Acute abdominal pain in the older adult

ACUTE ABDOMEN IN INTENSIVE CARE UNIT: ETIOLOGY, COMORBIDITY AND SEVERITY OF 1,523 PATIENTS

BACKGROUND

Clinical features and outcomes of patients admitted to the intensive care unit due to acute abdomen are important to be investigated.

AIMS

To evaluate the outcomes of critically ill subjects with acute abdomen according to etiology, comorbidity and severity.

METHODS

Outcomes of 1,523 patients (878 women, mean age 66±18 years) consecutively admitted to a specialized gastrointestinal intensive care unit with different causes of acute abdomen from January 2012 to December 2019, were retrospectively evaluated according to etiology, comorbidity and severity.

RESULTS

The most common causes of acute abdomen were obstructive and inflammatory, particularly large bowel obstruction (27%), small bowel obstruction (18%) and acute pancreatitis (17%). Overall mortality was 13%. Surgery was required in 34% of patients. Median length of stay in the hospital was 9 [1-101] days. On univariate analysis mortality was significantly associated with age, APACHE II, Charlson comorbidity index, requirement for surgery and malignancy (p<0.0001), but only APACHE II, Charlson comorbidity index and surgical interventional remained significant on multivariate analysis.

CONCLUSIONS

Critically ill patients admitted to the intensive care unit with acute abdomen constitute a heterogeneous group of subjects with different prognosis. Mortality is more related to the severity of the disease, comorbidity and need for surgery than to the etiology of the acute abdomen.

Indications for Emergency Abdominal Surgeries in Older Patients: 7-Year Experience of a Single Centre

The majority of patients undergoing emergency laparotomy are older adults that carry the highest mortality. More research into the development of targeted interventions is required. Therefore, the aim of the study was to analyse the indications for emergency abdominal surgery in patients aged ≥ 65 admitted to the Department of General Surgery. The study included consecutive patients aged ≥ 65 who underwent emergency abdominal surgery within 48 h after admission at one institution. In 2010–2017, 986 patients were enrolled in the study (female 57%, male 43%). Patients were divided into three age groups, 65–70, 71–84 and ≥ 85, with 255 patients (25.9%), 562 patients (57.0%) and 169 patients (17.1%) in each group, respectively. In the first and second age groups, the most common indications for surgery were acute cholecystitis, non-malignant ileus, colorectal cancer complications and acute appendicitis. In the oldest patients, the most common indications were complications of colorectal cancer, acute cholecystitis, non-malignant ileus and complications of diverticulosis. In the women, the biggest differences in indications between age groups were colorectal cancer (p = 0.025) and peptic ulcer disease complications (p = 0.005); in the men, the biggest difference was seen for complicated diverticulitis (p = 0.001). The most frequent comorbidities were heart diseases (81.0%), followed by endocrine (33.6%) and vascular diseases (22.7%). The three most common indications for emergency surgery in older patients at our institution were acute cholecystitis, colorectal cancer complications and non-malignant bowel obstruction, affecting 59.5% of this group of patients. Elective surgery and endoscopic screening have the potential to prevent major part of these acute diseases. However, further prospective research is necessary on this field, particularly among frail, older patients.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

BACKGROUND

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA).

METHODS

The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality.

RESULTS

182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications.

CONCLUSIONS

Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Diagnosing serious infections in older adults presenting to ambulatory care: a systematic review

OBJECTIVES

to summarise all available evidence on the accuracy of clinical features and blood tests for diagnosing serious infections in older patients presenting to ambulatory care.

METHODS

systematic review, searching seven databases using a comprehensive search strategy. We included cross-sectional prospective diagnostic studies on (1) clinical features, (2) diagnostic prediction rules based on clinical features alone, (3) blood tests and (4) diagnostic prediction rules combining clinical features and blood tests. Study participants had to be community-dwelling adults aged ≥65 years, in whom a physician suspected an infection. We used QUADAS-2 to assess risk of bias. We calculated measures of diagnostic accuracy and present descriptive statistics.

RESULTS

out of 13,757 unique articles, only six studies with a moderate to high risk of bias were included. There was substantial clinical heterogeneity across these studies. Clinical features had LR- ≥0.61 and LR+ ≤4.94. Twelve prediction rules using clinical features had LR- ≥0.30 and LR+ ≤2.78. There was evidence on four blood tests of which procalcitonin was the most often investigated: levels <0.37 ng/ml (LR- = 0.20; 95%CI 0.10-0.42) were suitable to rule out sepsis in moderately high prevalence situations. Two diagnostic prediction rules combining clinical features and procalcitonin had LR- of ≤0.12 (95%CI 0.05-0.33) and LR+ of maximum 1.39 (95%CI 1.30-1.49).

CONCLUSIONS

we found few studies on the diagnostic accuracy of clinical features and blood tests to detect serious infections in older people presenting to ambulatory care. The risk of bias was mostly moderate to high, leading to substantial uncertainty.

Acute abdominal pain in older adults: a clinical and diagnostic challenge

INTRODUCTION

Abdominal pain (AP) is one of the most frequent clinical condition observed in elderly patients. The differential diagnosis is wide and definitive diagnosis is often difficult due to delayed symptoms, altered laboratory parameters, pre-existing medical disorders, abuse of drugs and in absence of an accurate medical history.

EVIDENCE ACQUISITION

A systematic literature review was carried out through PubMed database for studies published in the last ten years. The following search string was used: {("geriatric"[Title] OR "older"[Title] OR "aged"[Title] OR "elderly"[Title]) AND ((("abdomen"[Title] AND "acute"[Title]) OR "acute abdomen"[Title] OR ("acute"[Title] AND "abdomen"[Title])) OR ("abdominal"[Title] AND "pain"[title]) OR "abdominal pain"[Title])}. Full articles and abstracts were included. Case reports, commentaries, editorials and letters were excluded from the analysis.

EVIDENCE SYNTHESIS

As the age of people presenting AP advances, both rates of surgical procedures and mortality rate increase.

CONCLUSIONS

A systematic approach based on the organization of differential diagnoses into categories, may provide a helpful framework by the combined use of history-taking, physical examination, and results of diagnostic studies. In elderly patients admitted to the emergency department, a crucial role is played by a prompt use of radiological investigations in order to discriminate between older subjects admitted to the emergency department with abdominal pain and pathological cases requiring immediate surgical treatment.

Acute Abdominal Pain: Missed Diagnoses, Extra-Abdominal Conditions, and Outcomes

Abdominal pain (AP) is a common reason for presentation to an emergency department (ED). With this prospective, observational all-comer study, we aimed to answer three questions: Which diagnoses are most often missed? What is the incidence of extra-abdominal causes? What is the prognosis of abdominal pain in a tertiary urban European ED? Participants were systematically interviewed for the presence of 35 predefined symptoms. For all patients with abdominal pain, the index visit diagnoses were recorded. Related representation was defined as any representation, investigation, or surgery related to the index visit (open time frame). If a diagnosis changed between index visit and representation, it was classified as missed diagnosis. Among 3960 screened presentations, 480 (12.1%) were due to AP. Among 63 (13.1%) related representations, the most prevalent causes were cholelithiasis, gastroenteritis, and urinary retention. A missed diagnosis was attributed to 27 (5.6%) presentations. Extra-abdominal causes were identified in 162 (43%) presentations. Thirty-day mortality was comparable to that of all other ED patients (2.2% vs. 2.1%). Patients with abdominal pain had a low risk of representation, and the majority of representations due to missed diagnoses were of benign origin. The high incidence of extra-abdominal causes is noteworthy, as this may induce change to differential diagnosis of abdominal pain.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Secondary peritonitis: principles of diagnosis and intervention

Secondary peritonitis accounts for 1% of urgent or emergent hospital admissions and is the second leading cause of sepsis in patients in intensive care units globally. Overall mortality is 6%, but mortality rises to 35% in patients who develop severe sepsis. Despite the dramatic growth in the availability and use of imaging and laboratory tests, the rapid diagnosis and early management of peritonitis remains a challenge for physicians in emergency medicine, surgery, and critical care. In this article, we review the pathophysiology of peritonitis and its potential progression to sepsis, discuss the utility and limitations of the physical examination and laboratory and radiographic tests, and present a paradigm for the management of secondary peritonitis.

Investigation of Geriatric Patients with Abdominal Pain Admitted to Emergency Department

INTRODUCTION

The aim of this study is to detect the possible reasons of abdominal pain in the patients aged 65 and older admitted to emergency department (ED) with complaint of abdominal pain which is not related to trauma, to determine the length of hospitalization of old (65-75 age) and elderly (aged 75 and older) patients, and to define the hospitalization and mortality rates.

MATERIAL AND METHODS

In the study, 336 patients were included. Groups were compared in respect to gender, internal or surgical prediagnoses, complaints accompanying abdominal pain, vital findings, comorbidities, requested consultations, hospitalizing service, waiting time in the ED and in the hospital, and treatment methods.

RESULTS

Of the patients, 48.2% were male, and 51.8% were female. While 52.4% of the patients were in 65-74 age group, 47.6% of them were aged 75 years and above. An internal disease was detected in 76.8% of the patients as an origin of abdominal pain. Most common prediagnoses were biliary diseases and diseases related to biliary tract followed by nonspecific abdominal pain, abdominal pain secondary to malignity, ileus, and acute gastroenteritis, respectively. The most frequent finding accompanying abdominal pain was vomiting. The most frequent chronic disease accompanying abdominal pain was hypertension in both age groups. We observed that 75.9% of the patients required consultation. We detected that 48.8% of the patients with abdominal pain were hospitalized and they were hospitalized mostly by gastroenterology ward (24.8%). Surgical treatments were applied to the 17.6% of the patients with abdominal pain.

CONCLUSION

Clinical findings become indistinct by age, and differential diagnosis of abdominal pain gets more difficult in geriatric patients. Therefore, physicians should consider age related physiological changes in order to distinguish geriatric patients admitted to emergency service with abdominal pain from pathological cases requiring immediate surgical operation.

Gallbladder perforation in a patient with alcoholic liver cirrhosis and asymptomatic gallstones: A case report

RATIONALE

Gallbladder perforation is a relatively uncommon complication of alcoholic liver cirrhosis and may happen with or without gallstones.

PATIENT CONCERNS

Here we report a 52-year-old male patient who was diagnosed as gallbladder perforation with chronic liver cirrhosis and asymptomatic gallstones. The patient was admitted with acute and severe abdominal pain during weight-bearing physical labor. He had a history of alcoholic liver cirrhosis but no chronic abdominal pain or gallstones. The patient presented with localized peritoneal irritation, and abdominal puncture showed non-clotting blood. A preliminary clinical diagnosis was made as hepatocellular carcinoma rupture based on imaging findings. However, this diagnosis changed to gangrenous cholecystitis with gallbladder perforation by the laparotomy examination.

DIAGNOSES

He was diagnosed with gangrenous cholecystitis with gallbladder perforation.

INTERVENTIONS AND OUTCOMES

The patient performed well postoperatively.

LESSONS

This case suggests that gallbladder perforation should be considered as a potential cause of acute abdominal pain even without evidence of gallstones. Early examination with a laparotomy examination can help achieve a timely diagnosis.

Acute pancreatitis: A 7 year retrospective cohort study of the epidemiology, aetiology and outcome from a tertiary hospital in Jamaica

BACKGROUND

Acute pancreatitis (AP) is a significant cause of acute abdominal pain, morbidity and hospitalisation. There was previously a dearth of studies exploring the incidence, risk factors and outcome of AP in the Caribbean region.

MATERIALS AND METHODS

All patients with a diagnosis of AP admitted to the University Hospital of the West Indies (UHWI) between 2006 and 2012 were reviewed. The epidemiological profile, risk factors, clinical presentation and outcomes of patients with AP were retrospectively studied.

RESULTS

There were 70 females and 21 males with a median age of 44 years (range 2-86). The median age of males was significantly higher than that of females (p = 0.041). The incidence of AP was 74 per 100,000 admissions per year. Vomiting and abdominal tenderness were noted in the majority of patients. The most common aetiology was biliary disease (71.4%), idiopathic (12%), post-ERCP (6.6%) and alcohol (5.5%). Alcoholic pancreatitis was only seen in males whereas idiopathic and post-ERCP pancreatitis only occurred in females. The mean duration of hospitalisation was 9.51 ± 8.28 days. Disease severity was mild in 61.1%, moderately severe in 26.7%, and severe in 12.2% of patients. Factors associated with more severe disease included overweight/obesity, idiopathic aetiology and post-ERCP status. The case fatality rate was 2%.

CONCLUSION

The incidence of AP was 74/100,000 hospital admissions annually. There was an unusual female preponderance, with biliary pancreatitis being the most common type occurring at an equal frequency among males and females. Only 12.2% of the total cases seen were severe. The case fatality rate was 2%. Local health policy should target timely interventions for biliary pancreatitis and should also address the local factors affecting disease severity.

Practical Considerations in Sepsis Resuscitation

BACKGROUND

Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment.

OBJECTIVE

This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment.

DISCUSSION

Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario.

CONCLUSIONS

The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.

Abdominal Pain in the Geriatric Patient

Abdominal pain in the elderly can be a challenging and difficult condition to diagnose and treat. The geriatric population has significant comorbidities and often takes polypharmacy that can mask symptoms. The presentation of common conditions can be different than that in the younger population, often lacking the traditional indicators of disease, making it of pivotal importance for the clinician to consider a wide differential during their workup. It is also important to consider extra-abdominal abnormality that may manifest as abdominal pain.

Clinical Features of Infection in Older Adults

The impact of infectious diseases on older adults is far greater than on younger adults because of significantly higher morbidity and mortality caused by infection. The reasons for this greater impact include factors such as lower physiologic reserve due to age and chronic disease, age-related changes in host defenses, loss of mobility, higher risk for polypharmacy and adverse drug reactions, and being on drugs that increase the risk for infection (e.g., anticholinergic and other sedating medications increase the risk for pneumonia).

Evaluating Patients with Left Upper Quadrant Pain

Imaging plays a major role in the evaluation of patients who present to the emergency department with acute left upper quadrant (LUQ) pain. Multidetector computed tomography is currently the primary modality used for imaging these patients. The peritoneal reflections, subperitoneal compartment, and peritoneal spaces of the LUQ are key anatomic features in understanding the imaging appearance of acute diseases in this area. Diseases of the stomach, spleen, pancreas, and splenic flexure are encountered in patients with acute LUQ pain. Optimization of the imaging protocol is vital for accurate diagnosis and characterization of these diseases in the acute setting.

Emergency gastrointestinal surgery in the elderly

The main problem in management of elderly patients who present to the emergency department with abdominal pain is related to difficulties in establishing a diagnosis, because of frequently impaired communication as well as to unusual clinical and laboratory presentations, resulting in delayed management. Early use of pertinent imaging may reduce this delay. Surgical procedures in the elderly do not differ from those in younger patients, but their associated morbidity is different. Assessing co-morbidities and patient frailty, as well as taking into consideration the diagnosis, patients' wishes and status should help in decision-making. Therapeutic decisions should involve surgeons, anesthesiologists and geriatricians alike, both pre- and postoperatively, with the goal of optimizing patients' rehabilitation and offering good and appropriate care while ensuring the humane, social and financial aspects.

Abdominal emergencies in the geriatric patient

Abdominal pain is one of the most frequent reasons that elderly people visit the emergency department (ED). In this article, we review the deadliest causes of abdominal pain in this population, including mesenteric ischemia, abdominal aortic aneurysm, and appendicitis and potentially lethal non-abdominal causes. We also highlight the pitfalls in diagnosing, or rather misdiagnosing, these clinical entities.

Abdominal Pain

Acute abdominal pain represents the cardinal symptom of a large number of intra-abdominal pathologies. Because of multiple organ systems, varied pathology from life threatening to benign, and differences in presentation related to sex and age, identifying a final diagnosis is a challenge. The clinician’s goal for patients with acute abdominal pain is to rapidly identify whether the underlying cause requires an urgent or immediate surgical intervention. By developing a systematic approach to evaluating patients with abdominal pain, clinicians can generate a differential diagnosis to ensure appropriate treatment and improved patient outcomes. The purpose of this article is to provide clinicians with a framework for evaluating the complaint of acute abdominal pain and recognizing patients who require expedited evaluation.

Emergency department observation units and the older patient

An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.