Diagnostic Considerations

A comprehensive review of diagnostic testing is available in the individual chapters covering the above conditions, however, certain general and specific points regarding the elderly patient are useful. The most critical axiom is to not let the results of diagnostic testing change your diagnostic thinking in the face of strong clinical evidence of a disease. Laboratory testing can be problematic in this age group. A normal white blood cell count cannot be used to exclude serious intraabdominal diseases, including those with an infectious component. For example, a normal total white blood cell count is found in 20 percent of elderly patients with appendicitis and 30 percent or more of those with cholecystitis. Serum amylase levels are frequently normal in the setting of pancreatitis. Serum lipase is more helpful but still not completely accurate. For the patient's sake, one should hope to see little or no evidence of lactic acidosis in mesenteric ischemia. An elevated bilirubin suggests hepatobiliary disease; however, in the ill older patient, this can be a nonspecific elevation. For example, up to 17 percent of elderly patients with appendicitis can have hyperbilirubinemia.13 Since undiagnosed cancer is a frequent cause of "nonspecific" abdominal pain in older patients, the clinician must be careful not to ignore a low hemoglobin or microcytic indices on the blood count.

Radiographic studies can be equally problematic. Plain radiographs in the setting of perforated ulcer do not show free air in up to 40 percent of the patients. In appendicitis, the abdominal series is often interpreted as supporting the diagnosis of small bowel obstruction. Ogilvie's syndrome will commonly include a radiographic picture consistent with true large bowel obstruction.

Bedside ultrasound in capable hands can assist in rapidly securing the diagnosis of abdominal aortic aneurysm. It can also help clarify the clinical picture in acute cholecystitis and renal colic. Computed tomography is an important diagnostic modality in the older population with abdominal pain. The physician must remember that the unstable patient with a suspected abdominal aortic aneurysm belongs in the operating room and not in the computed tomography suite.

Treatment of the specific entities is covered more thoroughly elsewhere. General measures for the elderly patient with an acute abdominal condition overlap those of younger age groups. Specific useful measures include nasogastric decompression, fluid and blood component resuscitation as indicated, judicious use of narcotic analgesia, and tailored antibiotic coverage.

A period of observation with serial examinations should be considered in the elderly patient with undifferentiated abdominal pain. Depending on the circumstances, this could occur either in the ED, an observation unit, or in an inpatient unit. Patients with severe pain or worsening pain while in the ED should generally not be sent home. Resolved pain is generally reassurring, and such patients who are discharged should receive routine follow-up with their primary care providers. Biliary tract disease and underlying cancer are possibilities in this circumstance. 14

If an older patient is to be discharged with abdominal pain, the patient should be instructed to return if the symptoms worsen or do not resolve in a brief period of time (6 to 8 h). Similarly, a time limit should be placed on vomiting, as this will quickly resolve in most benign causes. New vomiting after discharge should prompt reevaluation.

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