Colorectal Disease in the Elderly Patient

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.

Anatomical considerations on Sudeck's critical point and its relevance to colorectal surgery

Sudeck's critical point at the rectosigmoid junction is described as the point of origin of the last sigmoid arterial branch, originating from the inferior mesenteric artery (IMA). There is controversy on the importance of Sudeck's point, and the frequency in which the anastomosis is found. Furthermore, the diameter of the anastomosis, if present, may also impact on the viability of the caudal stump. This study aimed to determine the frequency in which a macroscopic anastomosis occurs, between the superior rectal artery and the last sigmoidal branch, in a cadaver population; the diameter of this anastomosis and the distance from the origin of the IMA to Sudeck's point. Sixty-four cadavers were included in the study, excluding those with previous surgery to the rectosigmoid junction. Sudeck's point was carefully identified and dissected to establish the presence of an anastomosis. Subsequent measurements were performed using a digital caliper (accuracy = 0.01 mm). A macroscopic anatomosis was absent in three cases (4.7%). The mean diameter of the anastomosis when present was 1.9 mm (SD: 0.5 mm), and the distance from the origin of the IMA to Sudeck's point was 55.5 mm (SD: 14.6 mm). Although an anastomosis is present in the majority of cases, the vessel is very small in diameter, and may not be sufficient to meet the demands of the caudal stump. The distance from the origin of the IMA to Sudeck's point is sufficient enough to allow for ligation of the IMA proximal to Sudeck's point.

Abdominal Pain

Evaluation of the elderly patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis and leading to adverse patient outcomes. Clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality. This article reviews abdominal pain in the elderly, discusses the clinical approach, and highlights key diagnostic considerations.

Abdominal Pain in the Elderly

Elderly patients who have abdominal pain remain one of the most challenging patient populations. Signs and symptoms of serious disease are often nonspecific. Atypical presentations are common in elderly patients. In addition, the higher incidence of serious pathology in this population requires emergency physicians to be vigilant and thorough in their work-up. Vascular catastrophes are more likely to be seen in this population, and a broad differential diagnosis needs to be considered.

Perforated Appendicitis in the Elderly Masquerading as Acute Coronary Syndrome

BACKGROUND

Evaluation of acute appendicitis in the elderly presents a diagnostic challenge to the surgeon. The diagnosis is often difficult to establish on account of general poverty of history and clinical signs, comorbidity and the unreliability of diagnostic procedures. Due to this, morbidity and mortality statistics in this group of patients is unacceptably higher than the general population.

METHODS

Individual case report and literature review.

RESULTS

We present an unusual case of perforated appendicitis masquerading as acute coronary syndrome.

CONCLUSIONS

Patient's education, high index of suspicion, and an aggressive surgical approach is needed if the outcome among the elderly population is to be improved.

Abdominal surgical emergencies in the elderly

The evaluation of abdominal pain can be considerably more challenging in elderly patients. A higher likelihood of life-threatening pathology combined with a myriad of diagnostic pitfalls in this population mandate a more cautious approach with greater use of diagnostic resources and specialist consultation.

Enema-induced perforation of the rectum in chronically constipated patients

INTRODUCTION

The use of retrograde irrigation enemas is common in the treatment of chronic constipation, especially in the elderly. Perforation of the rectum and sigmoid colon caused by cleansing enemas, used by chronically constipated patients, has not been previously described.

METHODS

We reviewed all patients with colorectal perforations caused by irrigation enemas admitted to our service in the three-year period between January 1995 and December 1997.

RESULTS

Thirteen patients were treated by our surgical service because of perforations of the rectum and sigmoid colon related to a previous retrograde irrigation enema. Ten of these patients came from nursing homes, and the other three lived at home. The relevant information relating the enema administration to the patient's condition was given in only two of the ten patients referred to the emergency room by the institution's nursing or medical staff. In the other eight the information was vague and sometimes misleading. The diagnosis of colorectal perforation was made by history, plain abdominal x-rays, and CT scan with or without meglumine diatrizoate enemas. Ten patients survived, regardless of age, previous diseases, or operative findings. In all of them, diagnosis was made within 36 hours from the perforation. The three deaths occurred in patients in whom the diagnosis was made late.

CONCLUSIONS

Awareness of the possible injury from enemas administered to chronically constipated patients should be stressed. A high degree of suspicion by the attending physician is extremely important, because prompt diagnosis and early surgical treatment carries a relatively good prognosis.

Ischemic colitis arising in watershed areas of the colonic blood supply: a report of two cases

There are several weak points in the colonic blood supply, known as watershed areas, which result from incomplete anastomoses of the marginal arteries. These watershed areas are more vulnerable to ischemic injury than other parts of the colon. We report herein the cases of two patients who developed ischemic colitis well localized in the cecum, and in the rectosigmoid region at Sudeck's point, respectively. This report and our review of the literature suggest that watershed areas, including the splenic flexure, or Griffith's point, Sudeck's point, and the ileocecal region, are high-risk regions for the development of ischemic colitis.