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Three Part Question

In [elderly patients presenting to Emergency Departments with non traumatic abdominal pain] what [factors] are associated with [poor prognosis]?

Clinical Scenario

An 87 years old man presents to the Emergency Department with acute onset of central abdominal pain.. The pain is mild and was relieved by simple analgesia. you noticed that he had a temp of 37.8 and whit cell count of 13,000 with elevated neutrophil count. examination revealed no tenderness, guarding or rigidity and there was no masses but bowel sounds were sluggish. You wonder if this patient can go home or need to be admitted for observation and if so why?. The patient's medical history included hyperlipaedemia, hypertension, and that he is a smoking 10 cigarettes every day for the past 55 years..

Search Strategy

Midline,CINAHL,EMBASE search using OVID interface (1950- September 2013)
Using Elderly OR Old age OR Above 65 years OR Geriatrics
AND Risk Factors.
AND Abdominal pain
Limit search to English language and human studies.
We also searched Google scholar for related literature

Search Outcome

66 papers were identified of which 4 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Parker JS et al 1996 USA	231 patients with acute non traumatic abdominal pain 65 years old or above attended ED of a large tertiary care centre.	Retrospective analysis of emergency department and hospital case notes over one year period.	51 patients were discharged from the emergency department, 94 were admitted without subsequent operation, and 86 were admitted directly for operation or had an operation during hospitalization. For all factors, a statistically significant difference was seen between the patients discharged and those admitted. However, the presence or absence of abnormal test values (haemoglobin, alkaline phosphatase, aspartate aminotransferase, bilirubin, lactate, and the degree of fever and leukocytosis) did not distinguish those who were admitted and did not require operation from those who needed surgery.	1. Temperature and laboratory screening tests for evaluation of abdominal pain in the elderly do not differentiate admittable, nonsurgical disease from surgical disease.2. There was a statistically significant difference in values in temperature, lab tests between those who were admitted and those who were discharged. 3.13% of patients who had surgical intervention also had normal temperature and blood counts.	Retrospective study of case notes with all excepted problems with missing data. Blood tests done were not detailed or comprehensive. No clear inclusion or exclusion criteria. The observed difference between the admitted group and the discharged group regarding blood test may be due to physician deciding to admit based on those tests rather than these tests reflecting sicker patients
Marco, C. A, 1998, USA	380 elderly patients (aged 65 years and older) presenting with non traumatic acute abdominal pain to the emergency department	longitudinal case series. eligible patients were identified and their case notes were reviewed daily. They were followed up by telephone interview and medical records review to determine final diagnosis.	Variables associated with adverse outcomes (death and need for surgical intervention) included hypotension, abnormalities on abdominal radiography, leukocytosis, abnormal bowel sounds, and advanced age or pyrexia.	Most physical examination findings were not helpful in identifying patients with adverse outcomes. The majority of patients admitted especially with high temperature, high white cell count or reduced bowel sounds	Retrospective study with missing data. missing data considered normal when analysis undertaken. Telephone follow up to determine outcome and final diagnosis may have resulted in errors as many patients might not know correct details.
Gardner RL, 2010 USA	131 consecutive patients aged 70 years or older presenting with non traumatic acute abdominal pain. evaluated, 60% were women 40%were men.	Observational cohort study of ED and hospital case notes comparing men and women regarding presentation, interventions and outcomes. Mortality data obtained from social security death index.	Men had a higher rate of death within 3 months of the visit (19% vs. 1%, respectively, p < 0.001). There was no difference between the groups in waiting time to be seen in ED,length of stay in ED,diagnostic tests used, admission rate or surgical referral.	Despite similarities in the clinical journey, men are at higher risk of dying from non traumatic abdominal pain than women.	The use of age of 70 years old as cut point for definition of elderly. Small sample size however the authors tried to justify that they have powered the study to detect high difference between the groups (25%)
Laurell H 2006 Sweden	Patients with acute non traumatic abdominal pain . Group 1. 557 patients aged 65-79 years Group 2. 274 patients aged 80 years old or more. Group 3. 1458 patients aged 20-64 years old served as a control group.	Prospective observational study of ED and admission case notes with follow up through hospital records at least 1 year after admission.	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 > or = 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 > or = 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).	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. Pain duration before admission increased with age p<0.003. Frequency and duration of admission increased with age p<0.0001. Older patients more frequently misdiagnosed than younger patients p< 0.001.	No standard follow up period. High proportion of women in the control and very old group.

Comment(s)

The available evidence suggest that men are at more risk of dying from non traumatic abdominal pain than women. Older age associated with more misdiagnosis, more frequency and length of admission. Patients with high temperature or abnormal blood are more likely to be admitted but no differential to who will have surgery or invasive procedure.

References

1. Parker JS, Vukov LF, Wollan PC. Abdominal pain in the elderly: use of temperature and laboratory testing to screen for surgical disease. Fam Med 1996 Mar;28(3):193.-7.
2. 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;5:1163–8.
3. Gardner RL, Almeida R, Maselli JH, Auerbach A. Does gender influence emergency department management and outcomes in geriatric abdominal pain? J Emerg Med. 2010 Sep;39(3):275-81.
4. Laurell H, Hansson LE, Gunnarsson U. Acute abdominal pain among elderly patients. Gerontology. 2006;52(6):339-44.