What is the leading cause of the acute
surgical abdomen in the elderly population?
A. Appendicitis
B. Biliary tract disease
C. Diverticulitis
D. Peptic ulcer disease
E. Pancreatitis
A 70-year-old patient with a history of diabetes and
hypertension presents to the emergency department
with syncope and severe sudden onset of low back
pain. Vital signs: BP 80/50,P 120,R24,T37 C. The
most appropriate initial diagnostic test is:
A.
B.
C.
D.
Angiogram
Ultrasonography
CAT scan of the abdomen
Magnetic resonance cholangiopancreatography
(MRCP)
E. Supine obstruction series
Which of the following statements is true
regarding abdominal pain in the elderly?
A. White blood cell counts are specifically elevated in
the acute abdomen.
B. Lactate elevations are not an early sign of mesenteric
ischemia.
C. Lipase elevation is a specific test for pancreatitis.
D. Positive fecal occult blood testing is specifically
useful.
E. Amylase elevation is a non-specific test for
pancreatitis.
Acute Geriatric Abdomen
Wayne Tamaska, D.O., FACOI, FACOEP
Acute Geriatric Abdomen
This Care of the Aging Medical Patient in
the Emergency Room (CAMPER)
presentation is offered by the Department of
Emergency Medicine in coordination with the
New Jersey Institute for Successful Aging.
This lecture series is supported by an educational grant from the
Donald W. Reynolds Foundation Aging and Quality of Life
program.
• According to the US Census Bureau, one in
eight Americans are elderly (over the age of 64).
• By the year 2030, one in five Americans will be
elderly.
U.S. Census Bureau, 2006.
• The elderly patient who has abdominal pain
consumes more time and resources than any
other emergency department patient
presentation.
• Their length of stay is 20% longer than younger
patients.
• They require admission half the time.
• They require surgical intervention one third of
the time.
Kizer KW, Vassar MJ. Am J Emerg Med 1998;16(4):357-362.
Brewer RJ, Golden GT, Hitch DC, et al. Am J Surg 1976;131(2):219-223.
• The overall mortality for elderly emergency
department patients with a chief complaint of
abdominal pain exceeds 10%, rivaling that of an
acute ST elevation MI.
Kizer KW, Vassar MJ. Am J Emerg Med 1998;16(4):357-362.
Difficulties In Diagnosing The Elderly
• History: dementia, stroke with aphasia, hearing
and vision loss.
• Altered pain perception.
• Medications that interfere with diagnosis.
• Lack of fever and leukocytosis.
• Co-morbid medical conditions.
• Atypical presentations.
Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.
Difficulties In Diagnosing The Elderly
• Fever tachycardia and hypotension may be
absent even in the seriously ill.
• Guarding and rigidity may be lacking because of
the laxity in abdominal wall musculature.
• 21% of patients older than 70 with a perforated
ulcer present with epigastric rigidity.
Fenyo G. Am J Surg 1982;143(6):751-754.
Medications That Interfere With
Diagnosis
• NSAIDs block inflammatory response and decrease
the degree of abdominal tenderness and contributes
to peptic ulcer disease.
• NSAIDs and APAP diminish febrile response.
• Narcotics can blunt the pain response.
• Beta blockers and negative chronotropes blunt
tachycardia.
• Normal blood pressure may not reflect the relative
hypotension in patients with chronic hypertension.
Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.
Differential Diagnosis Of Abdominal
Pain In The Elderly
•
•
•
•
•
•
•
•
Cholecystitis
Nonspecific abdominal pain
Obstruction
Hernia
Appendicitis
Diverticular disease
Perforation
Pancreatitis
•
•
•
•
•
•
•
•
12-41%
9.6-23%
7.3-14%
4-9.6%
2.5-15.2%
3.4-7%
2.3-7%
2-7.3%
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition. Philadelphia, PA:
Mosby Elsevier, 2009.
History: High Yield Questions
• Age : advanced age means increased risk.
• Which came first pain or vomiting: pain first is
worse( more likely surgical)
• Surgical history: obstruction more likely.
• Pain constant or intermittent: constant worse.
• Previous episodes: no prior episodes worse.
• History: Cancer, diverticulosis, pancreatitis, kidney
failure, gallstones, or inflammatory bowel disease.
All suggest more serious disease.
• Alcohol: consider pancreatitis, cirrhosis, hepatitis.
Colucciello SA, Lukens TW, Morgan DL. Emergency Medicine Practice 1999;1(1):1-20.
High-Yield Questions
• HIV status: drug-related pancreatitis.
• Antibiotics or steroids: May mask infection.
• Did pain starts centrally and migrate to RLQ:
appendicitis.
• Vascular , heart disease, hypertension, atrial
fibrillation: consider mesenteric ischemia or
abdominal aortic aneurysm.
Colucciello SA, Lukens TW, Morgan DL. Emergency Medicine Practice 1999;1(1):1-20.
Physical Examination
• Ill appearing verses well appearing.
• Well appearing patients may still have a serious
medical condition.
• Fever, tachycardia, and hypotension may be
absent in the elderly.
• Guarding and rigidity may be absent .
• The location of tenderness is generally a reliable
guide to the cause of pain.
Physical Examination
• Examined the skin for signs of herpes zoster,
Cullen’s or Grey Turner’s sign.
• Auscultate for bowel sounds and bruits.
• Rectal exam may be useful in diagnosing bowel
ischemia, GI malignancies and bleeding.
Laboratory Testing
• Many tests are nonspecific in the elderly.
• White blood cell count may be normal even in
the seriously ill.
• Lipase level is specific for pancreatitis.
• Lactate levels are helpful in diagnosing
mesenteric ischemia.
Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.
Radiographs
• Abdominal radiographs are of limited value.
• May identify obstruction, free air, or abdominal
aortic calcifications.
Abdominal Ultrasound
• Most useful in evaluating gallbladder and pelvic
organs.
• Bedside ultrasonography is most useful in
evaluating for abdominal aortic aneurysm in
hypotensive patients.
Computerized Tomography
• CT scanning has become one of the most viable
tools in diagnosing acute abdomen and the
elderly.
• CT angiography is replacing traditional
angiography in diagnosing mesenteric ischemia.
• Limitations include those with contrast allergies
and those with renal insufficiency.
Case Number 1
• A 73-year-old female presents with nausea
vomiting and progressive abdominal pain over
the past two days.
• Vital signs: BP 90/60 , P88,R 24,T 38C
• PMH: Hypertension, Hyperlipidemia, TIA.
• PSH: Appendectomy, hysterectomy, partial
colectomy.
• Meds: Metoprolol, Atorvastatin, Aspirin.
Physical Exam
• Ill appearing 72-year-old with active vomiting.
• Heart: RRR 1/6 SEM LSB, Lungs: Diminished breath
sounds bases
• Abdomen: distended, high pitched bowel sounds, diffuse
nonspecific tenderness, no rebound, no bruits, no
hernias.
• Skin: Dry mucus membranes, no rashes
• Neurologic: Awake alert and oriented, nonfocal.
• Extremities: +1 edema, symmetric pulses.
• Rectal exam: No masses, heme positive brown stool.
Laboratory Values
• WBC 12,000
• HB 9.9
• SMA 7: Na 150,K 4.8,CL 105,CO2 18,BUN 33,
Creat 2.8
• LFTS: T.Bili 2.0,AST 44,ALT 50
• Amylase 200, Lipase 34
• UA: SG 1.030,20 WBC,10 RBC, Nitrate pos
Differential Diagnosis?
Abdominal Radiograph
Image Source: Kennedy Health Systems
Diagnoses?
Small Bowel Obstruction
Discussion
• Tachycardia lacking due to beta blockade.
• WBC, Amylase, Bilirubin nonspecific in this
case.
• IV contrast CT scan limited with renal
insufficiency.
• Elderly may have more extensive past surgical
history which predisposes the patient to greater
risk of bowel obstruction.
Bowel Obstruction
• SBO :The most common cause for emergent
surgical intervention in the elderly.
• LBO : Less common then SBO. Prevalence
increases with age.(Colon cancer, diverticulitis)
• Sigmoid and cecal volvulus also cause LBO.
• Most cases of LBO must be managed by surgical
intervention, but some cases of volvulus may be
decompressed by endoscopy.
Case Number 2
• An 85-year-old man presents to the emergency
department after syncopal episode. The patient
complains of sudden onset of abdominal and back
pain.
• Vital signs: BP 95/50, P 120, R 24,T 38C.
• PMH: Hypertension, diabetes, hyperlipidemia,
prostate cancer.
• PSH: Prostatectomy, appendectomy.
• Medications: Captopril, ASA, Glucophage, Niacin
Physical Exam
• Uncomfortable, ill appearing, 85-year-old male
writhing in pain.
• Heart: Reg 120 no murmur
• Lungs: Clear
• Abdomen: Distended, obese, mild diffuse
tenderness, no rebound. No bruits.
• Extremities: No edema, cool with cyanosis and
decreased pulses.
Laboratory Testing
• WBC 15,000
• HB 8.0
• SMA 7;Na140,K4.8,Cl 100,CO2 18,BUN
22,Creat 1.5
• LFTS: Bili 1.4,AST 55,ALT 60.Amylase
160.Lipase 55
Differential Diagnosis ?
Bedside Ultrasonography
Image Source: Cooper Health Systems
Bedside Ultrasonography
Image Source: Cooper Health Systems
Diagnosis
Ruptured Abdominal Aortic Aneurysm
Image Source: Kennedy Health Systems
Discussion and Management
Abdominal Aortic Aneurysm
• Syncope can be an ominous sign in the elderly.
• One should always consider aortic aneurysm in
any geriatric patient presenting with back pain.
• Any patient over the age of 55 with
cardiovascular risk factors who presents to the
emergency department with a complaint of back
pain should have their aorta visualized by
ultrasound or CAT scan.*
*Emergency Medicine Reports
Abdominal Aortic Aneurysm
•
•
•
•
•
Early recognition
Aggressive resuscitation
Early vascular surgical intervention
Utility of bedside ultrasonography
Don’t wait for a CAT scan diagnosis to mobilize
vascular surgical intervention
Case Number 3
• An 85-year-old male presents to the emergency
department with increasing postprandial
abdominal pain.
• Vital signs: BP 180/95,P 120,R 26,T 39 C
• PMH: A Fib, PVD, HTN, DM
• PSH: Fem Pop Bypass, CEA, Appendectomy.
• Meds: Digoxin, Warfarin, Metoprolol,
Metformin, Aspirin.
Physical Exam
• 85 year old ill appearing male in considerable
pain.
• Heart: irregularly irregular 120
• Lungs: CTA
• Abdomen: Diffuse nonspecific tenderness,
abdominal bruit present. Guarding present
• Neurologic: Confused, non-focal.
• Extremities: +1 edema. Diminished pulses.
Laboratory Data
• WBC: 18,000
• Hb: 12
• SMA-7: Na148,K 5.0.CL 100,CO2
16,BUN25,Creat 1.6.Glucose 380
• LFTS: Normal
• Amylase: 400,Lipase: 60
• Lactate: 6.0
• INR: 1.4
• Digoxin : 1.9
Radiograph
Image Source: Kennedy Health Systems
Differential Diagnosis
CAT Scan Findings
Image Source: Kennedy Health Systems
Diagnosis: Intestinal Ischemia
• Rare disorder: less than 1/1000 hospital
admissions.
• High mortality: 30% to 90%.
• Mortality is dependent on time of diagnosis.
• Mortality approaches 100% when the diagnosis
is delayed greater than 24 hours.
Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.
Clinical Diagnosis
•
•
•
•
Pain out of proportion of the exam.
Rebound is initially absent.
When rebound is present the prognosis is poor.
The patients may present with: nausea, vomiting,
diarrhea.
• The elderly may present with less abdominal
pain and other signs such as tachypnea and
mental status changes.
Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.
Laboratory Data
• Really nonspecific
• Leukocytosis, elevated amylase, metabolic
acidosis, elevated AST and alkaline phosphatase,
hyperphosphatemia.
• Elevated lactic acid is helpful but is often a late
indicator.
Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.
Radiographic Studies
• Plain radiographs are often normal early on.
• Thumb printing is a late sign.
• Angiography is the gold standard.( 74-100%
sensitivity; 100% specificity.
• Standard CT has a sensitivity of 64%.
• CT Angiography may replace traditional
angiography. Some studies show a 96%
sensitivity.
Cangemi JR, Picco MF. Gastroenterol Clin N Am 2009;38(3):527-540.
Discussion
Case Number 4
• A 60-year-old male presents with postprandial
nausea vomiting and epigastric pain without
radiation.
• Vital signs: BP 90/55, P 80, R 24, T 37C
• PMH: hypertension, hyperlipidemia, PUD.
• PSH: Repair of a perforated gastric ulcer.
• Medications: Clonidine, aspirin, Omeprazole.
Physical Exam
• A 60-year-old male presents diaphoretic and
uncomfortable appearing.
• Heart: RRR no M.
• Lungs: CTA
• Abdomen: epigastric tenderness, soft, no
rebound, no guarding, no bruits.
• Extremities: no clubbing, cyanosis, or edema.
Pulses symmetric.
• Rectal exam: Brown stool heme positive.
Laboratory Data
• WBC 10,000
• HB 11
• T. Bili 2.0,ALT 40,AST 65,Amylase 150,Lipase
60.
• Na 134,K4.0,CL98,CO2 24,BUN 25,Creat
1.4,Glucose 190
Radiographic Studies
Image Source: Kennedy Health Systems
Discussion and Differential
Diagnosis
Diagnosis
Image Source: Kennedy Health Systems
Diagnosis: Acute Inferior Wall
Myocardial Infarction
Discussion
• Have a low threshold for ordering an EKG on any
elderly patient that presents with an abdominal
complaint.
• The incidence of atypical presentations of acute
myocardial infarction increases with age.
• Elderly patients may present without any chest pain.
• The elderly may present with flulike symptoms, nausea,
vomiting, or syncope.
Marx JA, et al.. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition, 2009.
Case Number 5
• A 60-year-old female presents with severe
postprandial epigastric pain. The patient has
had several episodes over the past few months
but not sought medical attention until today.
• Vital signs: BP 135/85, P 110, R 22,T 37.5C
• PMH: hyperlipidemia, osteoarthritis.
• PSH: hysterectomy.
• Medications: Ibuprofen.
Physical Exam
• To 60 year old female presents with moderate
epigastric discomfort that radiates to the back
with associated nausea and vomiting.
• Heart: tachycardia at 110 BPM
• Lungs: CTA
• Abdomen: tender epigastric and RUQ, guarding,
no rebound, no bruits, no CVAT.
• Extremities: no C/C/E. pulses symmetric.
Laboratory Data
•
•
•
•
•
WBC 15,000
Hb 14
T. bili 3.5, AST 125, ALT 150, Alk Phos 200
Amylase 300, Lipase 304
Na 140.K 4.0, CL 98, BUN 20, Creat 1.2,
Glucose 150
Electrocardiogram
Radiographic Studies
Image Source: Kennedy Health Systems
Differential Diagnosis
Diagnosis:
Gallstones/Gallstone Pancreatitis
• Biliary disease is the leading cause for acute abdominal
surgery in the elderly.
• When performed urgently and the elderly mortality rate is
increased fourfold.
• Cholelithiasis increases with age.
• Acalculous cholecystitis is increased in the elderly and
may not be readily apparent on ultrasound.
• Elderly patients may not have nausea and vomiting and
fever.
• Laboratory testing is also unreliable. Leukocytosis is
absent in 30 to 40% of the elderly.
Martinez JP, Mattu A. Emerg Med Clin N Am 2006;24(2):371-388.
Pancreatitis
• The most common nonsurgical abdominal condition
and the elderly
• Incidence increases 200-fold after age 65.
• Mortality approaches 40% after age 70.
• 10% of cases present with hypotension and altered
mental status in the elderly.
• The threshold for performing CAT scans and the
elderly when pancreatitis is suspected should be low.
Martinez JP, Mattu A. Emerg Med Clin N Am 2006;24(2):371-388.
Biliary Disease & Pancreatitis:
Diagnostic Tools
• Ultrasound is most useful in diagnosing biliary disease.
• The elderly have a higher incidence of acalculus
cholecystitis. HIDA scanning should be considered in
these patients.
• Laboratory findings may be absent in biliary disease in
the elderly. Lipase levels are helpful in diagnosing
pancreatitis.
• CAT scan is useful in diagnosing pancreatitis.
Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.
Case Number 6
• A 65-year-old male presents an increasing
nausea of vomiting and abdominal pain. The
pain preceded the vomiting.
• Vital signs: BP 100/70, P 100,R 20,T 37 C
• PMH: rheumatoid arthritis
• PSH: inguinal hernia repair, appendectomy,
cholecystectomy
• Medications: Prednisone, methotrexate.
Physical Exam
• A 65-year-old male presents with nausea and
vomiting. The patient is ill appearing, appears
uncomfortable.
• Heart: regular at 100BPM. No murmur.
• Lungs: CTA
• Abdomen: distended, diffusely tender, highpitched bowel sounds, no rebound, guarding
present, no masses or hernias palpable.
• Extremities: No C/C/E, pulses symmetric.
Laboratory Data
• WBC: 15,000
• Hb:15
• Na 150, K 5.0,CL 101, CO2 30, BUN 30,Creat
1.4, glucose 130.
• T. Bili 1.4, AST 44,ALT 45, amylase 150, lipase
40
• UA:SG >1.030,20 RBC/HPF
Radiograph
Image Source: Kennedy Health Systems
Discussion and Differential
Diagnosis
Large Bowel Obstruction
• Less common than small bowel obstruction.
• Prevalence rises with increasing age.
• Most common causes: Colon cancer,
diverticulitis, volvulus.
• Most require surgical intervention, however
sigmoid volvulus may be decompressed
endoscopically.
Yeh EL, McNamara RM. Clin Geriatr Med 2007;23(2):255-270.
Case Number 7
• Same clinical presentation physical exam and
laboratory data as the last case.
• Diagnose the case with the following substituted
radiograph.
Radiograph
Image Source: Kennedy Health Systems
CAT Scan
Image Source: Kennedy Health Systems
Discussion and Differential
Diagnosis
Perforated Viscus: Peptic Ulcer Disease
• An acute abdomen is the first presentation of
PUD in 50% of elderly patients.(1)
• Less than half of elderly patients have classic
acute onset of abdominal pain.(2)
• Rigidity is absent in nearly 80% of elderly
patients.(2)
• Free air is absent in 40% of plain radiographs.(3)
1.
2.
3.
Caesar R. Emergency Medicine Reports 1994;15:191-202.
Fenyo G. Am J Surg 1982;143(6):751-754.
McNamara R. In: Saunders AB, ed. Emergency Care Of the Elder Person. St. Louis, MO: Beverly Cracom Publications, 1996:219-243.
Case Number 8
• A 75-year-old female patient presents with
increasing lower abdominal pain nausea without
vomiting and low-grade fevers over three days.
• Vitals: BP120/80,P 100,R20.T37.8C
• PMH: hypertension
• PSH: hysterectomy
• Medications: hydrochlorothiazide
Physical Exam
• A non-toxic, uncomfortable appearing 75-yearold female.
• Heart: Reg 100. No M
• Lungs: CTA
• Abdomen: Soft bilateral lower quadrant
tenderness. Guarding in the lower quadrants.
No rebound. No bruits or masses. Bowel
sounds present but decreased.
• Extremities: No C/C/E. Pulses Symmetric.
Laboratory Data
• WBC 10,500
• HB 14
• Na 140,K 3.0,CL 100,CO2 23,BUN 15,Creat
1.2,Glucose 120
• Tbili 1.4,AST 44,ALT45,Amylase 120,Lipase 40.
• UA SG 1.030,40 WBC/HPF,30 RBC/HPF
Differential Diagnosis and
Discussion
Radiographic Study 1
Image Source: Kennedy Health Systems
Diagnosis: Diverticulitis (sigmoid)
Diverticular Disease
• Incidence: 50% in patients older than 70. 80% after
the age of 85.(1)
• Complications include: Abscess formation, bowel
obstruction, perforation, fistula, sepsis.
• Perforation is more common in the elderly it carries
a 25 percent mortality rate.(2)
• Clinically misdiagnosed 50% of the time.(3)
• Diverticular irritation of the urinary system may
produce hematuria pyuria, complicating the
diagnosis.
1.
2.
3.
Ferzoco L, Raptopoulos V, Silen W. N Engl J Med 1998;338(21):1521-1526.
Krukowski Z, Matheson NA. Br J Surg 1984;71(12):921-927.
Ponka JL, Welborn JK, Brush BE. J Am Geriatr Soc 1963;11:993-1007.
Case Number 9
• Same presentation as previous case with the
exception of the radiograph.
Radiographic Image
Image Source: Kennedy Health Systems
Differential Diagnosis And
Discussion
Diagnosis: Appendicitis
Appendicitis
• Thought to be a disease of young. It is the third
most common indication for abdominal surgery
in the elderly.(1)
• Less than one third of elderly patients have
fever, anorexia, RLQ pain, and leukocytosis.(2)
• Up to 1/5 of elderly patients present after three
days of symptoms.(5-10% after one week) (3)
• Mortality: General <1%. Elderly 4-8%.(4)
1.
2.
3.
4.
Kauvar DR. Clin Geriatr Med 1993;9(3):547-548.
McNamara R. Emergency Care Of the Elder Person. 1996.
Freund HR, Rubinstein E. Am Surg 1984;50(10):573-576.
Gupta H, Dupuy D. Surg Clin North Am 77 1997;77(6);1245-1264.
Extra Credit: Case Number 1
• A 56-year-old male presents to the emergency
department with sudden onset of stabbing
epigastric pain.
Diagnosis ?
Image Source: Kennedy Health Systems
Extra Credit: Case Number 2
• A 55-year-old male presents with increasing
abdominal pain and rectal bleeding over the past
day.
Diagnosis?
Image Source: Kennedy Health Systems
Conclusions
• United States population is aging at a tremendous
rate.
• Abdominal pain remains one of the most common
and potentially serious complaints.
• Atypical presentations are common in the elderly.
• Laboratory testing often lacks sensitivity and
specificity.
• Normal vital signs may be misleading in the elderly
even in the face of significant disease.
Conclusions
• Keep the differential diagnosis broad in elderly
patients.
• Liberal use of imaging and early surgical
consultation in the elderly.
• Serial examinations are extremely important.
Disposition
• An elderly patient with persistent abdominal pain
despite a negative initial evaluation should be
admitted to the hospital or an ED observation unit.
• Those patients discharged home should have
clinical improvement noted, negative acute
diagnostic testing, and should be able to tolerate
POs.
• Timely follow-up should be arranged.
• Caretakers need to be educated.
References
1. Brewer RJ, Golden GT, Hitch DC, et al. Abdominal pain: An analysis of 1,000
consecutive cases in a university hospital emergency room. Am J Surg
1976;131(2):219-223.
2. Caesar R. The acute geriatric abdomen. Emergency Medicine Reports 1994;15:191-202.
3. Cangemi JR, Picco MF. Intestinal ischemia in the elderly. Gastroenterol Clin N Am
2009;38(3):527-540.
4. Colucciello SA, Lukens TW, Morgan DL. Assessing abdominal pain in adults: A
rational, cost-effective, and evidence-based strategy. Emergency Medicine Practice
1999;1(1):1-20.
5. Fenyo G. Acute abdominal disease in the elderly: Experience from two series in
Stockholm. Am J Surg 1982;143(6):751-754.
6. Ferzoco L, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med
1998;338(21):1521-1526.
7. Freund HR, Rubinstein E. Appendicitis in the aged. Is it really different? Am Surg
1984;50(10):573-576.
8. Gupta H, Dupuy D. Abdominal emergencies: Has anything changed? Surg Clin North
Am 77 1997;77(6);1245-1264.
References
9. Kauvar DR. The acute geriatric abdomen. Clin Geriatr Med 1993;9(3):547-548.
10. Kizer KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in
the elderly. Am J Emerg Med 1998;16(4):357-362.
11. Krukowski Z, Matheson NA. Emergency surgery for diverticular disease complicated
by generalized and faecal peritonitis: A review. Br J Surg 1984;71(12):921-927.
12. Martinez JP, Mattu A. Abdominal pain in the elderly. Emerg Med Clin N Am
2006;24(2):371-388.
13. Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and
Clinical Practice, 7th Edition. Philadelphia, PA: Mosby Elsevier, 2009.
14. McNamara R. Acute abdominal pain. In: Saunders AB, ed. Emergency Care Of the Elder
Person. St. Louis, MO: Beverly Cracom Publications, 1996:219-243.
15. Ponka JL, Welborn JK, Brush BE. Acute abdominal pain in aged patients: An analysis
of 200 cases. J Am Geriatr Soc 1963;11:993-1007.
16. Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med 2007;23(2):255-270.