Acute Abdomen

Question 1

THE CHALLENGE OF DIAGNOSIS for Acute Abdomen:
1. History confounded by what? 5

2. Why is the physical exam often unreliable? Examples 2

Answer 1

1. History confounded by
   - stoicism
   - alterations in pain perception
   - memory deficits
   - communication problems
   - mental status changes
2. Physical exam unreliable
   - 80% will not have rigidity with peritonitis
   - 50% will be afebrile with acute cholecystitis

Question 2

Less abdominal inflammatory response in the elderly leads to what? 3

Answer 2

1. less guarding/spasm,
2. lower leucocytes count and
3. lower and delayed temperature.

Question 3

1. 60% of elderly requiring surgery will have a WBC of?

2. 40% with a perforated ulcer will not have what?

Answer 3

1. less than 10,000

2. free air on X-ray

Question 4

1. Different anatomical factors, eg. such as what that are predisposing to perforation & gangrene?
2. Multiple abdominal diseases that the elderly are at greater risk for? 3

Answer 4

1. poor blood supply to a thinner appendix
2. • gallstones,
   • diverticulosis,
   • atherosclerosis

Question 5

What is the single most common cause of

abdominal operations in the elderly?

Answer 5

BILIARY TRACT DISEASE

Question 6

1. 50% of >80 year olds will have what? (compared with 9% of 30-40 year olds)
2. “Biliary colic” is replaced by what?
3. In gallbladder perforation (occurring primarily in elderly), only a 1/3 of pts have a what?
4. What are found at the time of cholecystectomy in 10% of younger pts, but >50% of pts over age 70 years?

Answer 6

1. gallstones
2. vague abdominal complaints
3. history or prior symp. of gallstones.
4. Common bile duct stones

Question 7

Diagnosis of acute cholecystitis usually straightforward BUT

1. 15% will have no what?
2. 5% will have?
3. 40% will have a normal _____?
4. 10% will be______ with all lab tests normal
5. What is diagnostic in 90%?

Answer 7

1. epigastric or RUQ pain
2. no pain at all (probably mental status changes)
3. WBC
4. afebrile
5. Ultrasound

Question 8

What makes appendicitis dangerous in the elderly? 2

Answer 8

Elderly account for 5-10% of cases but >50% of deaths from appendicitis

1. 1/3 present late (>72 hours)
2. Misdiagnosed 50% on admission and 30% at time of surgery

Question 9

ACUTE PANCREATITIS
1. What is the most common cause in the elderly?

2. Major symptom?
3. Nonspecific signs? 4
4. What to ask for in the history? 2

Answer 9

1. In the elderly - gallstones etiology is the most common.
2. abdominal pain
3. Non specific signs;
   - tachycardia,
   - hypotension,
   - tachypnea,
   - confusion.
4. • alcohol
   • high triglycerides

Question 10

ACUTE DIVERTICULITIS: Diverticulitis may occur in an aggressive forms such as? 3

Many episodes subside, but the patient will present with what symptoms? 3

Answer 10

1. Phlegmonous inflammation,
2. Fistula to adjacent organs or skin,
3. Obstruction of the colon.

Many episodes subside, the patient has

1. left lower quadrant pain and tenderness,
2. moderate abdominal distension and
3. moderate temperature elevation.

Question 11

PEPTIC ULCERS – IN THE ELDERLY
1. Describe how pain could present in the elderly with ulcers? 2

2. Presenting symptom may be what and related to what?
3. Whats going to make this ulcer much worse leading to death?

Answer 11

1. • Pain is absent in one third of the cases.
   • Pain can be vague and poorly localized.
2. Presenting symptoms may be systemic and related to blood loss and anemia (i.e. falls, syncope)\
3. Aspirin

Question 12

ABDOMINAL AORTIC ANEURYSM
1. Typical presentation of rupture includes? 3

2. Key finding is what?

Misdiagnosed 30% of time DESPITE classic findings

Answer 12

1. • Hypotension (70-96%)
   • Abdominal pain (70-80%)
   • Back pain (>50%)
2. an enlarged, tender aorta

Question 13

ABDOMINAL AORTIC ANEURYSM
Late diagnosis increases mortality from 5% to 50-100%
Beware of what findings in the elderly that might be different in younger pts? 3

Answer 13

1. Renal colic symptoms in elderly
2. Labeling hypotension as vagal
3. Atypical location of abdominal pain

Question 14

ABDOMINAL AORTIC ANEURYSM

Dx? 3

Answer 14

1. Supine flat plate superior to cross table lateral
2. Ultrasound 98% sensitive for leaking AAA
3. CT with contrast useful in stable patient

Question 15

ISCHEMIC BOWEL
1. Characterized by?
2. Pain can be absent 25% of the time
Hard signs = TOO LATE!
What can lead = 90% survival?

3. What questions would we ask? 3

Answer 15

1. Severe, visceral pain out of proportion with physical exam in a patient with risk factors
2. Early angiography
3. • postprandial
   • warfarin/Afib
   • Is it diffuse

Question 16

ISCHEMIC BOWEL: Name 4 causes?

Answer 16

CAUSE
1. SMA embolus

2. SMA thrombosis
3. Venous thrombosis
4. Non-occlusive

Question 17

ISCHEMIC BOWEL: Match the risk factors with the following causes:
CAUSE
1. SMA embolus? 2

2. SMA thrombosis? 2
3. Venous thrombosis? 1
4. Non-occlusive? 4

Answer 17

RISK FACTOR

1. • A Fib,
   • recent MI
2. • CAD,
   • low flow states
3. Hypercoaguable states
4. Low CO
   - CHF,
   - sepsis,
   - digoxin,
   - hypovolemia

Question 18

MECHANICAL OBSTRUCTION
May result from what?
7

Answer 18

1. adhesions (scar tissue)
2. hernias (reducible, incarcerated, strangulated)
3. appendicitis,
4. malignancy,
5. volvulus,
6. diverticulitis or
7. AAA