Approach to the Acute Abdomen

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Geriatric Medicine

Approach to the Acute Abdomen Jeffrey S. Bender, MD*

The elderly patient who presents with abdominal pain poses a difficult problem for the practitioner. The need to provide a timely diagnosis and treatment is perhaps even more urgent than for younger patients, but the physician's hands are often tied by factors beyond his control. These include (1) any underlying dysfunction due to the patient's age and associated diseases; (2) a presentation that is often late in the course of the acute problem; and (3) some desire on both parties' part to avoid unnecessary tests or surgery. Such problems can test the judgment of even the most experienced clinician. To complicate this even further, there are remarkably few papers in the literature that can guide the physician in the differential diagnosis of acute abdominal pain in the elderly. 3. 7. 8. 17 In addition, there is a relative lack of outcome studies for these patients that would serve to reassure the patient and his physician that efforts to cure are worthwhile. 10 Before addressing the above concerns, I would like to discuss some general aspects of the initial approach to the geriatric patient with an acute abdomen, emphasizing the differences in presentation from that of a younger population. As it is not imperative that the primary provider obtain a completely accurate diagnosis, as opposed to merely establishing that a surgical problem exists, little emphasis will be placed on minutiae of differential diagnosis.

INITIAL EVALUATION History

While obtaining an accurate history is the cornerstone of diagnosing an acute abdominal condition, this can be difficult or even impossible in an elderly patient. Although many patients remain alert and cooperative to the end of their life, a significant number develop loss of short-term *Assistant Professor of Surgery, Wayne State University School of Medicine; and Associate Medical Director, Surgical Intensive Care Units, Harper Hospital, Detroit, Michigan

Medical Clinics of North America-Vo!' 73, No. 6, November 1989

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memory or an even further deterioration of mental status. These patients may be incapable of giving any history at all, let alone a helpful one. An acute onset of pain at almost any age generally indicates a surgical condition. This history can be surprisingly lacking in an older patient. The exact reason for this is unclear. Since many older individuals are used to caring for themselves, they do not want to bother others, including their physician, with what they consider to be trivial problems. A large number of patients self-diagnose indigestion or constipation and treat themselves accordingly before seeking help. However, there is another, and probably more likely, reason for this delay. This is the generally recognized inability of elderly individuals to perceive pain. This decreased sensibility to pain has not been documented in the laboratory, as have those to touch 19 and vibration,20 but is such a universally recognized phenomena that there is little doubt of its existence. Nevertheless, the importance of any abdominal pain in the aged cannot be overemphasized, as delay in diagnosis, perhaps because of this lack of appreciation, is a major cause of morbidity and mortality. 2. 4. 5. 14. 15. 18 An interesting corollary, which tends to support this thesis, is the work of Pathyl6 who found that only 19 per cent of elderly individuals with myocardial infarction had a history of chest pain. Other aspects of the history are less important than the elicitation of pain symptoms. In particular, little attention should be paid to constipation complaints as many elderly patients feel that the lack of a daily bowel movement is a serious problem. A symptom of more concern should be the failure to pass flatus. Since most flatus represents swallowed air, its lack generally indicates a complete obstruction. Absence of vomiting fails to exclude an acute abdomen, although vomiting prior to the onset of pain does make a surgical process unlikely. Physical Examination As with the elderly's perception of pain, it is amazing how few physical findings can sometimes be present with even diffuse peritonitis. This must particularly be kept in mind when the diagnosis of either mesenteric ischemia or small bowel obstruction is being considered. The presence of gangrenous bowel in both diseases is notorious for having few, if any, peritoneal signs. The presence of rebound tenderness has been emphasized as a reliable indicator of peritonitis, but I and others 4 . 7. 14. 15 have found this sign to be lacking in a large number of aged patients with gangrenous bowel. 2 Rebound tenderness, iflooked for, should be recorded as being present only if it can be reproduced with gentle depression and release of the abdominal wall. Pain reported to be greater after release of such pressure only when the examiner's hand is nearly touching the patient's spine does not represent true rebound tenderness and should not be recorded as such. A more reliable way of diagnosing peritonitis is the finding of involuntary guarding upon gentle palpation of the area of indicated greatest pain. I usually ask patients, assuming that they are sufficiently alert, to locate this painful area by pointing with one finger only. Auscultation for bowel sounds may be performed, but only rarely does

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this help in diagnosing an acute abdomen. Certainly, the presence of the classic, high-pitched "rushes" of small bowel obstruction are useful; however, their absence should not be used to rule out that diagnosis. Similarly, a complete lack of bowel sounds, as occurs in ileus or late, generalized peritonitis may be important, but should not be used to exclude early peritonitis. Another unanswered question concerns how long one should listen before declaring that bowel sounds are indeed absent. A lack of alteration in vital signs also should not be used to exclude an acute abdominal process. Normothermia and relative bradycardia are wellknown hallmarks in patients with gangrenous bowel or mesenteric ischemia. 4.5.7 There is also an absence of fever and tachycardia in other abdominal conditions such as appendicitis,15 acute cholecystitis, 11. 14. and small bowel obstruction. 2 If an accurate temperature is required, it is better to obtain one rectally, since most patients with pain tend to breathe through their mouth. This is particularly true in those with an altered mental status. Laboratory, Radiography, and Electrocardiogram Many elderly patients with an acute abdomen have markedly altered electrolytes. Associated with this sometimes is a seriously altered blood urea nitrogen:creatinine ratio reflecting their often profound dehydration. Curiously, the white blood cell count may be normal. 2~,). 7.14.15 The presence of anemia should also bc looked for, since this can indicate a malignancy, usually colonic. The classic case in which this procedure is helpful is when a patient presents with small bowel obstruction without a previous operation. A microcytic, hypochromic anemia associated with this represents an obstructing cecal carcinoma until proven otherwise. It should be remembered that anemia may not be present on the initial blood count if the patient is severely dehydrated. Thus, if immediate operation is not indicated, a repeat hemoglobin and hematocrit should be determined after rehydration. Plain abdominal radiographs are notoriously unproductive when done only for pain; one review 6 showed a radiographic abnormality in only 10 per cent of studies. It was suggested that one way of increasing thc yield was to limit examinations to those patients with moderate or severe tenderness, and those with a strong clinical suspicion of bowel obstruction, calculi, trauma, or gall bladder disease. This study unfortunately covered patients of all ages and lacked a breakdown for elderly patients. In addition, it raises the question of whether plain radiographs are actually needed to make a diagnosis. Clearly in patients in whom bowel obstruction is a strong consideration, the radiographs are invaluable. This is particularly so when an initial nonoperative approach is selected, and subsequent films to follow the progress are necessary. Just as clearly, radiographs are not needed in patients with generalized peritonitis. Unfortunately in our litigious society, if radiographs are not done and the patient subsequently suffers a bad outcome, their lack would certainly be questioned. An electrocardiogram is mandatory in elderly patients with abdominal pain of unclear etiology. The pain from a myocardial infarction may be referred, particularly to the upper abdomen, where it may easily be misdiagnosed as peptic ulcer disease or indigestion. Ponka l7 found that 1.5

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per cent of admissions for abdominal pain in patients aged over 60 years were actually for acute myocardial infarction. Similarly, a chest radiograph is useful in diagnosing basilar pneumonia that may also present with referred pain to the upper abdomen. The mechanism in both instances is probably diaphragmatic irritation.

DIFFERENTIAL DIAGNOSIS Reviews As mentioned previously, there is little in the literature dealing with the differential diagnosis of the acute abdomen in the elderly. Even these may well be outdated as most of the patients reported were treated in the 1960s. Ponka,17 in one of the first of such studies, observed 200 consecutive emergency admissions for abdominal pain in patients aged over 60 years. (The period covered was the years 1961 to 1962.) Biliary tract disease was found to be the most common cause of pain (27.5 per cent), followed in order by intestinal obstruction (17.5 per cent), peptic ulcer (10.5 per cent), diverticulitis (10.0 per cent), appendicitis (8.0 per cent), pancreatitis (7.5 per cent), incarcerated hernia (5.5 per cent), and miscellaneous causes (13.5 per cent). Although the exact number is not entirely clear, the majority of the patients underwent urgent or emergency operation. The overall mortality (including unoperated cases, which occasionally had potentially correctable pathology picked up on autopsy) was 11.0 per cent. The most common factors leading to death seemed to be delay in operation until after intractable sepsis arose and complications arising from atherosclerosis. Specific indications for earlier operation were not discussed. The next study that appeared was done by Fenyo.7 He reviewed the records of 726 patients over 70 years of age who were treated at one surgical department in Sweden from 1960 to 1961. Two hundred seven patients underwent emergency operation with a mortality of23.1 per cent, compared with a mortality of 14.0 per cent for the group as a whole. As with Ponka's series, cholecystitis was the primary cause of admission (40.8 per cent). This was followed by incarcerated hernia (9.6 per cent), appendicitis (6.7 per cent), acute pancreatitis (5.1 per cent), small bowel obstruction (3.7 per cent), large bowel obstruction (3.6 per cent), diverticulitis (3.4 per cent), and duodenal ulcer (3.3 per cent). Twenty-four per cent were either observed or underwent a negative exploration, almost all of these laparotomies being for suspected acute appendicitis. Contrary to current practice and recommendations, only 3 per cent of the patients with acute cholecystitis underwent early operation. Half of these operations were for perforation with generalized peritonitis and the others were apparently done when the preoperative diagnosis was acute appendicitis. No follow-up of the nonoperated cases was given. Fenyo concluded that delay in operation led to an increase in mortality. He attributed this delay to the difficulty in making diagnoses in elderly patients as signs and symptoms tended to be moderate and diffuse. His only recommendation to reduce mortality, however, was careful, repetitive physical examination.

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Fenyo reported a second series of 1000 patients in 1982. H This covered the years 1977 to 1978 at four Stockholm hospitals and differed in that the patients were studied prospectively. While this study was primarily concerned with length of stay, Fenyo did note some interesting changes from his first series. Although still the major cause of admission, acute cholecystitis fell to 26 per cent of cases; a higher percentage of these cases underwent surgery. Overall, the number of patients needing emergency operation increased to 34 per cent. The number of correct preoperative diagnoses increased and the mortality for each individual diagnosis decreased, often markedly. No explanation was given for these decreases, although it was suggestive of earlier and more accurate diagnosis. Overall mortality decreased only by 2.7 per cent, however, which was attributed to the large mortality among patients with malignancy. While 13 per cent of the patients had cancer (compared with only 3 per cent in his first series), they were responsible for 44 per cent of all deaths. Differences in presentation of acute problems in elderly patients were emphasized as causing delays in diagnosis and possible death. The major difference seemed to be lack of pain perception. The final series to be discussed is also over 10 years old, appearing in 1976. 3 Blake, from the Royal Victoria Hospital in Wales, reviewed the results of emergency abdominal operations in patients over 75 years of age from 1969 to 1975. He identified 348 patients who were operated on for an acute abdomen. The major indications were incarcerated hernia (33 per cent), large bowel obstruction (17 per cent), small bowel obstruction (12 per cent), acute appendicitis (10 per cent), gastroduodenal perforation (6 per cent), large bowel perforation (6 per cent), and biliary tract disease (6 per cent). The remaining cases were mostly vascular in nature (ruptured aneurysm or mesenteric ischemia). One patient was mistakenly operated on for a myocardial infarction. Overall mortality was 30.7 per cent. No careful analysis was carried out of mortality causes or prevention methods, other than noting that approximately half the deaths were due to underlying cardiovascular disease. Table 1 shows a summary of the above reviews. There are large differences between Blake's series and the others in the diagnoses of biliary tract disease, diverticulitis, and pancreatitis. This is because Blake's series Table 1. Collected Series of Abdominal Pain in the Elderly, as Per Cent of Total CAUSE

Biliary tract Intestinal obstruction * Peptic ulcer Diverticulitis Appendicitis Pancreatitis Incarcerated hernia Othert

PONKA J7

27.5 17.5 10.5 10.0 8.0 7.5 5.5 13 ..5

FENYO'

40.8 7.3 3.3 3.4 6.1 5.1 9.6 23.8

FENY0 8

26.0 10.7 8.4 7.0 3.5 4.1 4.8 35.5

BLAKE'

6.0 30.5 6.3 N/A 9.8 N/A 33.0 14.4

*Small and large bowel combined. tIncludes such diagnoses as ruptured aneurysm, mesenteric ischemia, and perforated

cancers.

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included only operative cases and not all admissions for pain. The relatively larger number of incarcerated hernias is probably explained by this series being from the United Kingdom, where there is often a long wait to have an elective hernia repair. Current Series

While the above reviews are helpful, they give little guidance as to current trends in diagnoses. To shed further light, I have reviewed a recent 5-year experience at Harper Hospital, a tertiary care facility in Detroit, Michigan. 1 The series may be somewhat skewed in that the majority of patients come from the surrounding area that has a larger than average indigent population. During the period January 1, 1980 to December 31, 1984, 168 patients aged 70 years or older underwent an emergency operation for abdominal pain. There were 94 females and 74 males. The ages ranged from 70 to 96 (mean, 82.8) years. The indications for operation are listed in Table 2. Overall mortality was 30 of 168 (17.9 per cent). Over half of the patients (109 or 64.8 per cent) were initially admitted to nonsurgical services, often because the initial diagnosis was not clear. Forty-eight (44.4 per cent) of the patients admitted to medical services had the wrong diagnosis on admission, compared to only 11 (18.6 per cent) of those admitted to surgical services. The morbidity in this group with mistaken diagnoses was especially high-33 per cent. This appeared to be due to delay in surgery until after sepsis was firmly established. Causes of mortality are shown in Table 3. The major cause of death in 22 of the patients was from overwhelming sepsis and subsequent multisystern organ failure. Fifteen of these deaths occurred in patients who had missed diagnoses on admission; their surgery was performed more than 24 hours after admission due largely to the delay in diagnosis. These patients will be analyzed further later. Five patients died from underlying atherosclerotic disease. Four of these deaths were from postoperative myocardial Table 2. Emergency Operations for Acute Abdominal Pain in Patients Greater than or Equal to 70 Years II'DlCATION

Small bowel obstruction Acute cholecystitis/other biliary Incarcerated groin hernia Perforated colon Perforated gastroduodenal ulcer or cancer Large bowel obstruction Mesenteric ischemia Incarcerated ventral hernia Appendicitis Carcinomatosis Ruptured abdominal aortic aneurysm Ovarian Total

I'UMBER

MORTALITY

(PER CEI'T)

(PER CENT)

43 32 24 20 17 11 10 7 6

(26) (19) (14) (12) (10) (7) (6) (4) (4)

4 (2)

2 (1) 2 (1) 168

6 (14) 4 (12) 1 (4) 2 (10) 7 (41) 2 (18) 5 (50)

o o

2 (50)

o

1 (50)

30 (18)

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Table 3. Causes of Mortality Sepsis and mllltisystem organ failure Cardiovascular Carcinomatosis

22* 5 3

*Number of patients.

infarctions, and the fifth was from acute aortic thrombosis in a patient who had undergone an otherwise uneventful lysis of adhesions for treatment of small bowel obstruction. Of the three patients who died of carcinomatosis, two had this found only on laparotomy for abdominal pain. The final two patients presented with bowel obstruction which was found to be due to metastatic cancer. Both patients' obstructions were relieved, but they subsequently manifested cerebral metastases while in the hospital and succumbed to their disease. The overall mortality of 17.9 per cent in this series is still distressingly high and not much different from that reported 20 years ago for similar problems. While deaths from underlying disease (that is, cardiovascular and cancer) may be unavoidable, septic deaths should be lessened by more prompt diagnosis and treatment. An analysis of the admission findings and diagnoses will give some indication as to why septic deaths are still frequent. Table 4 shows the missed diagnoses on admission in 15 patients who subsequently died of organ failure secondary to infection. In at least 12 of these patients-those with admitting diagnoses of abdominal pain, dehydration, or gastroenteritis-strong suspicion should have been given to a possible surgical etiology of the problem. While it is easy to be critical in retrospect, it is equally simple to see why the clinicians caring for these patients were misled when the patients were first seen. Table 5 shows the findings on admission of the 22 patients dying of sepsis, divided between those who are accurately diagnosed as haVing a surgical problem and those who were not. Of specific note, even though all inaccurately diagnosed patients had lethal sepsis, only one was febrile and only two had peritoneal findings other than some nonspeCific tenderness. Two thirds of the patients had a leukocytosis on admission, but none were greater than 20,000 per mm 3 . These were not subtle intraabdominal diseases either: the missed diagnoses were perforated viscus (n = 6), bowel infarction (n = 5), small bowel obstruction (n = 2, both with gangrenous small bowel), and acute cholecystitis (n = 2, one with generalized perforation and one with a liver abscess). None of the patients with a perforated viscus had free air on admission radiograph. The two patients with small bowel obstruction apparently had their radiographs miSinterpreted. All patients who died of bowel infarction were diagnosed Table 4. Inaccurate Diagnoses on Admission in Patients Dying of Sepsis Abdominal pain of unknown etiology Dehydration Gastroenteritis Rule 011 t cancer *Nllmber of patients.

4* 4 4

3

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Table 5. Findings on Admission in Patients Dying of Sepsis ACCuRATE DIAGNOSES

Tenderness Guarding rebound Distention Fever Increased white blood cells

INACCURATE DIAGMlSIS

(/I = 7)

(n = 15)

7 5

12 2

,3

2

5

6 1 10

as having nonsurgical problems on admission. The surviving patients (n = 4) were all correctly diagnosed on admission as having a surgical problem. Thirty-four (20 per cent) of these patients had known potentially correctable surgical problems prior to this admission. Most commonly these were hernia, gallstones, cancer, or ulcers. The results of this series are difficult to compare with others as the patients may be different. However, there seems to be a trend away from acute cholecystitis and incarcerated hernia; the latter can be particularly easily diagnosed, to potentially more rapidly life-threatening problems such as bowel obstruction, perforated viscus, or mesenteric ischemia.

OUTCOME Elderly patients are often not referred for elective surgery earlier because they are viewed as being of too high a risk. Similarly, when they do present acutely, a delayed workup is sometimes done on the basis that they have reached their natural end. While this somewhat nihilistic approach may be taken, several studies have appeared recently that refute this. Clearly, it is better to do an operation electively rather than in an emergency setting. Greenburg 9 reviewed 334 patients aged 70 years or older who had gastrointestinal surgery at the Veterans Administration Medical Center, San Diego, from 1972 to 1979. Mortality in elective operations was 6.7 per cent, while in emergency operations it was 20 per cent. Linn 13 performed a collective review of 108 articles covering over 50,000 patients. Mortality rates for emergency operations averaged three times greater than rates for similar elective operations. Greenburg concluded that delaying elective surgery in elderly patients led to an overall greater mortality. Even more impressive has been the recent work from the Mayo Clinic on outcome following surgical procedures in nonagenarians. They reviewed the results on 795 patients operated on 1063 times over the period 1975 to 1985. Thirty-day mortality was a surprisingly low 8.4 per cent. Using population statistics for Olmstead County, Minnesota, and the subgroup of their patients who resided there, they were able to predict the potential for 91,000 operations annually in the 90 years of age or older population in the United States. What was the most impressive about their work, however, was their

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evaluation of long-term benefit. Survival at 5 years postoperatively was comparable to what could be predicted from studying a similar group not undergoing operation. This seemed to be true for both elective and emergency operations. Emergency operations obviously had a much higher operative mortality, but the survivors did as well as the remaining population. It is impossible to a priori extrapolate this finding to include patients over the age of 70 as well, but this study does provide strong evidence that a hands-ofI' approach to patients with abdominal pain cannot be justified on the basis of age alone. Taking this even one step further, Kaltid 2 has reported good results in six cases from the Massachusetts General Hospital of successful surgery in patients aged 100 years or older.

SUMMARY As our population ages, more patients will be presenting with acute abdominal problems which require attention. Unlike younger patients, the aged present later in the course of their disease and also often have concomitant underlying diseases. The diagnosis of an acute abdomen is further complicated by the relative lack of physical findings which is due to the elderly's lack of pain perception. The surgical problems in the elderly also tend to be more rapidly life-threatening than in younger patients. This further emphasizes the need for rapid diagnosis should an elderly patient present with abdominal pain. Methods to decrease the mortality from acute surgical problems are limited, but are potentially very effective. The first is to arrange for elective correction of the problem should it be known, and the second is to refer the patients promptly for operative consideration before sepsis becomes firmly established. Exact diagnosis before referral, while intellectually satisfying, is often contributory to a poor outcome in these patients.

REFERENCES 1. Bender JS: unpublished data 2. Bender JS, Busuito MJ, Graham C, et al: Small bowel obstruction in the elderly. Am Surg 55:385, 1989 3. Blake R, Lynn J: Emergency abdominal surgery in the aged. Br J Surg 63:956, 1976 4. Block MA: Managing the silent, atypical acute abdomen. Geriatrics 38:50, 1983 5. Cooke M, Sande MA: Diagnosis and outcome of bowel infarction on an acute medical service. Am J Med 75:984, 1983. 6. Eisenberg RL, Heineken P, Hedgwek MW, et al: Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain. Ann Surg 197:464, 1983 7. Fenyo G: Diagnostic problems of acute abdominal diseases in the aged. Acta Chir Scahd 140:.396, 1974 8. Fenyo C: Acute abdominal disease in the elderly. Am J Surg 143:751, 1982 9. Greenburg AG, Saite RP, Coyle H, et al: Mortality and gastrointestinal surgery in tbe aged. Arch Surg 116:788, 1981 10. Hosking MP, Warner MA, Lobdell CM, et al: Outcomes of surgery in patients 90 years of age and older. JAMA 261:1909, 1989

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11. Huber DF. Martin E\V, Coopennan 1\1: Cholecystectomy in elderly patients. Am J Surg 146:719, 19113 12. Kaltic l\IH: Surgery in centenarians. JA~IA 2.53:3139, 1911.5 13. Linn BS, Linn M\V, \Vallen l\': Evaluation of results of surgical procedures in the elderly. Ann Surg 195:90, 1982 14. Morrow DJ, Thompson J, Wilson SE: Acute cholecystitis in the elderly. Arch Surg 113:1149, 1978 1.5. Owens BJ, Hammit HF: Appendicitis in the elderly. Ann Surg 187:392, 1978 16. Pathy l\IS: Clinical presentation of myocardial infarction in the elderly. Br Heart J 29:190, 1967 17. Ponka JL, Welborn JK, Brush BE: Acute abdominal pain in aged patients: An analysis of 200 cases. J Am Geriatr Soc 11:993, 1983 18. Reiss R, Deutsch AA, Eliashiv A: Decision-making process in abdominal surgery in the geriatric patient. World J Surg 7:.522, 1983 19. Thornberg J, Mistretta CM: Tactile sensitivity as a function of age. J Gerontol 36:34, 1981 20. Verrilo RT: Age-related changes in sensitivity to vibration. J Gerontol 3.5:18.5, 1980 21. Warner ~IA, Hosking MP, Lobdell CM, et al: Surgical procedures among those greater than or equal to 90 years of age. Ann Surg 207:380, 1988 Department of Surgery Harper Hospital 3990 John R Detroit, MI 48201