ORIGINAL CONTRIBUTION geriatrics, abdominal pain
A c u t e Abdominal Pain in the Elderly Study objectives: To determine the incidences of both specific diagnosis and surgical diseases in patients more than 65 years old who present to the emergency department with nontraumatic abdominal pain of less than one week's duration, and to determine the ED staff's ability to diagnose and triage elderly patients with acute abdominal pain. Design: A 12-month retrospective review of all elderly patients who presented to the ED with acute, nontraumatic abdominal pain. Setting: A regional trauma center serving a predominately rural population in the Midwest. The ED has 55,000 patient visits yearly. Measurements and main results: Of the 127 patients enrolled, 30 (24%) had no specific diagnosis made in the ED. Biliary tract disease (12%) and small bowel obstruction (12%) were the two most common specific diagnoses. Overall, 53 patients (42%) required surgery, usually during the initial hospitalization. In four cases, the postoperative diagnosis differed sig~ nificantly from the ED diagnosis. Of the 74 patients (58%) who did not undergo surgery, 51 had follow~up information available. In 14 patients, the follow-up diagnosis differed from the original diagnosis, but most of these changes did not appreciably alter the treatment and outcome. Conclusions: The incidence of surgical disease is high in elderly patients with acute abdominal pain, and ED staff are able to diagnose and triage these patients accurately. [Bugliosi TF, Meloy TD, Vukov LF: Acute abdominal pain in the elderly, A n n Emerg M e d D e c e m b e r 1990;19: 1383-1386.]
Thomas F Bugliosi, MD Thomas D Meloy, MD Larry F Vukov, MD Rochester, Minnesota From the Division of Emergency Medical Services and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Received for publication September 12, 1989. Revision received May 18, 1990. Accepted for publication June 14, 1990. Presented at the Scientific Forum of the American College of Emergency Physicians Scientific Assembly in Washington, DC, September 1989. Address for reprints: Thomas F Bugliosi, MD, Division of Emergency Medical Services and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
INTRODUCTION Abdominal pain is a common complaint of patients presenting to an emergency department.< 2 For all age groups, a specific diagnosis can be made in less than 65% of cases.l, 3-5 However, in elderly patients (aged 65 years and older), assessment may be even more difficult. Their symptoms often have been present longer and are less specific, and elderly patients are more likely to have coexistent disease. 6-12 Compared with younger patients, the elderly also are more likely to require hospitalization and emergency surgery.l,%5, 6 There is no universal agreement regarding what constitutes "acute" abdominal pain. However, less than one week's duration has been used in several studies. 3,9,13 We used this definition of acute abdominal pain in a retrospective year-long study of elderly patients presenting to the ED of a large hospital. The aims of this study were to determine the incidence of various diagnoses in elderly patients with acute abdominal pain, to determine the incidence of surgical disease in this patient population, and to assess the ability of the ED staff to diagnose and triage elderly patients with acute abdominal pain accurately.
METHODS The hospital studied is a regional trauma center serving a predominately rural population in the Midwest. The ED has 55,000 patient visits per year. All adult patients (15 years old or older) who complain of abdominal pain are evaluated initially by the ED medical service, which consists primarily of internal medicine and family practice residents supervised by a member of the permanent staff, who is a board-certified internist. The ED senior
19:12 December 1990
Annals of Emergency Medicine
1383/47
ABDOMINAL PAIN Bugliosi, Meloy & Vukov
surgical resident is asked to evaluate these patients before disposition. Patients more than 65 years old who presented to the ED between April 1, 1988, and March 31, 1989, w i t h a chief c o m p l a i n t of n o n traumatic abdominal pain were identified by a c o m p u t e r i z e d data retrieval system. Only patients whose pain had been present for less than one week were included. Patients who had been evaluated previously at our institution as well as those who were referred from other institutions were excluded. ED and hospital records were reviewed for all patients who met inclusion criteria. Outpat i e n t records of all p a t i e n t s discharged from the ED and subsequently seen in the outpatient clinic also were available for review. A twomonth follow-up period was used.
RESULTS During the 12-month study period, 127 patients (60 women and 67 men) met the inclusion criteria (Table 1). Mean + SD patient age Was 74.8 _+ 6.2 years; the oldest patient was 91 years old. Of the diagnoses made in the ED, the most c o m m o n was "indeterminate abdominal pain" (24% of patients) (Table 2). Diagnoses referable to the biliary tract and small bowel obstruction were the most frequent specific diagnoses made in the ED. Among the nine patients with diagnoses of perforated viscus, in only one was the cause of the perforation hypothesized. There were 12 elderly patients (9%) with acute abdominal pain who had diagnoses not referable to the gastrointestinal tract. The ED staff's diagnoses in the 26 patients taken directly to surgery are shown (Table 3). The most frequent reason cited for emergency surgical intervention was a perforated viscus. At operation, the causes of the perforation were found to be a gastric ulcer (three patients), diverticulitis (two patients), and carcinomatosis (jejunal perforation), duodenal ulcer, and foreign body (chicken bone) perforating the terminal ileum (one patient each). In no case did the postoperative diagnosis differ greatly from the preoperative ED diagnosis. Of the 26 patients undergoing emergency surgery, the mean length of hospital stay was 11.6 days. One patient died of a myocardial infarction before discharge. 48/1384
TABLE L Triage of 127 elderly patients seen in hospital ED with
abdominal pain Action
N
%
Directly to Surgery
26
20
Admitted
54
43
No surgery
32
...
Surgery
22
...
Dismissed Outpatient follow-up Returned to ED
47
37
21"
...
51-
...
*Subsequent surgery in three. tSubsequent surgery in two.
TABLE 2. ED diagnoses in 127 patients with abdominal pain* N
%
Indeterminate
30
23
Biliary colic or cholecystitis
16
12
Small bowel obstruction
15
12
Gastritis
10
8
Perforated viscus
9
7
Diverticulitis
8
6
Appendicitis
5
4
Incarcerated hernia
5
4
Renal colic
5
4
Pancreatitis
3
2
Urinary tract infection
3
2
Constipation
3
2 2
Sigmoid volvulus
2
Abscess
2
2
Medication related
2
2
10
8
Miscellaneoust
*One patient had two primary diagnoses. tSymptomatic abdominal aortic aneurysm, ischemic bowel, hiatal hernia, herpes zoster, umbilical hernia, reducible inguinal hernia, myocardial infarction, pneumonia, pulmonary embolism, and colonic obstruction secondary to rectal carcinoma (one patient each).
Of the 54 patients admitted for observation or medical management of their illness, 22 (41%) eventually had surgery because they did not respond to conservative therapy (eg, bowel obstruction), they were stabilized (eg, gallstone pancreatitis), or the initial diagnosis was incorrect. Of patients who were admitted and later required surgery, three had a postoperative diagnosis that differed appreciably from the ED staff's diagnosis. Two of Annals of Emergency Medicine
these three patients were admitted with a diagnosis of indeterminate abdominal pain. One had free air on a follow-up abdominal radiograph and was found to have a perforated colon secondary to diverticular disease; the other began to have findings consistent with acute cholecystitis and underwent an uneventful cholecystectomy. The third patient was thought to have an abdominal abscess from a prior colon operation; however, sur19:12 December 1990
TABLE 3. ED diagnoses in 26 patients taken directly to surgery
TABLE 4. ED diagnoses in 54 patients initially admitted to the hospital*
Diagnosis
Admitted and Surgery
Admitted and No Surgery
Diagnosis
N
Perforated viscus
8
Biliary colic and cholecystitis
7
5
Appendicitis
5
Indeterminate
2
9
Incarcerated hernia Bowel obstruction
4 3
Small bowel obstruction
5
5
3
Diverticulitis
1
5
Pancreatitis Gastritis
2 0
1 2
Miscellaneous
5
6
Cholecystitis
Miscellaneous* 3 *Symptomatic abdominal aortic aneurysm, colonic obstruction secondary to rectal carcinoma, and volvulus (one patient each).
gery revealed a perforation of the terminal ileum (no underlying cause given). ED diagnoses for 54 patients initially admitted to the hospital from the ED are given (Table 4). Of the 32 patients who did not require surgery, 11 had a hospital dismissal diagnosis that differed from the admission diagnosis (Table 5). In most, the change in diagnosis was not of major consequence. One patient admitted with i n t e r m i n a t e a b d o m i n a l pain was found to have free air on a computed tomography scan done on hospital day 2. Because of the patient's overall status and her family's wishes, she was treated nonsurgically and did well. Another patient who was initially thought to have an abdominal abscess secondary to a recent colect o m y was f o u n d to h a v e p s e u d o m e m b r a n o u s c o l i t i s and was treated with antibiotics. Four patients died before discharge. One was admitted with a diagnosis of indeterminate abdominal pain and died the next day of an intracerebral hemorrhage. Two patients died after surgery; one had intra-abdominal carcinomatosis as well as a perforated terminal ileum (caused by a chicken bone), and peritonitis and adult respiratory distress syndrome developed. The other patient had a diagnosis (inferior myocardial infarction) not referable to the gastrointestinal tract and died of left ventricular dysfunction after cardiac surgery. The fourth patient had massive ascites and indeterminate abdominal pain and died seven days after admission. Autopsy showed p u l m o n a r y edema in addi19:12 December 1990
*One patient had two primary diagnoses.
tion to ascites and liver disease. Forty-seven patients (37%) were discharged from the ED. Their diagnoses are given (Table 6). Of these 47, five (11%) returned to the ED; two required surgery (one for a previously diagnosed ureteral calculus and one for acute cholecystitis that was diagnosed initially as gastritis on the preceding day), and three did not undergo surgery (one received a new diagnosis of biliary colic but declined surgery). T w e n t y - o n e patients were seen s u b s e q u e n t l y for follow-up in the outpatient clinic; of these, three were scheduled for surgery (one for elective urologic surgery, and one for elective cholecystectomy). The third patient, originally diagnosed as having gastritis, was found ten days later to have obstructive jaundice. The cause of his jaundice was a common duct stone, and his postoperative course was uneventful. Three other patients had different diagnoses after outpatient follow-up. One patient, initially diagnosed as having gastritis, s u b s e q u e n t l y was found to have gallstones and was given a diagnosis of biliary colic; he refused surgery. A second, who had been diagn o s e d as h a v i n g g a s t r i t i s , w a s thought on follow-up to have a medication intolerance. The third, originally diagnosed as h a v i n g diverticulitis, was later thought to have irritable bowel syndrome.
DISCUSSION Although EDs vary in regard to physician staffing, available technology, and overall strategy for evaluat-
Annals of Emergency Medicine
ing patients with abdominal pain, the following observations can be applied to any ED that evaluates geriatric patients who have abdominal pain. First, the ED staff was able to make a specific diagnoses in 76% of cases. Most often, diagnoses were referable to the biliary tract (13%); if patients subsequently diagnosed as having biliary tract disease are included (ie, after hospitalization or follow-up), this rate increased to 18%. This might be expected because cholelithiasis was noted in 30% of patients autopsied who were more than 70 years old. 14 In two separate series of acute abdominal pain in Swedish patients more than 70 years old, Feny6 noted an even higher incidence of cholecystitis in hospitalized p a t i e n t s (41% and 26%, respectively). 6 Sixty-three percent of all elderly patients presenting to the ED with acute abdominal pain were admitted. Although this seems like a high percentage, in a study of abdominal pain in all age groups, Brewer et al 5 noted that patients more than 65 years old had a 51% admission rate. However, their study included patients with abdominal pain of any duration. It could be speculated that had their study been limited to patients with acute abdominal pain, their admission rates may have been higher. Forty-two percent of all patients (53 of 127) had a surgical procedure within the two-month follow-up period. The great majority of these (48 patients) underwent surgery during the initial hospitalization. In 49 pa1385/49
ABDOMINAL PAIN Bugliosi, Meloy & Vukov
tients (91%), the ED staff's diagnoses were not changed appreciably by surgery. T w o p a t i e n t s m a y h a v e b e e n d i s c h a r g e d i n a p p r o p r i a t e l y ; subsequently, both were diagnosed as having b i l i a r y t r a c t disease. H o w e v e r , t h e y r e t u r n e d and t o l e r a t e d surgical procedures well. T h r e e patients were a d m i t t e d to t h e h o s p i t a l w i t h uns u s p e c t e d early surgical disease. In two of these patients, free air was det e c t e d on f o l l o w - u p r a d i o g r a p h i c st udi e s (only one p a t i e n t agreed to surgery), and in one patient a clinical picture consistent with acute cholecystitis developed. Of the 71 patients w h o did not require surgery, follow-up i n f o r m a t i o n was available on 51. In 14 patients, follow-up diagnoses differed from ED diagnoses. A l t h o u g h s o m e of these diagnostic changes represented a different interpretation of data available to the ED staff, the m a j o r i t y of diagnostic changes were the result of furt h e r d i a g n o s t i c t e s t i n g (eg, c o l o n o scopy, c o m p u t e d tomography). Initial m a n a g e m e n t was n o t altered in the majority of these patients. CONCLUSION E l d e r l y p a t i e n t s w i t h a c u t e abd o m i n a l pain often require hospitalization and surgery. U s i n g extensive laboratory and radiographic testing as well as liberal surgical consultation, the ED staff is able to m a k e specific diagnoses in the m a j o r i t y of cases, particularly in patients who ultim a t e l y r e q u i r e surgery. A l t h o u g h changes in the r e i m b u r s e m e n t policy for elderly patients have emphasized the i m p o r t a n c e of a preadmission diagnosis and anticipated therapy, the ED staff should m a i n t a i n a liberal adm i s s i o n p o l i c y w h e n e v a l u a t i n g elderly patients w i t h acute abdominal pain. P a t i e n t s w h o are discharged from the ED w i t h no specific diagnosis or w i t h the diagnosis of gastritis should be f o l l o w e d s h o r t l y t h e r e a f t e r w i t h particular a t t e n t i o n paid to diagnoses t h a t are m o s t c o m m o n (eg, b i l i a r y tract disease). Finally, because both the absolute and t h e r e l a t i v e n u m bers of elderly patients are expected to increase in the future, additional studies are r e q u i r e d on h e a l t h care and cost issues relevant to geriatric patients w i t h acute abdominal pain.
REFERENCES 1. Janzon L, Ryd~n CI, Zederfeldt B: Acute ab-
50/1386
TABLE 5. D i a g n o s i s c h a n g e s i n p a t i e n t s a d m i t t e d requiring surgery
Patient 1 2 3 4 5 6 7 8 9 10 11
to hospital but not
ED Diagnosis
Hospital Discharge Diagnosis
Indeterminate Indeterminate Abdominal abscess Indeterminate Pneumonia Diverticulitis Indeterminate Small bowel obstruction Indeterminate Biliary colic Common duct stone
Irritable bowel syndrome Perforated viscus Pseudomembranous colitis Small bowel obstruction Rib fracture, urosepsis Spontaneous bacterial peritonitis Gastritis Indeterminate Nonspecific colitis Duodenal ulcer Gastritis
TABLE 6. E D d i a g n o s e s i n 4 7 p a t i e n t s d i s c h a r g e d f r o m t h e E D
Diagnosis
N
Indeterminate 19 Gastritis 8 Renal colic 4 Constipation 3 Small bowel obstruction 2 Diverticulitis 2 Urinary tract infection 2 Medication-related 2 Miscellaneous* 5 *Herpes zoster, reducible inguinal hernia, reducible umbilical hernia, diaphragmatic hernia, and biliary colic (one patient each).
domen in the surgical emergency room. Acta Chit Stand 1982;148:141-148. 2. Lowenstein SR, Crescenzi CA, Kern DC, et ah Care of the elderly in the emergency department. Ann Emerg Med 1986;15:528-535. 3. Wilson DH, Wilson PD, Wahnsley RG, et ah Diagnosis of acute abdominal pain in the accident and emergencydepartment. Br J Surg 1977; 64:250-254. 4. de Dombal FT: Acute abdominal pain An OMGE survey. Scand J Gastroenteroi (Suppl) 1979;14:29-43. 5. Brewer RJ, Golden GT, Hitch DC, et al: Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg 1976;131:219-223. 6. Feny6 G: Acute abdominal disease in the elderly: Experiencefrom two series in Stockholm. Am J Surg 1982;143:751-754. 7. Owen BJ III, Harnit HF: Appendicitis in the elderly. Ann Surg 1978;187:392-396.
Annals of Emergency Medicine
8. Yusuf MF, Dunn E: Appendicitis in the elderly: Learn to discern the UNtypical picture. Geriatrics 1979;34:73-79. 9. Vorhes CE: Appendicitis in the elderly: The case for better diagnosis. Geriatrics 1987;42: 89-92. 10. Block MA: Managing the silent, atypical acute abdomen. Geriatrics 1983;38:50-60. 11. Broders CW, Benavides RA: Acute cholecystitis in the elderly: A comparative study. Geriatrics Clin North A m 1985;1: 453-458. 12. Morrow DJ, Thompson J, Wilson SE: Acute cholecystitis in the elderly: A surgical emer gency. Arch Surg 1978;113:1149-1152. 13. Jess P, Bjerregaard B, Brynitz S, et ah Prognosis of acute nonspecifie abdominal pain: A prospective study. Am J Surg 1982;144:338-340. 14. Amberg JR, Zboralske FI~: Gallstones after 70: Requiescat in pace. Geriatrics 1965;20: 539-542.
19:12 December 1990
A c u t e Abdominal Pain in the Elderly Study objectives: To determine the incidences of both specific diagnosis and surgical diseases in patients more than 65 years old who present to the emergency department with nontraumatic abdominal pain of less than one week's duration, and to determine the ED staff's ability to diagnose and triage elderly patients with acute abdominal pain. Design: A 12-month retrospective review of all elderly patients who presented to the ED with acute, nontraumatic abdominal pain. Setting: A regional trauma center serving a predominately rural population in the Midwest. The ED has 55,000 patient visits yearly. Measurements and main results: Of the 127 patients enrolled, 30 (24%) had no specific diagnosis made in the ED. Biliary tract disease (12%) and small bowel obstruction (12%) were the two most common specific diagnoses. Overall, 53 patients (42%) required surgery, usually during the initial hospitalization. In four cases, the postoperative diagnosis differed sig~ nificantly from the ED diagnosis. Of the 74 patients (58%) who did not undergo surgery, 51 had follow~up information available. In 14 patients, the follow-up diagnosis differed from the original diagnosis, but most of these changes did not appreciably alter the treatment and outcome. Conclusions: The incidence of surgical disease is high in elderly patients with acute abdominal pain, and ED staff are able to diagnose and triage these patients accurately. [Bugliosi TF, Meloy TD, Vukov LF: Acute abdominal pain in the elderly, A n n Emerg M e d D e c e m b e r 1990;19: 1383-1386.]
Thomas F Bugliosi, MD Thomas D Meloy, MD Larry F Vukov, MD Rochester, Minnesota From the Division of Emergency Medical Services and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Received for publication September 12, 1989. Revision received May 18, 1990. Accepted for publication June 14, 1990. Presented at the Scientific Forum of the American College of Emergency Physicians Scientific Assembly in Washington, DC, September 1989. Address for reprints: Thomas F Bugliosi, MD, Division of Emergency Medical Services and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
INTRODUCTION Abdominal pain is a common complaint of patients presenting to an emergency department.< 2 For all age groups, a specific diagnosis can be made in less than 65% of cases.l, 3-5 However, in elderly patients (aged 65 years and older), assessment may be even more difficult. Their symptoms often have been present longer and are less specific, and elderly patients are more likely to have coexistent disease. 6-12 Compared with younger patients, the elderly also are more likely to require hospitalization and emergency surgery.l,%5, 6 There is no universal agreement regarding what constitutes "acute" abdominal pain. However, less than one week's duration has been used in several studies. 3,9,13 We used this definition of acute abdominal pain in a retrospective year-long study of elderly patients presenting to the ED of a large hospital. The aims of this study were to determine the incidence of various diagnoses in elderly patients with acute abdominal pain, to determine the incidence of surgical disease in this patient population, and to assess the ability of the ED staff to diagnose and triage elderly patients with acute abdominal pain accurately.
METHODS The hospital studied is a regional trauma center serving a predominately rural population in the Midwest. The ED has 55,000 patient visits per year. All adult patients (15 years old or older) who complain of abdominal pain are evaluated initially by the ED medical service, which consists primarily of internal medicine and family practice residents supervised by a member of the permanent staff, who is a board-certified internist. The ED senior
19:12 December 1990
Annals of Emergency Medicine
1383/47
ABDOMINAL PAIN Bugliosi, Meloy & Vukov
surgical resident is asked to evaluate these patients before disposition. Patients more than 65 years old who presented to the ED between April 1, 1988, and March 31, 1989, w i t h a chief c o m p l a i n t of n o n traumatic abdominal pain were identified by a c o m p u t e r i z e d data retrieval system. Only patients whose pain had been present for less than one week were included. Patients who had been evaluated previously at our institution as well as those who were referred from other institutions were excluded. ED and hospital records were reviewed for all patients who met inclusion criteria. Outpat i e n t records of all p a t i e n t s discharged from the ED and subsequently seen in the outpatient clinic also were available for review. A twomonth follow-up period was used.
RESULTS During the 12-month study period, 127 patients (60 women and 67 men) met the inclusion criteria (Table 1). Mean + SD patient age Was 74.8 _+ 6.2 years; the oldest patient was 91 years old. Of the diagnoses made in the ED, the most c o m m o n was "indeterminate abdominal pain" (24% of patients) (Table 2). Diagnoses referable to the biliary tract and small bowel obstruction were the most frequent specific diagnoses made in the ED. Among the nine patients with diagnoses of perforated viscus, in only one was the cause of the perforation hypothesized. There were 12 elderly patients (9%) with acute abdominal pain who had diagnoses not referable to the gastrointestinal tract. The ED staff's diagnoses in the 26 patients taken directly to surgery are shown (Table 3). The most frequent reason cited for emergency surgical intervention was a perforated viscus. At operation, the causes of the perforation were found to be a gastric ulcer (three patients), diverticulitis (two patients), and carcinomatosis (jejunal perforation), duodenal ulcer, and foreign body (chicken bone) perforating the terminal ileum (one patient each). In no case did the postoperative diagnosis differ greatly from the preoperative ED diagnosis. Of the 26 patients undergoing emergency surgery, the mean length of hospital stay was 11.6 days. One patient died of a myocardial infarction before discharge. 48/1384
TABLE L Triage of 127 elderly patients seen in hospital ED with
abdominal pain Action
N
%
Directly to Surgery
26
20
Admitted
54
43
No surgery
32
...
Surgery
22
...
Dismissed Outpatient follow-up Returned to ED
47
37
21"
...
51-
...
*Subsequent surgery in three. tSubsequent surgery in two.
TABLE 2. ED diagnoses in 127 patients with abdominal pain* N
%
Indeterminate
30
23
Biliary colic or cholecystitis
16
12
Small bowel obstruction
15
12
Gastritis
10
8
Perforated viscus
9
7
Diverticulitis
8
6
Appendicitis
5
4
Incarcerated hernia
5
4
Renal colic
5
4
Pancreatitis
3
2
Urinary tract infection
3
2
Constipation
3
2 2
Sigmoid volvulus
2
Abscess
2
2
Medication related
2
2
10
8
Miscellaneoust
*One patient had two primary diagnoses. tSymptomatic abdominal aortic aneurysm, ischemic bowel, hiatal hernia, herpes zoster, umbilical hernia, reducible inguinal hernia, myocardial infarction, pneumonia, pulmonary embolism, and colonic obstruction secondary to rectal carcinoma (one patient each).
Of the 54 patients admitted for observation or medical management of their illness, 22 (41%) eventually had surgery because they did not respond to conservative therapy (eg, bowel obstruction), they were stabilized (eg, gallstone pancreatitis), or the initial diagnosis was incorrect. Of patients who were admitted and later required surgery, three had a postoperative diagnosis that differed appreciably from the ED staff's diagnosis. Two of Annals of Emergency Medicine
these three patients were admitted with a diagnosis of indeterminate abdominal pain. One had free air on a follow-up abdominal radiograph and was found to have a perforated colon secondary to diverticular disease; the other began to have findings consistent with acute cholecystitis and underwent an uneventful cholecystectomy. The third patient was thought to have an abdominal abscess from a prior colon operation; however, sur19:12 December 1990
TABLE 3. ED diagnoses in 26 patients taken directly to surgery
TABLE 4. ED diagnoses in 54 patients initially admitted to the hospital*
Diagnosis
Admitted and Surgery
Admitted and No Surgery
Diagnosis
N
Perforated viscus
8
Biliary colic and cholecystitis
7
5
Appendicitis
5
Indeterminate
2
9
Incarcerated hernia Bowel obstruction
4 3
Small bowel obstruction
5
5
3
Diverticulitis
1
5
Pancreatitis Gastritis
2 0
1 2
Miscellaneous
5
6
Cholecystitis
Miscellaneous* 3 *Symptomatic abdominal aortic aneurysm, colonic obstruction secondary to rectal carcinoma, and volvulus (one patient each).
gery revealed a perforation of the terminal ileum (no underlying cause given). ED diagnoses for 54 patients initially admitted to the hospital from the ED are given (Table 4). Of the 32 patients who did not require surgery, 11 had a hospital dismissal diagnosis that differed from the admission diagnosis (Table 5). In most, the change in diagnosis was not of major consequence. One patient admitted with i n t e r m i n a t e a b d o m i n a l pain was found to have free air on a computed tomography scan done on hospital day 2. Because of the patient's overall status and her family's wishes, she was treated nonsurgically and did well. Another patient who was initially thought to have an abdominal abscess secondary to a recent colect o m y was f o u n d to h a v e p s e u d o m e m b r a n o u s c o l i t i s and was treated with antibiotics. Four patients died before discharge. One was admitted with a diagnosis of indeterminate abdominal pain and died the next day of an intracerebral hemorrhage. Two patients died after surgery; one had intra-abdominal carcinomatosis as well as a perforated terminal ileum (caused by a chicken bone), and peritonitis and adult respiratory distress syndrome developed. The other patient had a diagnosis (inferior myocardial infarction) not referable to the gastrointestinal tract and died of left ventricular dysfunction after cardiac surgery. The fourth patient had massive ascites and indeterminate abdominal pain and died seven days after admission. Autopsy showed p u l m o n a r y edema in addi19:12 December 1990
*One patient had two primary diagnoses.
tion to ascites and liver disease. Forty-seven patients (37%) were discharged from the ED. Their diagnoses are given (Table 6). Of these 47, five (11%) returned to the ED; two required surgery (one for a previously diagnosed ureteral calculus and one for acute cholecystitis that was diagnosed initially as gastritis on the preceding day), and three did not undergo surgery (one received a new diagnosis of biliary colic but declined surgery). T w e n t y - o n e patients were seen s u b s e q u e n t l y for follow-up in the outpatient clinic; of these, three were scheduled for surgery (one for elective urologic surgery, and one for elective cholecystectomy). The third patient, originally diagnosed as having gastritis, was found ten days later to have obstructive jaundice. The cause of his jaundice was a common duct stone, and his postoperative course was uneventful. Three other patients had different diagnoses after outpatient follow-up. One patient, initially diagnosed as having gastritis, s u b s e q u e n t l y was found to have gallstones and was given a diagnosis of biliary colic; he refused surgery. A second, who had been diagn o s e d as h a v i n g g a s t r i t i s , w a s thought on follow-up to have a medication intolerance. The third, originally diagnosed as h a v i n g diverticulitis, was later thought to have irritable bowel syndrome.
DISCUSSION Although EDs vary in regard to physician staffing, available technology, and overall strategy for evaluat-
Annals of Emergency Medicine
ing patients with abdominal pain, the following observations can be applied to any ED that evaluates geriatric patients who have abdominal pain. First, the ED staff was able to make a specific diagnoses in 76% of cases. Most often, diagnoses were referable to the biliary tract (13%); if patients subsequently diagnosed as having biliary tract disease are included (ie, after hospitalization or follow-up), this rate increased to 18%. This might be expected because cholelithiasis was noted in 30% of patients autopsied who were more than 70 years old. 14 In two separate series of acute abdominal pain in Swedish patients more than 70 years old, Feny6 noted an even higher incidence of cholecystitis in hospitalized p a t i e n t s (41% and 26%, respectively). 6 Sixty-three percent of all elderly patients presenting to the ED with acute abdominal pain were admitted. Although this seems like a high percentage, in a study of abdominal pain in all age groups, Brewer et al 5 noted that patients more than 65 years old had a 51% admission rate. However, their study included patients with abdominal pain of any duration. It could be speculated that had their study been limited to patients with acute abdominal pain, their admission rates may have been higher. Forty-two percent of all patients (53 of 127) had a surgical procedure within the two-month follow-up period. The great majority of these (48 patients) underwent surgery during the initial hospitalization. In 49 pa1385/49
ABDOMINAL PAIN Bugliosi, Meloy & Vukov
tients (91%), the ED staff's diagnoses were not changed appreciably by surgery. T w o p a t i e n t s m a y h a v e b e e n d i s c h a r g e d i n a p p r o p r i a t e l y ; subsequently, both were diagnosed as having b i l i a r y t r a c t disease. H o w e v e r , t h e y r e t u r n e d and t o l e r a t e d surgical procedures well. T h r e e patients were a d m i t t e d to t h e h o s p i t a l w i t h uns u s p e c t e d early surgical disease. In two of these patients, free air was det e c t e d on f o l l o w - u p r a d i o g r a p h i c st udi e s (only one p a t i e n t agreed to surgery), and in one patient a clinical picture consistent with acute cholecystitis developed. Of the 71 patients w h o did not require surgery, follow-up i n f o r m a t i o n was available on 51. In 14 patients, follow-up diagnoses differed from ED diagnoses. A l t h o u g h s o m e of these diagnostic changes represented a different interpretation of data available to the ED staff, the m a j o r i t y of diagnostic changes were the result of furt h e r d i a g n o s t i c t e s t i n g (eg, c o l o n o scopy, c o m p u t e d tomography). Initial m a n a g e m e n t was n o t altered in the majority of these patients. CONCLUSION E l d e r l y p a t i e n t s w i t h a c u t e abd o m i n a l pain often require hospitalization and surgery. U s i n g extensive laboratory and radiographic testing as well as liberal surgical consultation, the ED staff is able to m a k e specific diagnoses in the m a j o r i t y of cases, particularly in patients who ultim a t e l y r e q u i r e surgery. A l t h o u g h changes in the r e i m b u r s e m e n t policy for elderly patients have emphasized the i m p o r t a n c e of a preadmission diagnosis and anticipated therapy, the ED staff should m a i n t a i n a liberal adm i s s i o n p o l i c y w h e n e v a l u a t i n g elderly patients w i t h acute abdominal pain. P a t i e n t s w h o are discharged from the ED w i t h no specific diagnosis or w i t h the diagnosis of gastritis should be f o l l o w e d s h o r t l y t h e r e a f t e r w i t h particular a t t e n t i o n paid to diagnoses t h a t are m o s t c o m m o n (eg, b i l i a r y tract disease). Finally, because both the absolute and t h e r e l a t i v e n u m bers of elderly patients are expected to increase in the future, additional studies are r e q u i r e d on h e a l t h care and cost issues relevant to geriatric patients w i t h acute abdominal pain.
REFERENCES 1. Janzon L, Ryd~n CI, Zederfeldt B: Acute ab-
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TABLE 5. D i a g n o s i s c h a n g e s i n p a t i e n t s a d m i t t e d requiring surgery
Patient 1 2 3 4 5 6 7 8 9 10 11
to hospital but not
ED Diagnosis
Hospital Discharge Diagnosis
Indeterminate Indeterminate Abdominal abscess Indeterminate Pneumonia Diverticulitis Indeterminate Small bowel obstruction Indeterminate Biliary colic Common duct stone
Irritable bowel syndrome Perforated viscus Pseudomembranous colitis Small bowel obstruction Rib fracture, urosepsis Spontaneous bacterial peritonitis Gastritis Indeterminate Nonspecific colitis Duodenal ulcer Gastritis
TABLE 6. E D d i a g n o s e s i n 4 7 p a t i e n t s d i s c h a r g e d f r o m t h e E D
Diagnosis
N
Indeterminate 19 Gastritis 8 Renal colic 4 Constipation 3 Small bowel obstruction 2 Diverticulitis 2 Urinary tract infection 2 Medication-related 2 Miscellaneous* 5 *Herpes zoster, reducible inguinal hernia, reducible umbilical hernia, diaphragmatic hernia, and biliary colic (one patient each).
domen in the surgical emergency room. Acta Chit Stand 1982;148:141-148. 2. Lowenstein SR, Crescenzi CA, Kern DC, et ah Care of the elderly in the emergency department. Ann Emerg Med 1986;15:528-535. 3. Wilson DH, Wilson PD, Wahnsley RG, et ah Diagnosis of acute abdominal pain in the accident and emergencydepartment. Br J Surg 1977; 64:250-254. 4. de Dombal FT: Acute abdominal pain An OMGE survey. Scand J Gastroenteroi (Suppl) 1979;14:29-43. 5. Brewer RJ, Golden GT, Hitch DC, et al: Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg 1976;131:219-223. 6. Feny6 G: Acute abdominal disease in the elderly: Experiencefrom two series in Stockholm. Am J Surg 1982;143:751-754. 7. Owen BJ III, Harnit HF: Appendicitis in the elderly. Ann Surg 1978;187:392-396.
Annals of Emergency Medicine
8. Yusuf MF, Dunn E: Appendicitis in the elderly: Learn to discern the UNtypical picture. Geriatrics 1979;34:73-79. 9. Vorhes CE: Appendicitis in the elderly: The case for better diagnosis. Geriatrics 1987;42: 89-92. 10. Block MA: Managing the silent, atypical acute abdomen. Geriatrics 1983;38:50-60. 11. Broders CW, Benavides RA: Acute cholecystitis in the elderly: A comparative study. Geriatrics Clin North A m 1985;1: 453-458. 12. Morrow DJ, Thompson J, Wilson SE: Acute cholecystitis in the elderly: A surgical emer gency. Arch Surg 1978;113:1149-1152. 13. Jess P, Bjerregaard B, Brynitz S, et ah Prognosis of acute nonspecifie abdominal pain: A prospective study. Am J Surg 1982;144:338-340. 14. Amberg JR, Zboralske FI~: Gallstones after 70: Requiescat in pace. Geriatrics 1965;20: 539-542.
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