Acute Abdomen Flashcards

1
Q

Challenge of dx acute abdomen in elderly - hx and physical?

A

hx confounded by:
-stoicism
-alterations in pain perception
- memory deficits
- communication problems
- mental status changes
- physical exam unreliable:
80% won’t have rigidity w/ peritonitis (no rebound tenderness)
50% will be afebrile w/ acute cholecystitis
(won’t have elevated WBC either)
- PE must be complete - include all potential hernia sites, abdominal aorta, the rectum and pelvis
- only 5% of female elderly pts had a pelvic exam, 70% of which were abnormal
- dx difficult b/c of unique factors
- less abdominal inflammtory response: less guarding/spasm, lower leukocytes count and lower and delayed temp

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2
Q

Why isn’t ancillary testing reliable?

A
  • 60% of elderly requiring surgery will have WBC less than 10,000
  • 40% w/ perforated ulcer will not have free air on x-ray
  • ancillary testing may delay dx: other imaging techniques such as CT and US must be used liberally
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3
Q

Why is acute abdomen so common in the elderly?

A
  • diff anatomical factors: poor blood supply to thinner appendix predisposing to perforation and gangrene
  • mult abdominal diseases: gallstones, diverticulosis, atherosclerosis
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4
Q

MC cause of abdominal operations in elderly?

A
  • biliary tract disease
  • 50% of 80yo and up will have gallstones
  • biliary colic is replaced by vague abdominal complaints
  • in gallbladder perf (occurring primarily in elderly), only a 1/3 of pts have a hx or prior sx of gallstones
  • common bile duct stones are found at time of cholecystectomy in 10% of younger pts, but over 50% of pts over 70
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5
Q

How is biliary tract disease dx in elderly?

A
  • dx of acute cholecystitis usually straightforward but:
  • 15% will have no epigastric pain or RUQ pain (neg murphys)
  • 5% will have no pain at all (mental status changes?)
  • 40% will have normal WBC
  • 10% will be afebrile w/ all lab tests normal
  • US dx 90%
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6
Q

How common is appendicitis in the elderly? Presentation?

A
  • account for 5-10% of cases but over 50% of deaths from appendicitis
  • 1/3 present late (over 72 hrs)
  • misdx 50% on admission and 30% at time of surgery
  • in a study done:
    only 20% presented classically w/: nausea or vomiting, fever (38.6 degrees C), RLQ pain, elevated or shifted WBC
  • only 60%, 30%, 40% had RLQ pain, N/V and fever of over 37.6 degrees C
  • 70% of pts had perforated appendicitis, 30% abscess formation
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7
Q

Presentation of acute pancreatitis?

A
  • in the elderly - gallstones etiology is the most common
  • as in young abdominal pain is major sx
  • in 5-10% of cases, pain is absent
  • pain may be vague, physical exam unremarkable
  • non specific signs: tachycardia, hypotension, tachypnea, confusion
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8
Q

Acute diverticulitis presentation? what can this lead to?

A
  • diverticulitis may occur in aggressive form
  • phlegmonous inflammation, fistula to adjacent organs or skin, obstruction of colon (may not present w/ a lot of pain)
  • many episodes subside, the pt has LLQ pain, tenderness, moderate abdominal distension and moderate temperature elevation
  • get a CT scan
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9
Q

Why are peptic ulcers so common in elderly? Presentation?

A
  • have sig higher risk to develop peptic ulcers and complications from NSAIDs ( and sphincter relaxation, less gastric motility, increased risk for H pylori)
  • pain is absent in 1/3 of cases
  • pain can be vague and poorly localized
  • presenting sxs may be systemic and related to blood loss and anemia (falls and syncope)
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10
Q

How common is a AAA in elderly? presentation?

A
  • 6% prevalence in over 80yo group
  • typical presentation of rupture includes:
    hypotension (70-96%)
    abdominal pain (70-80%)
    back pain (over 50%)
  • misdx 30% of time despite classic findings
  • key findings is an enlarged tender aorta
  • late dx increases mortality from 5% to 50-100%
  • beware of:
    renal colic sxs
    labeling hypotension as vagal (do orthostatics)
    atypical location of abdominal pain
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11
Q

Testing for AAA?

A
  • US 98% sensitive for leaking AAA

- CT w/ contrast useful in stable pt

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12
Q

Presentation of an ischemic bowel? Tx?

A
  • severe, visceral pain out of proportion w/ physical exam in pt w/ risk factors
  • pain can be absent 25% of time
  • hard signs = too late
  • early angiography = 90% survival
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13
Q

Causes and RFs for ischemic bowel?

A
  • SMA embolus: RF - a fib, recent MI
  • SMA thrombosis: CAD, low flow states
  • venous thrombosis: hypercoaguable states
  • non-occlusive: low CO (CHF, sepsis, digoxin, hypovolemia )
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14
Q

What could cause a mechanical obstruction?

A
  • may result from adhesions, hernias, appendicitis, malignancy, volvulus, diverticulitis, or AAA
  • delayed surgery increases complication rate by 250% in some studies
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