THE MERCK MANUAL OF GERIATRICS, Ch. 112, Acute Abdomen and Surgical Gastroenterology

Section 13. Gastrointestinal Disorders
Chapter 112. Acute Abdomen and Surgical Gastroenterology
Topics: Introduction \| Gastrointestinal Bleeding \| Disorders of the Lower Esophagus \| Intestinal Obstruction \| Ischemic Syndromes \| Diaphragmatic Hernia \| Inguinal Hernia \| Disorders of the Jejunum and Ileum \| Appendicitis \| Disorders of the Colorectum \| Disorders of the Gallbladder and Biliary Tree \| Disorders of the Liver \| Disorders of the Pancreas \| Disorders of the Spleen

Introduction

Surgical problems of the abdomen are different in many ways in elderly patients compared with those in younger patients. Diagnosis, particularly in emergencies, is more difficult because sensation is not as acute as in younger patients, and pathophysiologic reactions (eg, pain, tenderness, response to inflammation) are not as quick or effective. Thus, minimal symptoms may accompany a potentially fatal intestinal perforation, and the first sign may be free subphrenic gas on a plain abdominal x-ray.

Acute abdomen should be suspected in patients who complain of only minimal abdominal pain. Peritonitis caused by perforation of the sigmoid, stomach, or duodenum may be present even if the patient has only slight abdominal tenderness. Vascular lesions (eg, mesenteric artery thrombosis) also are common. With appendicitis, acute cholecystitis, and strangulated hernias, the interval between onset and gangrene may be only a few hours.

The physical examination is extremely important. Old incisional scars raise the likelihood of intestinal obstruction. An examination of potential hernia sites is essential. Absence of bowel sounds indicates aperistalsis, a serious finding that requires other diagnostic tests be performed expeditiously.

The major indications for emergency surgery are perforation of a viscus, appendicitis, intestinal obstruction, and massive hemorrhage. Acute cholecystitis often requires urgent surgery.

Most elective surgery is for malignant disease. Excluding hernia repairs, > 90% of abdominal procedures involve the colon, gallbladder, and stomach; with effective medical treatment for peptic ulcer disease, operations on the colon and gallbladder now predominate.

Generally, the elderly tolerate a single operation well, provided the offending lesion is removed. However, complications from second or third operations performed soon after the first carry a high mortality rate. Staged procedures should be spaced apart to allow complete recovery. These considerations are particularly important in gastrointestinal (GI) disorders.