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Acute abdominal pain among elderly patients
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences. (Gastrointestinal Surgery)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences. (Gastrointestinal Surgery)
2006 (English)In: Gerontology, ISSN 0304-324X, E-ISSN 1423-0003, Vol. 52, no 6, 339-344 p.Article in journal (Refereed) Published
Abstract [en]

Background: Diagnosis of acute abdominal pain in older persons is a challenge, with the age-related increase in concurrent diseases. In most western countries the number of elderly people is constantly rising, which means that an increasing proportion of patients admitted for abdominal pain at the emergency department are elderly. Objective: To characterize differences in clinical presentation and diagnostic accuracy between younger and more elderly patients with acute abdominal pain. Methods: Patients admitted to Mora Hospital with abdominal pain of up to seven days' duration were registered according to a detailed schedule. From 1st February 1997 to 1st June 2000, 557 patients aged 65-79 years and 274 patients aged ≥80 years were registered. Patients aged 20-64 years (n = 1,458) served as a control group. Results: A specific diagnosis, i.e. other than 'non-specific abdominal pain', was established in 76 and 78% of the patients aged 65-79 and ≥80 years respectively, and in 64% of those aged 20-64 (p < 0.001). Pain duration before admission increased with age (p < 0.003), as did frequency and duration of hospitalization (p < 0.0001). Hospital stay increased from 170 days per 100 emergency admissions in the control group to 320 and 458 days in the younger and older study groups, respectively. At the emergency department, older patients were more often misdiagnosed than control patients (52 vs. 45%; p = 0.002). At discharge the diagnosis was more accurate in the control group (86 vs. 77%; p < 0.0001). Hospital mortality was higher among older patients (23/831 vs. 2/1,458; p < 0.001). The admission-to-surgery interval was increased (1.8 vs. 0.9 days, p < 0.0001) in patients ≥65 years. Rebound tenderness (p < 0.0001), local rigidity (p = 0.003) and rectal tenderness (p = 0.004) were less common in the older than in the control patients with peritonitis. In patients ≥65 years, C-reactive protein did not differ between patients operated on and those not, contrary to the finding in patients <65 years (p<0.0001). Conclusion: Both the preliminary diagnosis at the emergency department and the discharge diagnosis were less reliable in elderly than in younger patients. Elderly patients more often had specific organic disease and arrived at the emergency department after a longer history of abdominal pain compared to younger patients.

Place, publisher, year, edition, pages
2006. Vol. 52, no 6, 339-344 p.
Keyword [en]
Acute abdominal pain, Decision making, Diagnosis, Morbidity, Mortality
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-94907DOI: 10.1159/000094982ISI: 000241816800002PubMedID: 16905885OAI: oai:DiVA.org:uu-94907DiVA: diva2:168925
Available from: 2006-09-22 Created: 2006-09-22 Last updated: 2011-05-17Bibliographically approved
In thesis
1. Acute Abdominal Pain
Open this publication in new window or tab >>Acute Abdominal Pain
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim was to identify diagnostic difficulties for acute abdominal pain at the emergency department and during hospital stay. A total of 3349 patients admitted to Mora Hospital with acute abdominal pain of up to seven days duration, were registered prospectively for history and clinical signs according to a structured schedule. The preliminary diagnosis from the attending physician at the emergency department, any investigations or surgery and final diagnosis were registered at a follow-up after at least one year.

There were no differences in diagnostic performance between physicians with 0.5 to 5 years of medical experience. The information collected and a careful examination of the patient was more important than formal competence. The main differential diagnostic problem was non-specific abdominal pain; this was the same for diagnoses requiring surgery. Patients originally diagnosed as not needing surgery had a median delay before operation of 22 hours (mean 40 hours, with 95% confidence interval of 30-50 hours), compared to 8 hours (mean 15 hours, 95% confidence interval of 12-28 hours) for patients with the same final follow-up diagnosis as the preliminary diagnosis. Constipation was a diagnostic pitfall, as 9% of the patients considered constipated required surgery for potentially life threatening reasons and 8% were later found to have an abdominal malignancy. Both the preliminary diagnosis and the discharge diagnosis were less reliable for elderly patients than for younger patients. Elderly patients often had specific organ disease and arrived at the emergency department after a longer history of abdominal pain.

This study confirms that assessment of suspected appendicitis can still be based on clinical judgements combined with laboratory tests. Classical clinical findings indicating localised inflammation, such as isolated pain in the right iliac fossa, rebound tenderness, right-sided rectal tenderness, pain migration to the right iliac fossa, local guarding and aggravation of pain when moving, were reliable for predicting acute appendicitis. A CT scan can be saved for the more equivocal cases of acute abdominal pain. A generous strategy regarding CT scan among elderly patients with acute abdominal pain, even in the absence of pronounced signs of an inflammatory intra-abdominal process, is recommended.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2006. 72 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 174
Keyword
Surgery, acute abdominal pain, diagnostic pitfalls, decision-making, competence, sensitivity, specificity, high age, acute appendicitis, Kirurgi
Identifiers
urn:nbn:se:uu:diva-7161 (URN)91-554-6664-8 (ISBN)
Public defence
2006-10-13, Enghoffsalen, Thoraxcentrum, ingång 50, Akademiska sjukhuset, Uppsala, 13:15
Opponent
Supervisors
Available from: 2006-09-22 Created: 2006-09-22 Last updated: 2011-06-10Bibliographically approved

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Laurell, HelenaGunnarsson, Ulf

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