Abdominal Pain vs. Chest Pain in the Elderly

2 patients present to the ED at the same time.

• In room 1, there is an 80 year old male. T 37.0, HR 70, BP 120/80, RR 20, spO2 99%. The chief complaint is "abdominal pain".
• In room 2, another 80 year old male. T 37.0, HR 70, BP 120/80, RR 20, spO2 99%. The chief complaint is "chest pain".

Which patient is more likely to be sick and have a an acute life threatening illness?

Which patient is more likely to be hospitalized?

• Chest pain in the elderly (>75 years old): 77% are admitted (1)
• Abdominal pain in the elderly (>60 years old): 60% are admitted (2)

Which patient has the greater likelihood of undergoing an operative or invasive procedure?

• Abdominal pain in the elderly (>60 years old): 20% undergo operative or invasive procedures (2, 3)
• Chest pain in the elderly (>75 years old): 20% undergo cardiac catheterization. (1)

Which patients has the greater likelihood of 14 day mortality?

• Chest pain in the elderly (>75 years old): 2.7% 14 day mortality (1)
• Abdominal pain in the elderly (>60 years old): 5% 14 day mortality (2, 3)

14 day mortality for elderly patients presenting with abdominal pain is 5%!

Elderly patient presenting with abdominal pain in the ED is 1.85 times as likely to die in the next 14 days compared to the elderly patient with chest pain. Yet the ESI level for a chest pain patient is generally 2, while the ESI level for abdominal pain is 3.

There is little you can do prior to imaging to predict the likelihood of an acute life threatening etiology as well.

• Regarding vital signs:
  • Fever is often absent despite a serious bacterial infection or surgical condition (4)
  • Elderly patients often have suppressed tachycardia from medications or intrinsic cardiac disease (5)
• With labs:
  • WBC often normal despite a surgical condition (4)
• On physical exam, elderly patients have:
  • An altered pain perception from chronic pain medications; coexistent disease (5)
  • A four times higher likelihood of hypothermic response with a significant intra-abdominal process lower likelihood of localized tenderness despite a focal surgical condition (5)
  • Reduced rebound and guarding from decreased abdominal wall musculature (5)

Summary

Abdominal pain in the elderly is more likely to be life threatening compared to chest pain in the elderly. In addition, there's no great way to be reassured based on vitals, laboratory findings, or physical exam alone. Given this, it is important to have a very low threshold to obtain CT imaging in the elderly patient presenting to the ED with abdominal pain and even if negative, have a low threshold to either have the patient admitted for observation or ensure close follow up and reassessment is available.

Update November 9

@cabreraERDR @cwangsgard as ED visits increase the percentage of serious CP is decreasing, but abd pain stay the same pic.twitter.com/PStaEctOxe

— Zack Repanshek (@ZackRepEM) November 9, 2014

References:

1. Han, Jin H., et al. "The elder patient with suspected acute coronary syndromes in the emergency department." Academic Emergency Medicine 14.8 (2007): 732-739.
2. Lewis, Lawrence M., et al. "Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study." The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60.8 (2005): 1071-1076.
3. Marco, Catherine A., et al. "Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes." Academic emergency medicine 5.12 (1998): 1163-1168.
4. Potts FE 4th, Vukov LF. Utility of fever and leukocytosis in acute surgical abdomens in octogenarians and beyond. J Gerontol A Biol Sci Med Sci. 1999;54:M55–8
5. Bryan ED, et. al. Abdominal Pain in Elderly Persons. (2013): eMedicine. Web. 4 Oct. 2014.