Gastroenterology

Acute abdominal pain

Four classifications can guide assessment and management
Chat Dang, MD Patrick Aguilera, MD Alexis Dang, BS Leon Salem, MD

Abdominal pain is a common occurrence in older persons and a frequent catalyst for office and emergency room visits. Complaints must be investigated thoroughly because they often indicate serious underlying pathology such as infection, mechanical obstruction, malignancy, biliary disease, cardiac problems, and GI ischemia. One means of overcoming a sprawling differential diagnosis is to determine whether the problem falls into one of four general categories: peritonitis, bowel obstruction, vascular catastrophe, or nonspecific abdominal pain. A comprehensive history, careful physical examination, and use of abdominal imaging studies facilitate effective assessment. As atypical presentations are frequently encountered in older persons, liberal use of ultrasound and contrast CT and early surgical consultation are recommended.
Dang C, Aguilera P Dang A, Salem L. Acute abdominal pain: Four classifications can guide , assessment and management. Geriatrics 2002; 57(March):30-42.

mon identifiable causes of abdominal pain are acute cholecystitis, mechanical bowel obstruction, and cancer complications. Mild episodes of drug-induced abdominal pain or diarrhea also occur frequently in the geriatric population. Drug-induced pain is discussed in the section on nonspecific pain.
Hospitalization and surgery

bdominal pain is one of the most frequently cited presenting complaints among older persons.1 Many of these cases are caused by serious underlying pathology and frequently require surgical interven-

Dr. C. Dang is associate professor of emergency medicine, Charles R. Drew University, College of Medicine, King-Drew Medical Center, Los Angeles, CA.

Dr. Aguilera is assistant professor of emergency medicine, Charles R. Drew University, College of Medicine, King-Drew Medical Center, Los Angeles, CA. A. Dang is a third-year medical student, University of California, San Francisco, School of Medicine. Dr. Salem is assistant professor of emergency medicine, Charles R. Drew University, College of Medicine, KingDrew Medical Center, Los Angeles, CA.
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tion.2 Prompt and precise diagnosis of the older patient with abdominal pain remains a clinical challenge, not only because of a broad differential diagnosis but because older patients may exhibit atypical presentations.3 This article helps simplify initial assessment of the patient presenting with acute abdominal pain by providing an easy-to-use classification system for general symptoms. Examples of presentations discussed include MI, acute appendicitis, cholethiasis and cholecystitis, diverticular disease, constipation, bowel obstruction, abdominal aortic aneurysm, mesenteric infarction, nonspecific abdominal pain, and unsuspected trauma.
Etiology

Abdominal pain in older persons often precipitates an office or emergency room visit, and a significant portion of the latter cases necessitate surgical intervention.4,5 Among the most com-

In a longitudinal study by Marco et al of persons evaluated in an emergency department, most geriatric patients (age 65 and older) with abdominal pain had significant disease that necessitated hospitalization.4 Of 380 eligible patients, 50% were admitted. Follow-up information was available for 375 patients. Final diagnoses included: infection (19%; eg, UTI, gastroenteritis, diverticulitis, appendicitis, sepsis, Varicella zoster, abcess, food poisoning, Clostridium difficile colitis, hepatitis, and colitis) mechanical obstruction (16%) malignancy (7%) biliary disease (6%) and cardiac problems (4%). An additional 5% had perforated viscus, ruptured abdominal aortic aneurysm (AAA), ischemic bowel, and arteriovenous malformations. In another study involving 1,700 patients over age 70 presenting with abdominal pain, approximately one-third required surgical intervention. Among the common causes of the abdominal pain were acute cholecystitis (26%),

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malignancy (13.2%), bowel obstruction (10.7%), nonspecific abdominal pain (9.6%), peptic ulcer disease (PUD [8.4%]), acute diverticular disease (7.0%), incarcerated hernia (4.8%), acute appendicitis (3.5%), and other causes (12.7%).5 Abdominal pain in older persons results in surgical intervention twice as often as it does in younger persons. In an analysis of 1,000 patients presenting with abdominal pain, 33% of older patients required surgery compared with 16% of younger patients.6 Bugliosi et al found that 42% of patients older than age 65 presenting with nontraumatic abdominal pain ultimately required surgery.7 In the study by Marco et al, 22% of those admitted for hospitalization required surgery or in-patient procedures.4 Thus older persons presenting with abdominal pain are likely to need hospitalization and surgical evaluation and therefore the primary care physician should be prepared to perform preoperative evaluations in these patients.
Presentation

In the office setting, common abdominal pathologies include constipation, diarrhea, and abdominal cramps. Some patients may have a history of intermittent abdominal pain. In the emergency department, patients experiencing acute abdominal pain may present with decreased mental status, hypotension, hypothermia, fever, or shortness of breath. Management principles. Older patients presenting with abdominal pain need routine pulse oximetry, supplemental oxygen as indicated, ECG monitoring, and IV access. In most cases they should receive nothing by mouth until abdominal causes are ruled out. Nasogastric intubationused to decompress the stomach and prevent further abdominal distensionmay be indicated, as well as bladder catheterization, used to monitor adequate urinary output. Frequent reevaluations and early surgical consultation will help define
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Abdominal pain is one of the most frequently cited presenting complaints of persons age 65 and older. The most common identifiable causes include acute cholecystitis, mechanical bowel obstruction, and cancer complications.
Illustration for Geriatrics by Sally Cummings

ongoing disease processes. Until a definitive diagnosis is made, optimization of the cardiovascular and pulmonary functions by the emergency team offers the older patient the best chance for recovery. Given the broad differential diagnosis for abdominal pain in older persons, assessment and patient management

can be problematic. This task can be made less complicated by classifying the diverse clinical presentations into four recognizable syndromes (table): peritonitis bowel obstruction abdominal vascular catastrophe and nonspecific abdominal pain or medical conditions.
continued
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Table Four classifications of acute abdominal pain
Peritonitis
Localized (acute appendicitis, cholecystitis, diverticulitis) Generalized (perforated viscus)

Bowel obstruction
Strangulated hernia Volvulus

Abdominal vascular catastrophe

Abdominal aortic aneurysm (leaking or ruptured) Acute mesenteric infarction

Nonspecific abdominal pain or medical conditions

Drug-induced Constipation, acute gastroenteritis Acute MI, lower lobe pneumonia
Source: Prepared for Geriatrics by Chat Dang, MD, Patrick Aguilera, MD, Alexis Dang, BS, and Leon Salem, MD

Peritonitis

Patients presenting with appendicitis, cholecystitis, or diverticulitis typically exhibit localized involuntary guarding and rebound tenderness; thus it is possible to diagnose these conditions clinically, guided by the location of the physical findings. Diffuse tenderness and anterior abdominal wall rigidity of sudden onset suggests a perforation into the free peritoneal cavity caused by a peptic ulcer or colon carcinoma. Sometimes a ruptured appendiceal or peridiverticular abscess underlies the clinical picture. Acute pancreatitis of biliary or alcoholic origin may present as an acute abdomen. In the patient with ascites, spontaneous bacterial peritonitis (SBP) may produce diffuse abdominal pain, although the rigidity may be less evident due to the stretching of the anterior abdominal wall. Acute gastroenteritis and constipationthe latter of which is a symptom, not a diagnosisfrequently present as nondescript abdominal pain. In such cases, other morbid conditions must be carefully ruled out. For patients who have intra-abdominal infection, the main diagnostic clues may be an acute change in mental status, hypotension, hypothermia, hyperventilation associated with lactic acidosis, or diabetic ketoacidosis.8
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Five medical conditions, in particular, produce abdominal pain symptoms and should always be ruled out during assessment of the older patient. They are: inferior MI pneumonia or pulmonary infarct (especially of the lower lobes) diabetic ketoacidosis pyelonephritis and inflammatory bowel disease. Echocardiography, chest radiograph, arterial blood gas, urinalysis, and bed-

side analysis of stool hemoccult are among the most effective tools for ruling out these conditions. Appendicitis. Acute appendicitis occurs infrequently in the geriatric population. In one study, acute appendicitis accounted for 3.5% of acute abdominal pain cases out of 1,000 older patients.5 Despite the low incidence, atypical presentations of acute appendicitis deterioration in mental status, hypotension, or hypothermiamay be encountered. Minimal signs and symptoms can delay presentation and prolong diagnosis, resulting in a higher incidence of perforation.9 Recognizing the condition requires clinical alertness and occasional reliance on emergency abdominal sonogram or spiral CT. Cholelithiasis and cholecystitis. In all age groups, women are twice as likely as men to develop gallstones (figure 1). The prevalence of gallstones in the eighth decade is estimated to be 22% in men and 38% in women.10 In the American Indian population, the incidence of cholelithiasis is high, affecting by the fifth decade 70% of men and >80% of women.10 This high incidence is equally seen in people of Mexican origin, who constitute a large

Figure 1. Multiple gallstones (arrow) outlining the shape of the gall bladder.
Source: Chat Dang, MD

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patient population in the Southwestern states, from Texas to California. Thus gallstone-related pain should be a major concern in this at-risk segment of the U.S. population. The high susceptibility to gallstones is due to increased cholesterol synthesis and decreased bile acid production from abnormal hepatic cholesterol 7- -hydroxylase activity, which promotes conversion of cholesterol to bile acids.10 Overall in the geriatric population, 25% of those with acute cholecystitis have had no previous biliary colic; 33% will present with minimal abdominal pain and minimal or no peritoneal signs. Typically, white blood cell counts in these patients will not be elevated. Acute cholecystitis constitutes the most common indication for surgery, accounting for 40% of acute abdomen in patients older than age 55.9 Diverticular disease. Diverticular disease refers to any manifestations of diverticulosis (anatomic presence of diverticula in the intestine) or diverticulitis (symptomatic inflammation or perforation of the diverticulum). Painful diverticular disease or symptomatic diverticulosis suggests the presence of pain due to colonic spasm or microperforations of the diverticula. Involuntary guarding or rebound tenderness is not present. In the absence of peritoneal signs, a clinical diagnosis of frank diverticulitis cannot be made.11 Diverticulosis occurs predominantly in Western populationsprimarily in western Europe, Australia, and the United Statesand appears to be associated with low-fiber diets. Approximately 10% of the Western population is affected before age 40, and more than 50% are affected after age 70. In 90% of cases of diverticulosis, the sigmoid colon is involved. Eighty percent of patients with diverticula are asymptomatic. More than one-half of patients who experience abdominal pain caused by advanced colon cancer also have developed diverticula.12 Diverticulitis manifests first as an
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Figure 2. Free air under the diaphragm (arrow) is more easily detected on the patients right side due to the opacity of the liver. Free air is best detected by chest radiograph with patient in the upright position.
Source: Chat Dang, MD

inflammation, then as an infection. It usually is caused by obstruction at the neck of the diverticulum. But atypical presentation is the normfever may be absent, pain minimal, and tenderness unremarkable. In such cases, medical care might be precipitated by an altered level of consciousness, reduced food intake, or decreased level of activity. The implications of an attack should not be discounted even when symptoms are mild and leukocytosis is insignificant or absent. Liberal use of contrast CT is helpful in confirming the diagnosis. Management consists of surgical consultation and hospital admission for administration of IV fluids and antibiotics targeted at colonic flora. In most cases, 75% of patients will respond to conservative measures. Peptic ulcer perforation. Perforation occurs in approximately 5 to 10% of geriatric patients with peptic ulcers, and it is associated more frequently with duodenal than gastric ulcers.13 In most cases, older patients with a perforated ulcer will report abdominal

discomfort; approximately 16% will have minimal abdominal pain.13 The physical consequences of a perforated ulcer have been likened to lightning in a blue sky to characterize the sudden onset of severe abdominal pain and rigidity. Abdominal radiography (with the patient in the upright position or left lateral decubitus if the patient is unable to stand) reveals peritoneal free air (figure 2) in up to 60% of persons over age 60 who experience peptic ulcer perforation. Mimicking acute appendicitis, a small gastric perforation that is quickly sealed by omentum may present with initial epigastric pain. In a sequence of migration that is a hallmark of acute appendicitis, the pain subsequently moves to the right lower quadrant of the abdomen. The migration is explained by the leaked gastric fluid gravitating down the right colon gutter to the appendiceal region. Thus the clinician should seek evidence of free intraperitoneal air before committing the patient to a McBurney incision.
continued
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involved bowel is not compromised. In mechanical obstruction, the intestinal content cannot progress distally because the lumen is blocked. With functional or paralytic obstruction, gut motility is impaired. Vomiting caused by proximal obstruction leads to severe dehydration, hypokalemic hypochloremic alkalosis, and minimal distenFigure 3. Small bowel obstruction with the characteristic sion. In distal obplicae circulares or valvulae conniventes (arrows) as seen on a flat plate of the abdomen. struction, large Source: Chat Dang, MD amounts of fluid accumulate inside the Bowel obstruction distended proximal intestine, resultConstipation is characterized by in- ing in massive third spacing, marked frequent evacuation of bowel fecal distension, severe dehydration, and content, whereas obstipation is char- feculent vomiting. Structural pathology. Gallstone ileus (inacterized by the absence of fecal or gas evacuation. Patients experiencing ob- traluminal obstruction of the ileum by stipation, intermittent colicky ab- a large gallstone) is suspected when dominal pain, and vomiting may have there is air in the biliary tree (as seen intestinal obstruction, especially if they on radiograph findings) because pneumobilia often accompanies a biliaryhave a laparotomy scar. In the United States, bowel obstruc- enteric fistula. Cholangitis with gas-protions are most frequently caused by ducing bacteria may also explain the postoperative adhesions, followed by presence of air in the bile ducts. Sigmoid volvulus is associated with acutely incarcerated or strangulated inguinal hernias.14 Other less common chronic constipation, massive distencauses of obstruction include ob- sion, and characteristic radiographic structing tumors (often of colonic lo- findings (bent inner tube). A barcation), gallstone ileus, and volvulus, ium enema study will demonstrate the especially sigmoid volvulus. narrow twisted portion of lumen Diagnosis of bowel obstruction (fig- (birds beak). ure 3) is usually straightforward, but Provided there is no clinical eviit is essential to attempt a clinical clas- dence of bowel ischemia or perforasification to explain important patho- tion, initial management is aimed at physiologic findings and facilitate the decompression. This may be achieved treatment. by gentle insertion of a lubricated small Bowel obstruction can be high rectal tube. Ideally, direct visualization (proximal) or low (distal), complete of the mucosa through sigmoidoscopy or partial, simple or strangulated, me- is the preferred nonsurgical approach. chanical or functional, dynamic or paralytic. When the obstruction is com- Abdominal vascular catastrophe plete, surgery is indicated. In simple Often striking in presentation, abobstruction, the vascularization of the dominal vascular catastrophes are difficult to identify clinically and require a high index of suspicion. Typically the patient is in severe pain, yet examination of the abdomen produces deceptively benign signs. The differential diagnosis includes leaking or ruptured AAA and mesenteric infarction. AAA. Abdominal aortic aneurysm is one manifestation of arteriosclerosis. The prevalence and frequency increase with age, and episodes are three to eight times more common in men than in women.15 The distal aorta is the site of the most common and dangerous atherosclerotic aneurysms; approximately 98% of AAAs are infrarenal in origin, often involving the proximal common iliac arteries.13 An AAA >6 cm presents an increased risk for rupture. Unless severe comorbid conditions are present, elective surgical repair is recommended. Little data exist regarding the behavior of AAAs <6 cm in size; nevertheless a small aneurysm can rupture. Patients with an AAA >4 cm that shows evidence of growth on sonogram should be referred to a vascular surgeon. Overt signs of AAA may be nonexistant; 75% of patients are asymptomatic when first diagnosed. Typically AAA is discovered as a result of routine examination either during palpation or on examination of imaging findings. All older patients presenting with backache should undergo palpation of the abdomen to help rule out AAA. Abdominal, flank, or back pain indicates imminent if not actual rupture. The patient also may present with syncope, hypotension, or a pulsatile, tender mass. The most common misdiagnosis related to a ruptured AAA is renal colic, a conclusion often based on the existence of hematuria.16 An AAA may be confirmed by the presence of curvilinear calcifications on plain films or by evidence from sonography. When the patient is in shock, sonogram documentation of the presence of AAA is sufficient. CT may be contraindicated as the patient may exsanguinate and die in the CT

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suite. Helical CT should be ordered only if it can be obtained rapidly and the cardiovascular status of the patient is normal. In leaking or ruptured AAA, angiography is contraindicated. Emergent proximal control of the aorta to prevent onset of shock is indicated when: a reliable medical history confirms the existence of previously diagnosed AAA evidence from plain abdominal radiography or ultrasound implicates AAA acute abdominal pain cannot be explained clinically by any other pathology. Mesenteric infarction. The celiac, superior mesenteric, and inferior mesenteric arteries are interconnected by an extensive collateral system. Progressive arteriosclerotic stenosis precipitates further collateral circulation. As a result, intestinal angina occurs only after significant stenosis (>60%) of two of the three of these main arteries. Mesenteric thrombosis accounts for 25% of mesenteric infarction cases. Patients typically have a history of intestinal angina, MI, cerebrovascular accident, or intermittent claudication. Symptoms of mesenteric thrombosis are similar to those of paralytic ileus abdominal distension and moderate pain. Mesenteric embolus, which occurs in 50% of mesenteric infarction cases, is characterized by hyperacute symptoms disproportionate to the clinical findings. Diagnosis of mesenteric infarction is based on identification of a possible source for embolus (eg, atrial fibrillation, a mural thrombus from a recent MI, or valvular disease). Nonocclusive mesenteric ischemia from a low-flow state accounts for 20% of cases of mesenteric infarction. It is common in patients in the ICU who have experienced septic or cardiogenic shock. Most of these patients are intubated and unable to communicate. A high index of suspicion is appropriate when there is unexplained deterioration of vital signs.
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Nonspecific abdominal pain

After ruling out peritonitis, bowel obstruction, or abdominal vascular catastrophe, clinicians should consider nonspecific abdominal pain, which may include constipation, infectious enteritis, MI, or unsuspected trauma. Nonspecific abdominal pain also is referred to as: abdominal pain of undetermined etiology undifferentiated abdominal pain2,17 or dyspepsia. Consideration of this syndrome is especially appropriate for the patient who is afebrile, nontachycardic, exhibits a soft abdomen, and has no peritoneal signs. A reliable patient history is valuable for patients harboring uncomplicated PUD or gastroesophageal reflux disease (GERD). However, the presentation of more serious, life-threatening conditions, such as acute MI and ischemic colitis, can mimic the symptoms of PUD and GERD. Thus patients should be re-evaluated by a physician within 24-hours of the initial assessment. Confirmation of the diagnosis of PUD or GERD requires upper GI contrast studies or upper GI endoscopy, which may take a week to obtain. Three afflictions notorious for producing nonspecific abdominal pain are mild chronic alcoholic pancreatitis, sickle cell occlusive crisis, and large ventral incisional hernia. If any doubt exists about the benign nature of the abdominal complaint, emergent surgical consultation should be sought. Drug-induced pain. Drug-induced abdominal pain is associated with the high prevalence of polypharmacy in the geriatric population. Several of the agents that can cause problems are commonly prescribed in adults. Nonsteroidal anti-inflammatory drugsoften prescribed for arthritis symptoms in older patientscan cause abdominal pain associated with gastritis. Erythromycin, a macrolide antibiotic, is notorious for inducing gastric irritation and intestinal cramps.

Several agents are associated with development of pancreatitis. They include the immunosuppressive antimetabolite azathioprine, estrogen, furosemide, sulfonamides, and tetracyclines.18 Antibiotic-associated colitis is another major diagnosis to consider in the older patient presenting with abdominal pain. This condition is common among patients on broad-spectrum antibiotic regimens. Patients taking clindamycin, cephalosporins and ampicillin or amoxicillin may be at highest risk for development of colitis, but other agents have been implicated.

Drug-induced pain is associated with the high prevalence of polypharmacy in the geriatric population
During the antibiotic regimen or within 2 weeks of its discontinuation, the patient complains of abdominal cramps and diarrhea characterized by mucoid or watery stools. In the more severe form of antibiotic-associated colitis, fever, dehydration, electrolyte imbalance, and hypovolemic shock may be present. When possible, antibiotic therapy should be discontinued immediately. If the diagnosis is confirmed by stool toxin assay or by flexible sigmoidoscopy with visualization of pseudomembranes, administration of metronidazole (Flagyl) is indicated. Constipation. As noted above, constipation is characterized by infrequent evacuation of the bowel fecal content. Because of the prolonged stay in the colon and rectum, water is reabsorbed and the stools are hard and small. Constipation is a nonspecific presentation. One study found that of 3,000 community-dwelling persons over age 65, 26% of men and 34% of
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women complained of constipation. In a nursing home setting, 50% of individuals reported constipation.19 Studies have shown, however, that colonic and rectal functions in general remain normal in older persons, and most do not complain of constipation.20 This discrepancy may be explained in part by the perception that the straining associated with passage of hard stools indicates constipation. Diagnosis of constipation is confirmed by radiograph results that show large amounts of feces filling the rectum and colon and by the systematic elimination of other pathologies that may cause abdominal pain. Inferior MI. All older persons who present with epigastric pain should undergo ECG. If these patients also have cardiac risk factors, cardiac enzyme testing is prudent. All patients with new ECG changes should be admitted for further evaluation. Changes are considered new when abnormal patterns are not present on previous ECG obtained from the patients medical record, or when no previous ECGs are available for comparison. Trauma. Abdominal pain that cannot be explained medically may signal elder abuse. Victims of abuse are unlikely to volunteer information about the problem and may even deny its existence. Thus administering a comprehensive physical exam and careful questioning are key to diagnosing elder abuse. In some cases, signs of abuse are conspicuous. Bruises of different colors purple, green, yellowattest to repeat injuries. Ecchymosis of the flank (Grey Turner), umbilicus (Cullen), or scrotum may point to intraperitoneal bleeding.21
Conclusion

tion, vascular catastrophe, or nonspecific abdominal pain. During assessment, clinicians must be on the alert for atypical presentations as well as the presence of afflictions notorious for producing nonspecific abdominal pain. Imaging via ultrasonography and spiral CT with contrast should be staples among the assessment tools. Surgical consultation is the prudent choice for the inscrutable abdomen. G
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10. Mezey E. Diseases of the gallbladder and biliary tree. In: Hazard WR, Blass JP , Ettinger, Jr. WH, Halter JB, Ouslander JGH (eds). Principles of geriatric medicine and gerontology (4th ed). New York: McGraw-Hill, 1999:873-75. 11. Cheskin LJ. Diverticular disease of the colon. In: Barker LR, Burton JR, Zieve PD (eds). Principles of ambulatory medicine (4th ed). Baltimore: Williams & Wilkins, 1995:499-502. 12. Cheskin LJ, Shuster MM. Colonic disorders. In: Hazard WR, Blass JP , Ettinger, Jr. WH, Halter JB, Ouslander JGH (eds). Principles of geriatric medicine and gerontology (4th ed). New York: McGraw-Hill, 1999:881-8. 13. Gastrointestinal disorders. In: Beers MH, Berkow R (eds). The Merck manual of geriatrics. Whitehouse Station, NJ: Merck Research Laboratories, 2000:1000-152. 14. Soybel DI. Ileus and bowel obstruction. In: Greenfield LJ, Mulholland M, Oldham KT, Zelenock GB, Lillemoe KD (eds). Surgery, scientific principles and practice (2nd ed). Lippincott-Raven 1997:817-31. 15. Bickerstaff LK, Hollier LH, Van Peenen HJ, Melton LJ 3rd, Pairolero PC, Cherry KJ. Abdominal aortic aneurysms: The changing natural history. J Vasc Surg 1984; 1(1):6-12. 16. Silen W. Pitfalls to avoid when evaluating severe abdominal pain. J Crit Illness 1992; 7(5):685-9. 17. Clinical policy: Critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. American College of Emergency Physicians. Ann Emerg Med 2000; 36(4):406-15. 18. Ellenhorn MJ. Principles of poison management. In: Ellenhorn MJ, Barceloux DG (eds). Ellenhorns medical toxicology: Diagnosis and treatment of human poisoning (2nd ed). Baltimore: Williams & Wilkins, 1997:3-46. 19. Harari D. Constipation in the elderly. In: Hazard WR, Blass JP Ettinger, Jr. WH, , Halter JB, Ouslander JGH (eds). Principles of geriatric medicine and gerontology (4th ed). New York: McGraw-Hill, 1999:1491-1505. 20. Varma JS, Bradnock J, Smith RG, Smith AN. Constipation in the elderly. A physiologic study. Dis Colon Rectum 1988; 31(2):111-5. 21. Ratzan RM, Donaldson MC, Foster JH, Walzak MP The blue scrotum sign of . Bryant: A diagnostic clue to ruptured abdominal aortic aneurysm. J Emerg Med 1987; 5(4):323-9.

References
1. Powers RD, Guertler AT. Abdominal pain in the ED: Stability and change over 20 years. Am J Emerg Med 1995; 13(3): 301-3. 2. Cooper GS, Shlaes DM, Salata RA. Intraabdominal infection: Differences in presentation and outcome between younger patients and the elderly. Clin Infect Dis 1994; 9(1):146-8. 3. Kizer KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med 1998; 16(4):357-62. 4. Marco CA, Schoenfeld CN, Keyl PM, Menkes ED, Doehring MC. Abdominal pain in geriatric emergency patients: Variables associated with adverse outcomes. Acad Emerg Med 1998; 5(12):1163-8. 5. Fenyo G. Acute abdominal disease in the elderly: Experience from two series in Stockholm. Am J Surg 1982; 143(6):751-4. 6. Brewer BJ, Golden GT, Hitch DC, Rudolf LE, Wangensteen SL. Abdominal pain. An analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg 1976; 131(2):219-23. 7. Bugliosi TF, Meloy TD, Vukov LF. Acute abdominal pain in the elderly. Ann Emerg Med 1990; 19(12):1383-6. 8. Dunne ML, Strauss RW. Approach to the elderly patient. In: Judd RL, Warner CG, Shaffer MA (eds). Geriatric Emergencies. Aspen Publishers 1986:1-10. 9. Telfer S, Fenyo G, Holt PR, de Dombal FT. Acute abdominal pain in patients over 50 years of age. Scand J Gastroenterol Suppl 1988; 144:47-50.

Diagnosing the cause of acute abdominal pain in the older patient can be complicated, but the process can be streamlined by focusing on basic clues from the patient history and physical exam and the most conspicuous signs and symptoms. The goal is to assign the condition to one of four classificationsperitonitis, bowel obstruc42

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