Aging Begins at 30

Abdominal Emergencies in the Elderly

A neighbor of ours aged 86 was struck down with abdominal pain in Geneva, Switzerland. Another friend, a physician, went with him to the Emergency Room and insisted on close monitoring as an inpatient instead of returning to his hotel room. A few hours later he was operated on and found to have a gangrenous (blackened and blood deprived) perforated appendix. His life was saved. The majority of recent fatalities from appendicitis have occurred in geriatric patients.

The diagnosis of acute abdominal emergencies in the elderly can be difficult. Fever, lower abdominal pain, vomiting, and typical right lower abdominal pain in appendicitis occurs in half or a quarter as many elderly as is found in children and young adults. In contrast perforation and abscess are twice as common in the geriatric patient.

Emergency abdominal operations are defined as those that can't wait for the next routine operating list. A quarter of these operations are in people over 80.

Abdominal emergencies that occur in people from 75 to 100 or more (average age 82) are strangulated hernia (20%), intestinal obstruction (25%). Figures vary but 10-30% of these emergencies involve problems with the gallbladder. About 15% have acute appendicitis. Five to ten percent in each group of patient's bleed, perforate an ulcer or a diverticulum (a large bowel pouch). A serious emergency in about 2% is rupture of an abdominal aneurysm or a main artery blow-out. A majority of young people with acute abdominal emergencies have appendicitis (80%) or gynecological complications.

Diagnosis can be difficult as clear cut symptoms (your problems) and signs (what the doctor finds on examination) are often absent and about half arrive at the hospital with non-specific vague abdominal pain. There are delays before getting to the hospital and delays after the elderly get to the hospital. The elderly have many other medical problems that add to or confuse the initial presentation. Vital signs and lab tests may be muted but anyone with a rapid pulse is in trouble. The important matter is not to procrastinate but to reach a diagnosis rapidly and operate immediately after the patient has been stabilized with nasogastric suction and I.V. fluids. Mental deterioration can affect as many as 20% of those over 80 adding to the doctors diagnostic difficulties.

In most operations in the over 75's the mortality rate is about double that in the middle aged. Looked at another more optimistic way, a survival rate of 95% in the young is reduced to 90% in the old. Generalized infection (often from delay in going to the hospital) or cancer can increase the death rate. Elderly patients who die post-operatively usually have pre-existing lung trouble, pneumonia, heart attack, heart failure or lungs damaged by wandering clots (pulmonary emboli).

I have a good follow-up on our neighbor as he is alive and well five years after his abdominal surgery. If you are not happy with an emergency room diagnosis ask for a second opinion.

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See related Patient Topics Abdominal Pain, Appendicitis, Brain and Nervous System, Digestive System, Pain or Symptoms and Manifestations.

See related Provider Topics Abdominal Pain, Appendicitis, Brain and Nervous System, Digestive System, Pain or Symptoms and Manifestations.

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