Acute Abdominal Pain in the Elderly: Diagnosis and Management

Diagnostic Approach

The American College of Radiology recommends computed tomography (CT) with intravenous contrast as the initial imaging study for all elderly patients with acute abdominal pain, as it allows for confirmation of diagnosis and distinction between complicated and uncomplicated conditions 1
The clinical presentation of acute abdominal pain in elderly patients is often atypical, with only 50% of patients over 65 years old with acute diverticulitis of the left colon presenting with pain in the lower quadrants, and only 17% presenting with fever 2
Laboratory and clinical findings can be normal despite severe infections, making diagnosis based solely on clinical evaluation difficult 3
CT of the abdomen and pelvis with intravenous contrast is essential, as clinical diagnosis may be unsuspected before CT in up to 43% of cases, with significant difficulty in diagnosing conditions such as diverticulitis 1

CT with intravenous contrast is the first-line imaging modality for acute abdominal pain in elderly patients, regardless of leukocyte and PCR values 1
Alternatives in case of contraindication for intravenous contrast (severe renal disease or contrast allergy) include ultrasound 1, magnetic resonance imaging 4, and non-contrast CT 1

For right upper quadrant pain, ultrasonography is the initial study (especially for suspected cholecystitis) 5, 6
For lower right or left quadrant pain, CT with contrast is the initial study (especially for suspected diverticulitis or appendicitis) 5, 7
For generalized or non-localized abdominal pain, CT with contrast is used to evaluate multiple organ systems 3

Common pathologies include acute cholecystitis, intestinal obstruction, pancreatitis, renal colic, perforated peptic ulcer, cancer, and diverticulitis 3
Other causes include pneumonia, hepatobiliary disease, complicated pancreatic processes, nephrolithiasis, gastrointestinal perforation or inflammation, intestinal infarction, and abdominal abscesses 3

CT influences treatment plans in 65% of elderly patients with acute abdominal pain, with changes in surgical management in 48% of these cases 1
The presence of distant intraperitoneal air on CT is a significant parameter that correlates with surgical management of colonic diverticulitis 2
Conventional radiography has limited diagnostic value in the evaluation of patients with acute abdominal pain 5, 4

Do not rely solely on inflammatory markers (PCR, leukocyte count) to rule out severe pathology, as they can be normal despite severe infections in elderly patients 3, 2
The prevalence of chronic kidney disease is high in elderly patients (39.4% in people over 60 years old), but this should not discourage the use of CT with contrast when necessary, as the benefit of rapid diagnosis generally outweighs the risk of contrast-induced acute kidney injury 1
Recent studies suggest that the risk of contrast-induced acute kidney injury may be lower than previously thought, even in patients with chronic kidney disease 1
Consider that up to 39% of patients with complicated diverticulitis episodes may have PCR levels below the optimal threshold (175 mg/l), so a low PCR level does not exclude complicated diverticulitis 2