SECOND PRIZE PAPER

THE EVALUATION OF
ACUTE ABDOMINAL PAIN
IN THE ELDERLY PATIENT
C. Funsho Fagbohun, MD, PhD, Eugene C. Toy, MD, and
Benton Baker, III, MD

Obstetrician/Gynecologists frequently encounter older patients

complaining of acute abdominal
pain. Because of physiologic
changes, medication use, and preexisting conditions, the elderly patient often does not manifest overt
signs of disease. Also, while appendicitis is the most common
cause of abdominal pain in the
general population, biliary disease, small bowel obstruction and
perforated viscus constitute the
leading etiologies in the geriatric
population. The older patients
physical findings often do not correlate with the severity of disease;
however, mental status changes,
hypothermia, bandemia, and metabolic acidosis are helpful indicators of significant derangement.
Emergent abdominal pain, defined as hemodynamic instability
such as that caused by massive
hemorrhage, requires immediate
surgery. Otherwise, the most effective work-up includes a detailed
history and physical examination,
and selective screening laboratory
tests. When the diagnosis is still
unclear, repeat physical examination, in-patient observation, and
consultation should be considered.
The decision of whether to perform diagnostic laparoscopy or
laparotomy should be individualized after assessing the patients
entire clinical presentation and
progress. Acute abdominal pain
in the older patient is associated
From the Residency training program, St. Joseph
Hospital/CTMF Brackenridge Hospital-Austin Obstetrics & Gynecology, Houston, Texas.

Volume 6, Number 6, 1999

with low diagnostic accuracy, but

high mortality. Therefore, as a
primary care physician, the obstetrician/gynecologist must be
proficient in the evaluation of
acute abdominal pain in the elderly patient. (Prim Care Update
Ob/Gyns 1999;6:181185. 1999
Elsevier Science Inc. All rights
reserved.)

Acute abdominal pain, defined as

lasting less than one week, is one of
the most formidable diagnostic
challenges faced by the primary
care physician.1 Nowhere is this
problem potentially more difficult
and important than in patients of
the geriatric age group, the fastest
growing segment of the American
population. Up to 10% of emergency room visits are due to abdominal pain; elderly patients, primarily women, account for one-fifth of
these visits. Incomplete or confusing history, atypical and subtle
physical findings, and the presence
of preexisting conditions complicate the diagnostic process.2 Furthermore, mortality rates associated with acute abdominal pain
increase with age, reaching 15% in
patients over the age of 50, and
exceeding 70% in those over the
age of 80.3 Hence, the obstetrician/
gynecologist must formulate a
careful and systematic approach to
abdominal pain in the older patient, beginning with an understanding of the age-related physiologic alterations.

1999 Elsevier Science Inc., all rights reserved. 1068-607X/99/$20.00

Physiologic
Changes With Aging
Age-related physiologic changes affect nearly every organ system, influencing disease presentation and
response to intervention. Diminished immune function and
changes in the nervous system affect
pain perception, particularly the
patients ability to accurately localize pain. Decreased T-cell function,
increased autoantibodies, and decreased bone marrow reserve reduce the older patients inflammatory response to infection.
Frequently, bacteremic elderly patients do not develop a fever, but
instead present with hypothermia.4,5 Additionally, the older patients appendix develops vascular
sclerosis, luminal narrowing by fibrosis, and fatty infiltration of the
muscularis leading to structural
weakness and earlier perforation.
Along with the changes in physiology, there are also differences in the
spectrum of diseases seen in older
patients with abdominal pain.

Etiologies of
Acute Abdominal Pain
The causes of nontraumatic acute
abdominal pain in patients over the
age of 50 are shown in Table 1.2,3,6
Whereas appendicitis is the most
common cause of acute abdominal
pain in younger patients, acute cholecystitis is the most common etiology in those over age 50.

PII S1068-607X(99)00021-9

181

FAGBOHUN ET AL
Table 1. Major Causes of Abdominal
Pain in the Elderly
Cholecystitis
Bowel obstruction
Appendicitis
Gastritis/Peptic Ulcer Disease
Pancreatitis
Diverticulitis
Vascular Causes
Urinary Tract Diseases
Miscellaneous/Indeterminate
Causes

25%
20%
15%
8%
6%
6%
2%
2%
16%

CHOLECYSTITIS
Biliary disease is the most common
indication for intra-abdominal surgery in the elderly patient. Gall
stones are found in more than onehalf of the patients over the age of
70. Instead of the typical slow onset
colicky pain, older patients usually
report the acute onset of steady
epigastric, or right upper quadrant
pain with radiation to the upper
back. Nausea and/or vomiting is
common, but peritoneal signs are
often absent. Leukocytosis and fever are noted in less than 70% of
older patients with acute cholecystitis. Importantly, the clinical findings often do not correlate with the
severity of the disease.4 In one study
involving 88 patients over age 60
with acute cholecystitis, 40% were
found to have empyema, necrosis,
or perforation of the gall bladder,
and 15% had concomitant subphrenic or hepatic abscesses. Of
these patients with complicated
cholecystitis, 38% were afebrile
and 26% did not have abdominal
tenderness.7 Therefore, it is prudent
to treat any elderly patient with
possible cholecystitis as having a
significant infection. Mortality approaches 7% in patients whose conditions preclude surgery, and 14%
when emergency cholecystectomy
is necessary.3,7

INTESTINAL OBSTRUCTION
Bowel obstruction constitutes the
second most common cause of acute
abdominal pain in the elderly pa182

tient.6 The most common causes of

small bowel obstruction are adhesions from prior surgery and incarcerated external hernias. With small
bowel obstruction, the pain is initially colicky and intermittent, then
over time, it decreases as bowel
motility diminishes. Finally, the
pain is constant due to bowel ischemia or strangulation. Vomiting is a
prominent symptom with proximal
small bowel obstruction. The elderly patient is usually restless during the bouts of pain, with slight
abdominal distention. Highpitched, hyperactive bowel sounds
are characteristic. The stool is usually negative for occult blood.8
Large bowel obstruction is associated with less pain and vomiting
as compared with small bowel obstruction. Constipation or a change
in bowel habits often precedes complete obstruction. Other clinical
findings include abdominal distention, diarrhea, and occasionally occult blood in the stool. The most
common cause of large bowel obstruction is colon cancer. Incarcerated hernias cause 10% of cases,
with vasculitis and sigmoid volvulus occurring less commonly. The
risk of intra-abdominal cancer is
age-dependent, doubling with every decade over the age of 40.4 The
overall mortality rates are 6% for
benign causes, and 62% when malignancy is present.9

APPENDICITIS
Although considered a disease of
the young, appendicitis comprises
15% of emergency room visits for
abdominal pain in the elderly.
While early diagnosis and surgery
are paramount in reducing mortality, less than half of elderly patients
with appendicitis present with the
classic symptoms of nausea, vomiting, anorexia, and right lower quadrant pain.6 The pain usually lasts
longer, and is accompanied by abdominal distention, decreased
bowel sounds, and a palpable mass.

Right lower quadrant abdominal

tenderness, at McBurneys point, is
the most reliable diagnostic sign. As
opposed to the classic movement of
pain over time from the epigastrium
to the umbilical region to the right
lower quadrant, older patients report localized pain at McBurneys
point.6 Appendicitis tends to be
more advanced at presentation, often complicated by perforation. A
right colonic malignancy may accompany appendicitis in the older
patient.8 Hence, a very high index of
suspicion is required to diagnose
appendicitis in the elderly patient.

GASTRIC/PEPTIC ULCER DISEASE

Gastritis makes up 8% of emergency
room visits for abdominal pain. Gastrointestinal bleeding, the most
common presenting symptom, is
noted by 62% of elderly patients
with gastritis. Epigastric pain is also
common. Perforation without peritoneal signs frequently complicates
ulcer disease in elderly patients,
predisposing them to increased
mortality. The mortality rates of
older patients, which are 100 times
greater than that of younger individuals, are partially explained by
the greater use of nonsteroidal antiinflammatory agents and the slower
healing process in the elderly.4,8

PANCREATITIS
Older patients with pancreatitis
usually present with mid-epigastric
pain which radiates to the back,
nausea, vomiting, low grade fever,
and dehydration. However, 10% of
elderly patients will complain of
mild or no abdominal pain. Physical findings may be unremarkable,
or may include hypotension, tachycardia, tachypnea or confusion.
Pancreatitis should be suspected in
patients with alcohol abuse, peptic
ulcer disease, cholelithiasis, drug
reactions, hypertriglyceridemia, or
hypercalcemia.4 Acute pancreatitis
in the geriatric patient is more likely
to be necrotizing and to be caused
Prim Care Update Ob/Gyns

ACUTE ABDOMINAL PAIN IN THE ELDERLY

by biliary disease. The clinical

symptoms do not correlate well
with the disease severity.4,10 Complications of pancreatitis include
hemorrhage, pseudocyst formation,
and respiratory and renal failure.
Acute pancreatitis carries a mortality rate of 17% in patients 6179
years of age, and 41% in patients
more than 80 years of age, regardless
of the intervention.10

DIVERTICULITIS
The incidence of diverticulitis increases markedly with age, affecting
50 75% of patients by the age of 90,
as compared to only 5% of the
general population.4 The classic
presentation of diverticulitis in the
elderly patient includes left lower
quadrant pain, low grade fever, nausea and vomiting, and mild abdominal distention. The most important
risk factors are a history of diverticulosis and recurrent constipation. A
fixed palpable left lower quadrant
mass just medial to the anterior iliac
spine is often noted. Leukocytosis, a
prominent finding in younger patients, is rarely seen in older individuals. Mortality approaches 17%
due to perforation, abscess formation, generalized peritonitis, obstruction, and fistula formation.4,8

ated 80% mortality in geriatric patients.4

Of equal importance is abdominal
pain secondary to dissection of the
abdominal aorta, or a ruptured abdominal aortic aneurysm. Aortic
aneurysms should be suspected
when patients have a history of
smoking, peripheral vascular disease, or hypertension.4 Usually, the
patient reports acute severe back
pain radiating to the groin, sacrum
or flank regions. Occasionally, a
pulsatile abdominal mass may be
palpable. The pain is progressive in
nature as dissection advances, and
is associated with a mortality rate of
70%, even with rapid surgical correction.11

URINARY TRACT DISEASES

Infection of the urinary tract is the
most common cause of sepsis in the
elderly, especially in women. Up to
half of all women will have a urinary tract infection by age 80. Fever,
abdominal pain, and chills may be
present, while at times, only lethargy and hypothermia are seen. Patients with urolithiasis usually report the sudden onset of severe back
or flank pain, radiating to the groin
or lower abdomen.4

MISCELLANEOUS ETIOLOGIES
VASCULAR ETIOLOGIES
Acute occlusion of the superior
mesenteric, inferior mesenteric,
and celiac arteries may be caused by
embolic or thrombotic events. The
clinical presentation of acute mesenteric ischemia is that of severe
pain, out of proportion to physical
findings. With an embolus, the patient will frequently report prior
episodes of abdominal pain. The
onset of pain after meals is typical of
the thrombotic variety. Other symptoms include vomiting, bloody diarrhea, abdominal distention with
little guarding, and reduced bowel
sounds. Even with prompt surgical
management, which is the hallmark
of therapy, there is still an associVolume 6, Number 6, 1999

Ovarian cancer should be considered in an elderly woman who presents with abdominal swelling, a
pelvic mass or ascites, dyspepsia,
flatulence, back pain, rectal fullness, or early satiety. Also, abdominal pain in the presence of a pelvic
mass may indicate ovarian torsion.4
Myocardial infarction or angina
pectoris must be considered in any
older patient complaining of epigastric pain. Nausea, vomiting, or abdominal pain can also be caused by
pain referred from pulmonary embolism or infarction, and lower lobe
pneumonia.4 Diseases affecting the
abdominal wall, such as myositis,
hematomas and trauma, usually
cause constant, achy pain that is

exacerbated by movement or pressure on the abdominal musculature.12

Work-up of
Abdominal Pain
In the evaluation of abdominal pain,
an attempt should be made to differentiate emergent pain from acute
or chronic pain. Emergent abdominal pain, defined as hemodynamic
instability such as that caused by
massive hemorrhage, requires immediate surgery.13 Acute abdominal pain requires an urgent workup, often requiring hospital
admission, consultation, and possible surgical intervention. Chronic
abdominal pain can be assessed at a
more gradual pace, allowing time to
explore the patients problems.1,12
The single most important tool in
uncovering the cause of abdominal
pain is the meticulous and systematic elicitation of history.2,4,12 Patience and persistence, and the use
of open-ended questions by the
physician, will often lead to the
diagnosis. Obtaining a history may
be difficult due to the patients cognitive impairment from dementia,
psychiatric disorders, cerebrovascular disease, or drug toxicity.4
Slow responses or inconsistent answers to questions frequently frustrate the physician; patients or their
family may give abbreviated history
so as not to bother the busy doctor. Also, elderly patients are less
likely to seek timely medical attention and may have more serious
illnesses when they present for
care.5
The character, onset, exacerbating or relieving factors, location,
and evolution of the pain should be
explored. A history of pre-existing
medical conditions such as a history of prior colon cancer or radiation therapy, and previous surgeries
should be obtained. Discussion
with family members or nursing
home personnel may be invaluable
183

FAGBOHUN ET AL

in discerning changes in the patients function or level of consciousness. A thorough list of medications both prescribed and overthe-counter is important. The use of
nonsteroidal anti-inflammatory
agents or corticosteroids may mask
infection and predispose to gastritis.4
The physical examination should
be thorough, beginning with the
patients general appearance, vital
signs, and weight. A core temperature of less than 35C strongly suggests septicemia.13 The skin should
be examined for stigmata of domestic abuse or chronic diseases. The
chest should be inspected for splinting, and the heart for murmurs or
evidence of heart failure. A careful
and gentle abdominal examination
should be performed to avoid exacerbating the pain or inflicting unnecessary discomfort on the patient.
Observation of the patients facial
expression during coughing or
movement, and gentle percussion of
the abdomen will effectively reveal
rebound tenderness instead of relying on forceful palpation.12 The abdomen should be palpated for hepatosplenomegaly or other masses, as
well as auscultated for bruits. A
pelvic and rectal examination, as
well as a test of stool for occult
blood should be performed. A systematic search for inguinal, femoral,
umbilical, or incisional hernias is
paramount. If psychogenic pain is
suspected, the examination should
be done while distracting the patient. Finally, the mental status,
neurologic and musculoskeletal examinations should be performed.4,12
In general, the history and physical examination should guide the
laboratory and imaging studies.
When the history and physical examination do not provide direction,
the initial laboratory tests should be
limited to a complete blood count
with differential, chemistry panel
(including electrolytes, renal and
liver function tests), urinalysis,
amylase, and lipase. A bandemia of
184

greater than 6% has an excellent

positive predictive value for appendicitis in the elderly.14 Therefore,
the white cell differential should be
done even with a normal leukocyte
count. In most cases of acute cholecystitis, the serum bilirubin or the
amylase is elevated.8 Although
slight elevation may be seen in nonpancreatic disease, serum amylase
or lipase levels exceeding three
times the normal level is usually
diagnostic of pancreatitis.4 Serum
lipase has been shown to be a better
test than serum amylase, either to
exclude or to confirm the diagnosis
of pancreatitis.15 A urinalysis may
reveal urinary calculi or pyelonephritis.
Abdominal radiographs should
be performed when there is a clinical suspicion of bowel obstruction,
renal or ureteral calculi, or gall bladder disease.2 Free air under the
diaphragm is indicative of viscus
perforation, and multiple air-fluid
levels and bowel distention are consistent with intestinal obstruction,
while absence of the psoas shadow
is suggestive of retroperitoneal
bleeding, an abdominal abscess, or a
mass. Fecal impaction causing colonic obstruction is easily seen on
abdominal films. However, even after relieving the fecal impaction,
colonoscopy or barium enema
should be performed to search for a
structural bowel lesion.13
In a patient with rectal bleeding
associated with abdominal pain,
sigmoidoscopy, colonoscopy, or a
barium enema study may be indicated. Oral contrast is not recommended when colonic obstruction
is suspected. Abdominal ultrasonography and computerized tomography are the procedures of
choice in delineating abdominal or
pelvic masses, abscesses, gallstones, or biliary obstruction.4,12
Since 4 8% of cholecystitis are
acalculous, a radioisotope (HIDA)
scan is useful even when sonography does not demonstrate cholelithiasis. The presence of metabolic

acidosis may indicate bowel ischemia, which can be confirmed by

arteriogram.13
It is crucial to diligently pursue
any abnormality of the history,
physical examination, laboratory
tests, or imaging studies. Most importantly, the history and physical
examination should be repeated at
short intervals, as the underlying
disease may be apparent with
time.4,12

Admission
and Consultation
Because of the subtlety of physical
findings and significant mortality
associated with acute abdominal
pain in the elderly patient, hospital
observation is usually necessary.12
Suspicion of intestinal obstruction,
acute vascular compromise and
peritoneal irritation are strong indications for surgical consultation.
Further investigation and/or consultation with a gastroenterologist
or a surgeon should be considered
when unexplained abdominal pain
is associated with nausea, vomiting,
jaundice, fever, weight loss exceeding 10% of body weight, or gastrointestinal bleeding.12
Definitive therapy should be directed toward the etiology of the
abdominal pain. Any evidence of
dehydration and caloric deficiency
must be corrected. At times, such as
in the septic patient, empiric antibiotic therapy must be initiated
prior to a definitive diagnosis. If
possible, analgesics, which can confuse the physical findings, should
be withheld prior to establishing the
diagnosis.
Perhaps the most difficult diagnostic decision is whether and
when to perform laparoscopy or
laparotomy for unexplained acute
abdominal pain. An individualized
approach should be used, weighing
the historical factors, physical findings, laboratory and imaging test
results, and the patients progress.
Prim Care Update Ob/Gyns

ACUTE ABDOMINAL PAIN IN THE ELDERLY

Although consultation is important,

the continuity provided by one examiner is more effective in clarifying a diagnosis and allaying the
anxiety in the patient and his/her
family members.

Conclusion
The evaluation of acute abdominal
pain in the elderly patient is a diagnostic dilemma often faced by the
primary care physician. The older
patient has more subtle disease
manifestations, more often uses
multiple medications, and frequently has preexisting illnesses.
The obstetrician/gynecologist, combining the knowledge of primary
care and surgical disease, is well
equipped to assess the older patient
with abdominal pain. Most diagnoses are apparent after a careful
history, physical examination, and
selective laboratory tests are performed. At times, diagnostic laparoscopy or laparotomy is required.
Acute abdominal pain in the older
patient is associated with significant mortality. Hence, it is vital for
the obstetrician/gynecologist to be
adept in the work-up and differen-

Volume 6, Number 6, 1999

tial diagnosis of acute abdominal

pain in the elderly patient.
References
1. Jess P, Bjerregaard B, Brynitz S, et al.
Prognosis of acute non-specific abdominal pain: a prospective study.
Am J Surg 1982;144:338 40.
2. Bugliosi TF, Meloy TD, Vukov LF.
Acute abdominal pain in the elderly. Ann Emerg Med 1990;19:
1383 6.
3. DeDombal FT. Acute abdominal
pain in the elderly. J Clin Gastroenterol 1994;19:3315.
4. Sanson TG, OKeefe KP. Evaluation
of abdominal pain in the elderly.
Emerg Med Clin North Am 1996;14:
61527.
5. Cooper GS, Shlaes DM, Salata RA.
Intra-abdominal infection: differences in presentation and outcome
between younger patients and the
elderly. Clin Infect Dis 1994;19:
146 8.
6. Telfer S, Fenyo G, Holt PR, et al.
Acute abdominal pain in patients
over 50 years of age. Scand J Gastroenterol 1988;23(Suppl 144):47
50.
7. Morrow DJ, Thompson J, Wilson SE.
Acute cholecystitis in the elderly: a
surgical emergency. Arch Surg
1978;113:1149 52.
8. Fenyo G. Diagnostic problems of
acute abdominal diseases in the
aged. Acta Chir Scand 1974;140:
396 405.

9. Reiss R, Deutsch AA. Emergency

abdominal procedures in patients
above 70. J Gerontol 1985;40:154 8.
10. Paajanen H, Jaakola M, Oksanen H,
et al. Acute pancreatitis in patients
over 80 years. Eur J Surg 1996;162:
4715.
11. Johansen K, Kohler TR, Nicholls
SC, et al. Ruptured abdominal aortic aneurysm: the Harborview experience. J Vasc Surg 1991;13:240 7.
12. Richter JM. Evaluation of abdominal pain. In: Goroll AH, May LA,
Mulley AG, eds. Primary Care Medicine. 3rd. edition. Philadelphia: JB
Lippincott, 1995:32534.
13. Silen W. Abdominal Pain. In: Fauci
AS, ed. Harrisons Principle of Internal Medicine. 14th. edition. New
York: McGraw-Hill, 1998:65 8.
14. Elangovan S. Clinical and laboratory findings in acute appendicitis
in the elderly. J Am Board Fam Pract
1996;9(2):75 8.
15. Chase CW, Barker DE, Russell WL,
et al. Serum amylase and lipase in
the evaluation of acute abdominal
pain. Am Surg 1996;62(12):1028 33.
Address correspondence and reprint requests to Benton Baker, III, MD, St.
Joseph Hospital, St. Joseph Hospital/
CTMF Brackenridge Hospital-Austin
Obstetrics & Gynecology, Residency
Training Program, 1819 Crawford
Street, Suite 1708, Houston, Texas
77002.

185