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Elderly people die from abdominal pain
Step 1: Risk Stratify
- Certain patient groups have VERY high mortality when having abdominal pain
- Geriatrics
- Immunocompromised
- Diabetics
Step 2: Consider Genitourinary Causes
- Be especially cautious with lower abdominal/flank pain
- Mention that you performed or considered performing GU exam during presentation!
- Common GU causes of abdominal pain
- Testicular/ovarian torsion
- Prostatitis/pelvic inflammatory disease
- Ectopic pregnancy
Step 3: High-Yield Tests to Consider
- CBC and Electrolytes
- EKG and Troponin
- Liver Panel and Lipase
- Urinalysis and Urine pregnancy
Step 4: Order Appropriate Imaging
- CT scan is most useful test with abdominal pain in adults
- Need to give IV contrast if concerned for vascular pathology
- Usually performs just as well as ultrasound (even in cases where ultrasound is the classic, initial test)
- 3 “exceptions” to the CT first rule
- If concerned for biliary pathology
- RUQ ultrasound
- If concerned for genitourinary pathology
- Testicular/Pelvic ultrasound
- Renal ultrasound (kidney stone)
- If concerned for Abdominal Aortic Aneurysm
- Bedside Aorta ultrasound
- If concerned for biliary pathology
Step 5: Disposition
- Classic teaching is that patients discharged with undifferentiated abdominal pain need follow up in 12-24 hours
- It’s ok to have them come back to the ED if necessary
Additional Reading
- Abdominal Pain History (EM Clerkship)
- Abdominal Pain Exam, Plan, and Disposition (EM Clerkship)
Hi Dr. Olson,
I am looking for your reference on the comment that geriatric patients presenting to ED with abdominal pain have a higher mortality rate than patients presenting to cardiac centers with STEMI (or something to this nature was said). Mentioned to my attending, but can’t find reference!
Thanks so much, love the podcast
No study compares head to head that I can find. Current in-hospital mortality for STEMI at PCI capable centers 5-7% (Claeys MJ, Sinnaeve PR, Convens C, et al. STEMI mortality in community hospitals versus PCI-capable hospitals: results from a nationwide STEMI network programme. Eur Heart J Acute Cardiovasc Care. 2012;1(1):40–47)
If you look at abdominal pain mortality data it depends on the study. From what I can find, the mortality number most frequently cited (10%) is traced back to a study from 1982.
There is a more recent study from Turkey with geriatric abdominal pain mortality around 12% (Pınar Henden Çam, Ahmet Baydin, Savaş Yürüker, Ali Kemal Erenler, and Erdinç Şengüldür, “Investigation of Geriatric Patients with Abdominal Pain Admitted to Emergency Department,” Current Gerontology and Geriatrics Research, vol. 2018, Article ID 9109326, 8 pages, 2018.)
Geriatric abdominal pain is very bad. Admittedly, there are lots of confounding factors between studies that make comparison difficult.