and elevation of the left hemidiaphragm by phrenic nerve paralysis or left lung resection.8. 16. 60 There are two types of acute gastric volvulus, organoaxial and mesenteroaxial. The organoaxial type is more common and is caused by rotation of the stomach along the longitudinal or cardiopyloric axis. This type most often is associated with diaphragmatic defects, paraesophageal hernia or intra-abdominal conditions. The mesenteroaxial type is a result of the stomach rotating about an imaginary line drawn from the midline to the greater curvature of the stomach at a right angle to the cardiopyloric axis. The obstruction is limited to the mobile pyloric-antral area and is likely to be partial in extent and idiopathic in nature. The clinical presentation, physical, and radiographic findings are distinctly different in the two types. In the organoaxial type, there is abrupt onset of abdominal pain and vomiting, followed by retching without vomiting. If strangulation has occurred, then a distinctive thoracoabdominal complex of features occurs. The abdominal features include those previously mentioned, along with the inability to pass a nasogastric tube. The thoracic manifestations are severe substernal or lower chest pain with radiation to the neck or shoulder, dyspnea, and, occasionally, cyanosis. 7 A chest radiograph may show a large paraesophageal hernia, with an upside-down stomach, left basal atelectasis, and pleural effusion. The esophagogram will show a distal esophageal obstruction or spiral twist. Immediate surgical reduction and correction is required. The mesenteroaxial type presents with sudden onset of epigastric and left upper quadrant pain, nausea, and vomiting. Marked abdominal distension and a tympanitic large left upper quadrant mass may be felt. A chest radiograph may show an elevated left hemidiaphragm with an air fluid level in it. A nasogastric tube can be passed and a gastrografin study will reveal marked gastric distension with complete pyloric-antral obstruction. Because this form of torsion often is partial and spontaneous, detorsion can occur. Recurrent torsion is likely and, because of the possibility of eventual strangulation, surgical correction is indicated. 57

ACUTE APPENDICITIS Although this is much less common in the aged than in the younger patient, it always must remain a consideration in the diagnosis of the acute

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abdomen. In the elderly patient, the appendiceal lumen often is narrowed; strictures may he present from old inflammation; the mucosa is thin, with almost total absence of lymphocytes; fecaliths are present in 25 per cent; and atherosclerosis of the arteries has reduced the blood supply to a level at which minimal obstruction of the lumen can lead to thrombosis and gangrene of the wall. 59 These factors lead to early perforation of the appendix in older patients. The overall perforation rate in acute appendicitis is around 20 per cent"l but in the elderly, perforation rates of 70 per cent,09 55 per cent,20 and 46 per cent 21 have been recorded. ~1ost elderly patients with acute appendicitis have abdominal pain, usually in the right lower quadrant. Tenderness in the right lower quadrant can be demonstrated in 80 to 90 per cent. 20. 43 Leukocytosis is present in 75 to 80 per cent. 34.41 Fever has been observed less regularly, being noted by McCallion 14 in 43 per cent, by Hubell and coworkers21 in 21 per cent, but by Owens 43 in 74 per cent. It should be noted that the delay in diagnosis, delay in operation, and increasing age all are factors that increase the complication rate and mortality. In patients over the age of 75, the mortality from acute appendicitis is approximately 25 per cent. It therefore is important for the physician to expedite the diagnosis and surgical management. Radiologic studies are of little help to the clinician, although ultrasound or computerized tomography scanning is highly accurate in the diagnosis of an established appendix abscess. The early diagnosis therefore depends on a high index of suspicion, the careful eliciting of symptoms from the patient or relatives, and the demonstation of the classical abdominal physical signs. A study of 60 patients by McCallion 34 indicated that the clinical features in the elderly are quite similar to those in the younger age groups. ACUTE DIVERTICULITIS

The incidence of diverticulosis steadily increases with age, reaching more than 50 per cent in patients over 80 years of age. 44 The exact pathological mechanism producing acute diverticulitis is not clear but the attack usually starts as a small abscess in a single obstructed diverticulum that extends to involve either the adjacent colon or pericolic area. The serious complications are pericolic abscess, perforation, obstruction, or bleeding. In the elderly, diverticulitis may occur in a particularly aggressive form, which has been designated "malignant diverticulitis" by Morgenstern and colleagues. 35 The features are: (1) phlegmonous inflammation, (2) fistula formation to skin, bladder, or small bowel, (3) obstruction of the colon, (4) high postoperative morbidity and mortality. Many episodes of acute diverticulitis subside. The patient has left lower quadrant pain, tenderness, and moderate abdominal distension. The temperature elevation is modest, with an elevated white cell count. A plain abdominal radiograph will reveal a somewhat dilated colon above the sigmoid. Sigmoidoscopy usually will show a tender area of colon above the rectosigmoid junction. A palpable tender mass in the left lower quadrant or left flank usually indicates a pericolic abscess, although existing carcinoma

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may be present. The barium enema or, preferably, gastrografin enema will show diverticulosis, spasm, and narrowing. An extravasation of thc contrast material occasionally will occur becausc of a small perforation, but spillage into the gencral peritoneal cavity rarely is seen.

COLONIC VOLVULUS Within the United States and western Europe, colonic volvulus accounts for 3 to 5 per cent of all intestinal obstructions in the geriatric population. 50 Some predisposing factors are the consumption of a bulky, high fiber diet, physical inactivity, and institutionalization for psychiatric problems and/or senility. 25, .0.5 The colon segment must be able to twist around its base, the prerequisite being that the colon is large and mobile, as occurs in acquired megacolon. In the geriatric population, acquired megacolon can result from the excessive usage of anthraquinone laxatives, anticholinergic medications, tranquilizers, ganglionic blocking agents, and antiParkinsonian drugs. lO , 48, 52 In the geriatric population, colonic volvulus occurs in the sigmoid colon (75 to 80 per cent), the cecum (15 to 20 per cent), and the transverse colon (5 per cent).l Acute colonic volvulus is heralded by sudden colicky pain, abdominal distension, and vomiting caused by early occlusion of the mesenteric blood vessels (torsion is greater than 180 degrees). The patient is acutely ill and sometimes in shock. The physical findings are a distended abdomen, often with obstructive bowel sounds, although the latter may be absent. Perfl)ration and peritonitis should be suspected if muscle guarding is present. The rectal ampulla is empty on digital examination. A plain radiograph of the abdomen may show non diagnostic colonic dilatation by gas and fluid or the diagnostic "bird beak," "large horseshoe," or "Y" signs. Air fluid loops may be either single or double, which are diagnostic of cecal and sigmoid volvulus, respectively. 29, 54, 62 A study by Arnold and Nance showed that plain radiographs of the abdomen made the correct diagnosis of colonic volvulus in 60 per cent of cases. 2 The diagnosis is confirmed by sigmoidoscopy, which often will be accompanied by the sudden passage of liquid stool and gas as the tip of the instrument is passed into the sigmoid. The passage of a rectal tube will lead to further decompression. It is important on sigmoidoscopy to look carefully for any cyanosis or friability of the mucosa, which would indicate necrosis of the bowel wall. The complications include perforation, gangrene of the bowel, and peritonitis. When any of these are present, immediate surgical intervention is required.

ABDOMINAL AORTIC ANEURYSM Ruptured abdominal aortic aneurysm continues to carry a high mortality rate. 12, 51 Chung reviewed 187 cases and found that mortality depends on when the diagnosis is made. 12 The classic triad is pain, abdominal mass,

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and hemorrhagic shock. m U nf()rtunately, these clinical features are not always evident, or even sought, during initial evaluation. 51 Pain usually is present in every case, although there is variability in the site of origin and radiation. Initially, the pain may mimic appendicitis, diverticulitis, perforated ulcer, mesenteric thrombosis, or bowel obstruction. Depending on the path of dissection of hematoma along the retroperitoneal space, the pain may radiate from the back into the flank, groin, hip, or scrotum and testicles."n A tender, pulsatile abdominal mass is present on palpation. Upon initial presentation, the patient occasionally may be in a compensated state of shock. One therefore must be suspicious in all geriatric patients presenting with an acute abdominal process. If the patient is completely stable, a lateral abdominal film may be taken to show the curvilinear egg shell border of the aneurysm. Abdominal aortography should not be performed in symptomatic patients because it delays the operative procedure and frequently fails to show the aneurysm, which is filled with clot. 2 ' Moreover, sudden catastrophic hemorrhage may occur during aortography, with irreversible shock or cardiac arrest.

UROGENITAL DISEASE Acute urinary tract infections are common in the elderly and may present as fever and abdominal pain. These symptoms may be accompanied by gastrointestinal distension and give rise to diagnostic confusion. The dilemma often is resolved only by urine culture and antibiotic treatment. Malignant renal tumors are one of the truly great mimics encountered in clinical medicine. A variety of disorders can be reproduced by direct pressure, necrosis, hemorrhage, or extension, or by metastasis of the renal tumor. 15 When bleeding into the tumor occurs, the pain can become acute and severe, with development of reflex ileus and a clinical picture of an acute abdominal process. 38, 42 If any urologic symptoms are present and the clinical setting is confusing, a renal tumor should be considered. 42 Spontaneous nontraumatic perforation of the bladder can occur in elderly patients, with obstructive symptoms caused by lesions outside the bladder wall or irritative symptoms caused by lesions originating within the bladder wall. I, 33, 5H Mild lower abdominal pain with distension, diffuse tenderness with rebound, and associated anuria are present. Placement of a Foley catheter without return of urine followed by upright radiographs of the abdomen, showing air under the diaphragm, indicates the necessity for cystography and surgical exploration. 22

NONABDOMINAL DISEASES PRESENTING AS ACUTE ABDOMEN There are numerous medical conditions that can produce acute abdominal symptoms in the elderly. These include diabetic ketoacidosis, acute pancreatitis, tabes dorsalis, hypercalcemia, hemochromatosis, Addison's disease, and porphyria. 23 Acute abdominal symptoms also can be caused by extra-abdominal diseases such as spondylosis, extradural lesions, ureteral

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calculi, pleurisy, pneumonitis, pulmonary emboli, pneumothorax, congestive heart failure with hepatic congestion, acute myocardial infarction, and herpes zoster. 6. 27. 4.5 The past medical history, physical findings, clinical laboratory tests, electrocardiogram, and chest and spinal roentgenograms are helpful in diagnosing these medical conditions and extra-abdominal diseases.

SUMMARY The elderly patient with acute abdominal disease may present with a classical clinical picture. However, the presentation often is atypical and perplexes the physician. The factors involved include altered anatomical features, fear of being placed in an institution, difficulty in communicating with the physician and family members, diminished response to infection, and multiple coexisting diseases. Awareness of the atypical clinical presentations and the judicious use of special investigations will enable the clinician to make earlier and more accurate diagnoses and, thus, reduce morbidity and mortality.

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20. Goldenberg IS: Acute appendicitis in the aged. Geriatrics 10:324. 1955 21. Hubbell DS, Barton WK, Solomon OD: Appendicitis in older people. Surg Gynecol Obstet 110:289, 1960 22. Huffman JL, Schraut W, Bagley DW: Atraumatic perforation of bladder: Necessary differential in evaluation of acute condition of abdomen. Urology 22:30, 1983 23. Hyams DE: Gastrointestinal problems in the old. n. Br Med J 1:150, 1974 24. Hyatt R: Colonic pseudo-obstruction: An important complication in hospitalized elderly patients. Age Ageing 16:145, 1987 25. Ingalls JM, Lynch MF, Schilling JA: Volvulus of the sigmoid in a mental institution. Am J Surg 108:339, 1964 26. Jamieson WG, Marchuk S, Rowsom J, et al: The early diagnosis of massive acute intestinal ischemia. Br J Surg 69:S52, 1982 27. Jooma R, Torrens MJ, Veerapen RJ, et al: Spinal disease presenting as acute abdominal pain: Report of two cases. Br Med J 287:117, 1983 28. Kadir K, Athanasoulis CA, Brewster DC, et al: Tender pulsatile abdominal mass: Abdominal aortic aneurysm or not? Arch Surg 115:631, 1980 29. Kerry RL, Ransom HK: Volvulus of the colon. Arch Surg 99:215, 1969 30. Kraft E, Finby N: Megasigmoid and the megasigmoid syndrome. Gen Prac 36:104, 1967 31. Lewis FR, Holcroft JW, Boey J, et al: Appendicitis. Arch Surg 677:110, 1975 32. Lieber MM: The incidence of gallstones and their correlation with other diseases. Ann Surg 135:394, 1952 33. Maddocks RA, Leadbetter GW: Spontaneous bladder rupture: Rare cause of peritonitis. J Am Coll Emerg Physicians 5:591, 1976 34. McCallion J, Canning G, Knight PV, et al: Acute appendicitis in the elderly: A 5 year retrospective study. Age Ageing 16:256, 1987 35. Morgenstern L, Weiner R, Michel SL: "Malignant" diverticulitis, a clinical entity. Arch Surg 114:112, 1979 36. Morrow DJ, Thompson J, Wilson SE: Acute cholecystitis in the elderly. Arch Surg 113:1149, 1978 37. Mucha P Jr: Small intestinal obstruction. Surg Clin North Am 67:597, 1987 38. Mukamel E, Nissankorn I, Avidor I, et al: Spontaneous rupture of renal and ureteral tumors presenting as acute abdominal condition. J Urol 122:696, 1979 39. Munro A, Youngson G: Colonoscopy in diagnosis and treatment of colonic pseudoobstruction. J R Coli Surg (Edinb) 28:391, 1983 40. Nakhgevany KP: Colonoscopic decompression of the colon in patients with Ogilvie's syndrome. Am J Surg 148:317, 1984 41. Ogilvie H: Large intestinal colic due to sympathetic denervation: A new clinical syndrome. Br Med J 1:671, 1948 42. Orr WS, Gillenwater JV: Hypernephroma presenting as an acute abdomen. Surgery 70:656, 1971 43. Owens BJ, Hamit HF: Appendicitis in the elderly. Ann Surg 187:392, 1978 44. Parks TG: Natural history of diverticular disease of the colon. Clin Gastroenterol 4:53, 1975 45. Pathy MS: Clinical presentation of myocardial infarction in the elderly. Br Heart J 29:190, 1967 46. Ponka JL, Welborn JK, Brush BE: Acute abdominal pain in aged patients: An analysis of 200 cases. J Am Geriatr Soc 11:993, 1963 47. Sarr MG, Bulkley GB, Zuidema GD: Preoperative recognition of intestinal strangulation obstruction: Prospective evaluation of diagnostic capability. Am J Surg 145:176, 1983 48. Scharer LL, Burhenne JJ: Megacolon associated with administration of an anticholinergic drug in a patient with ulcerative colitis. Am J Dig Dis 9:268, 1964 49. Shackelford RT: Diagnosis of Surgical Disease, Vo!. 3. Philadelphia, WB Saunders, 1968, p 1577 50. Sivousjpour D, Berardi RS: Volvulus of the sigmoid colon: A 10 year study. Dis Colon Rectum 19:535, 1976 51. Soreide 0, Grimsgaard C, Myhra HD, et al: Time and cause of death for 301 patients operated on for abdominal aortic aneurysms. Age Ageing 11:256, 1982 52. Sriram K, Schurrer W, Ehrenpreis S, et al: Phenothiazine effects on gastrointestinal tract function. Am J Surg 137:87, 1979 53. Starling JR: Initial treatment of sigmoid volvulus by colonoscopy. Ann Surg 190:36, 1979

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54. String ST, DeCosse JJ: Sigmoid volvulus. Am J Surg 121:293, 1971 55. Sutclifl'e MML: Volvulus of the sigmoid colon. Br J Surg 55:903, 1968 .56. Szilagyi DE, Smith RF, Mackrood AI. et al: Expanding and ruptured abdominal aortic aneurysms. Arch Surg 83:395, 1961 57. Tanner NC: Chronic and recurrent volvulus of the stomach. Am J Surg 115:505, 1968 58. Thompson IM, Johnson EL, Ross G: The acute abdomen of unrecognized bladder rupture. Arch Surg 90:371, 1965 59. Thorbjarnarson B, Loehr WJ: Acute appendicitis in patients over the age of 60. Surg Gynecol Obstet 125:1277, 1967 60. Was tell C, Ellis H: Volvulus of the stomach. Br J Surg 58:557, 1971 61. Wilder JR: Geriatric emergencies: On improving older people's chances. Geriatrics 42:17, 1987 62. Xingrong OH: Problems in roentgen diagnosis of sigmoid volvulus. Chin Med J 92:483, 1979 (English translation) Division of Geriatrics Veterans Administration Medical Center 150 Muir Road Martinez, CA 94553