Elderly acute abdominal diseases

　　The causes of acute abdominal pain are numerous, often involving multiple departments, but they can be simply divided into abdominal organ diseases and extra-abdominal organ diseases. This section focuses on acute abdominal diseases in the elderly.

　　1. Peptic ulcer

　　With the rapid development of population aging, the incidence of senile peptic ulcer is on the rise. However, due to its atypical clinical manifestations, it often presents with obstruction and perforation as the initial symptoms of onset. Complications are numerous and severe, which should be paid attention to.

　　2. Gastric stone disease

　　It is common in the elderly, especially after vagotomy or subtotal gastrectomy, and may be related to reduced gastric motility. It also often occurs in elderly diabetic patients. When gallstones block the pylorus, it can cause high-grade obstruction.

　　3. Gastric torsion

　　It is more common in the elderly, due to the relaxation of the ligaments supporting the stomach, which is prone to stomach torsion.

　　4. Vascular disease

　　Due to atherosclerosis, it often causes colonic ischemia, known as ischemic colitis. In severe cases, colonic ischemia can lead to gangrene, often involving the entire colon, with the splenic flexure being the most severe. It is an acute, difficult-to-diagnose abdominal critical illness.

　　5. Crohn's disease (limited colitis)

　　It often involves the terminal ileum or colon, characterized by full-thickness inflammation, accompanied by linear ulcers, granulomas, and jumping lesions. Obstruction and perforation occur due to hyperplasia.

　　6. Gallbladder and bile duct diseases

　　Acute cholecystitis often occurs on the basis of chronic lesions. More than 90% are accompanied by cholelithiasis, and it is induced by the impaction of gallstones in the cystic duct or gallbladder neck.

　　7. Pancreatic disease

　　The main diseases of senile pancreas are blunt trauma, biliary pancreatitis, and cancer.

　　8. Liver disease - liver abscess

　　It is divided into bacterial abscess and amebic abscess. Amebic abscess is the most common extraintestinal amebiasis. Bacterial liver abscess is caused by the invasion of purulent bacteria into the liver. If the two types of liver abscess are not treated in time and effectively, the abscess may break into the pleural cavity, forming pleurisy; or break into the abdominal cavity, causing acute peritonitis.

　　9. Gastrointestinal tumor cancer

　　It is the second leading cause of death in the elderly after heart disease. Common ones include:

　　① Gastric cancer.

　　② Small intestine tumor, it often occurs in people aged 50 to 70, with carcinoid tumors being the most common, followed by adenocarcinoma, lymphoma, and leiomyosarcoma.

　　③ Colorectal tumor, the incidence of colorectal cancer begins to rise at the age of 40, with a peak at 80. Rectal cancer is more common in men, while colon cancer is almost equal in both men and women.

　　④ Pancreatic cancer, the incidence rate in people over 75 years old is 10 times higher than that of the general population.

　　⑤ Liver tumor, the liver is the most common site of metastasis of other tumors. Primary liver cancer is rare in America and Western Europe, but it is the most common in Africa and Asia, with 90% originating from liver cells, known as hepatocellular carcinoma or liver cancer; 5% to 10% originating from bile ducts are bile duct cancer, or a mixed type called cholangiocellular carcinoma.

　　⑥ Cholecystoma, there are reports that in patients who underwent cholecystectomy, malignant tumors of the gallbladder accounted for 0.2% to 5%, most of whom were women aged 60 to 70, with adenocarcinoma accounting for 80%, and 20% being squamous cell carcinoma. In the late stage of various cancers, mainly due to the obstruction of organs or the rupture of the tumor itself, acute abdomen of different etiologies appear.

　　The etiology of elderly acute abdomen is complex, and the pathogenesis has not been elucidated yet.

　　Elderly acute abdomen generally starts abruptly with severe abdominal pain and must be treated in a timely manner at the hospital. Elderly acute abdomen is prone to complications such as shock, multiple organ dysfunction syndrome, multiple system organ failure, hemorrhage, and acid-base imbalance.

　　The etiology of elderly acute abdomen is complex, and the symptoms are atypical, with certain characteristics compared to other age groups.

　　1. Pathophysiological Characteristics
　　1. Poor Reaction Ability
　　Due to the degeneration of organ function and the reduction of reaction ability in the elderly, the symptoms and signs during acute abdomen are often inconsistent with pathological changes. The local pathological changes are often severe, while the symptoms and signs are not obvious. The changes in body temperature and white blood cell count are not significant, and the pain is not as severe as that in young people. Due to the relaxation of the abdominal wall muscles or excessive fat, the tension of the abdominal muscles during peritonitis is not obvious.
　　2. Hypotonic State (Hyponatremia)
　　Due to the elderly often being in a hypotonic state, the concentration of electrolytes in extracellular fluid and the concentration of hydrogen ions are often at the compensatory edge. When suffering from acute abdomen or injury, although there is no obvious loss of sodium, it can quickly enter a severe hyponatremia state.
　　3. Vascular Degeneration
　　Elderly people often have vascular degeneration, which is prone to organ blood supply disorders when suffering from acute abdomen, easily leading to organ necrosis, such as gangrenous appendicitis and strangulated intestinal obstruction, with a high incidence. In addition, postoperative complications such as mesenteric thrombosis or lower limb thrombophlebitis are more likely to occur.
　　4. Degenerative Diseases
　　Elderly people often suffer from degenerative diseases such as cardiovascular diseases, kidney diseases, chronic lung lesions, diabetes, and so on. When complications occur with acute abdomen, the condition becomes more complex, and the two often confuse each other and affect each other, making diagnosis and treatment difficult. In addition, due to the reduced tolerance of elderly people to drugs and the decreased drug excretion, adverse reactions are more likely to occur, increasing the severity of the problem. Clinical doctors should master these pathophysiological characteristics.

　　Symptoms and signs
　　1. Acute abdominal pain
　　(1) The location where most abdominal pain begins is the location of the affected organ, such as the pain starting from the upper abdomen is often due to diseases such as the stomach, duodenum, and pancreas; but any part of the large intestine disease causes abdominal pain, it starts from the lower abdomen, the initial pain is general abdominal pain, it is often seen in sudden congestion and fluid filling in the abdomen, which stimulates the peritoneum extensively, such as internal bleeding due to rupture of solid organs such as liver and spleen, perforation of peptic ulcer or sudden rupture of abdominal abscess, etc.
　　(2) The transfer of pain location (transitory abdominal pain), there are two common situations, acute appendicitis: the early pain often starts from the upper abdomen or umbilical area, after several hours to ten or so hours, it turns and becomes fixed in the right lower abdominal appendiceal location or ectopic appendiceal location; perforation or rupture of hollow organs or solid organs, the contents spread rapidly to the whole abdomen, that is, after the local sudden pain, it quickly expands into general abdominal pain, such as gastric or duodenal ulcer perforation, gallbladder or liver rupture, the contents often along the transverse colon and ascending colon sulcus to the ileocecal region, quickly spread to the whole abdomen, that is, from the upper right abdomen to the right abdomen, through the lower abdomen to the whole abdominal pain. Due to the different etiology of acute abdomen, the manifestation of abdominal pain is not the same. Sudden abdominal pain is mainly caused by spasm and contraction of smooth muscle. Persistent abdominal pain is often caused by inflammation and infection of abdominal organs and peritoneum, chemical factors or stimulatory and blood secretion, and changes in the condition; persistent abdominal pain with sudden exacerbation often indicates inflammation accompanied by obstruction or obstructive diseases with hemodynamic disorders. While the elderly have poor body response ability, are insensitive to pain, abdominal muscle atrophy, so the clinical manifestations are often not consistent with pathological changes. Even if acute abdomen occurs, the clinical manifestations are mild and hidden, which requires high attention.
　　2. Nausea and vomiting
　　Nausea and vomiting occur before abdominal pain, which is more common in internal medicine diseases. Nausea and vomiting occur after abdominal pain, which is more common in abdominal inflammatory and obstructive diseases, such as appendicitis, cholecystitis, pancreatitis, peritonitis, cholelithiasis, low intestinal obstruction; vomit with the smell of rotten eggs or cadaveric odor is more common in diseases with gastric emptying disorders, fecal vomiting is often due to low intestinal obstruction, late-stage colonic obstruction, or gastric colonic fistula; biliary vomiting is more common in duodenal obstruction below the level of the Vater壶腹 and high intestinal obstruction; hematemesis is a characteristic of upper gastrointestinal hemorrhage.
　　3. Fever
　　An increase in body temperature, generally 38～39℃, often indicates inflammatory diseases or concurrent infection. It should be pointed out that some patients with acute abdomen, especially the elderly, due to the decrease in the body's response ability, the body temperature is not high but low, often indicating a serious condition, such as gastrointestinal perforation, acute hemorrhagic pancreatitis, severe toxicosis, late-stage peritonitis, severe shock, etc.
　　4. Shock
　　Shock is a common symptom and sign of acute abdomen, and the occurrence of shock indicates a serious condition. It can be caused by severe abdominal injury, severe abdominal pain, intraperitoneal hemorrhage or acute gastrointestinal hemorrhage, fluid loss or acid-base imbalance, intraperitoneal infection and toxin absorption intoxication. Acute abdomen shock can be divided into three types:
　　(1) Traumatic shock.
　　(2) Hemorrhagic shock.
　　(3) Toxic shock (this is more common), characterized by a drop in blood pressure, a decrease in pulse compression, altered consciousness, decreased urine output, peripheral circulation disorders, cyanosis, and the syndrome of damp and cold extremities.
　　To improve the accuracy of diagnosis in elderly patients with acute abdomen, when there is a lack of typical medical history and signs, attention should be paid to the main symptoms and grasp the clinical characteristics.

　　To prevent the occurrence of acute abdomen in the elderly, attention should be paid to the following points in daily life:

　　I. General preventive measures:
　　1. Maintain psychological hygiene
　　The elderly often suffer from mood swings and psychological imbalance due to stress and unexpected stimulation, which seriously affects the physiological function of the digestive system. Therefore, the elderly should pay attention to eliminating tension, anxiety, unease, and pessimism, adjusting their emotions, and maintaining psychological balance to prevent functional disorders of the digestive system leading to the occurrence of acute abdomen.
　　2. Pay attention to proper diet
　　The elderly often suffer from many acute abdomen due to improper diet, such as: overeating fatty foods can trigger cholecystitis; excessive alcohol consumption can cause pancreatitis; insufficient fiber intake can lead to constipation, and there is often sigmoid colon volvulus and obstructive intestinal obstruction. Therefore, the elderly should avoid overeating and excessive alcohol consumption, choose easily digestible, nutritious foods, and ensure regular and quantitative intake, appropriate softness and hardness, adequate protein, low fat, drinking plenty of water, low sodium, controlled sugar intake, and supplementing vitamins A, B, D, K, etc., to ensure smooth defecation.
　　3. Prevent excessive fatigue
　　The elderly are prone to fatigue, and excessive fatigue can lead to indigestion and metabolic disorders, triggering acute abdomen. Therefore, the elderly should maintain a moderate work-rest balance and a regular lifestyle to enhance their ability to resist diseases.
　　4. Adapt to weather changes
　　The elderly have poor stress response to sudden changes in temperature, especially those with a history of abdominal surgery, who often develop intestinal obstruction as a result. Therefore, the elderly should pay attention to strengthening outdoor activities, adapting to cold and hot stimuli, keeping warm, and not catching a cold, which is of certain significance in preventing the occurrence of acute abdomen.
　　5. Regular health checks
　　Vascular degenerative changes centered on arteriosclerosis in the elderly almost affect all organs, so the elderly should undergo regular health checks, detect lesions in a timely manner, and receive early treatment to achieve the combination of inspection, prevention, and treatment, and prevent the occurrence of acute abdomen.

　　II. Prevention of postoperative complications
　　The common complications of severe complications after emergency abdominal surgery in the elderly are as follows, and effective measures can be taken during the perioperative period to prevent them:
　　1. Incision rupture
　　The elderly often suffer from anemia and hypoproteinemia, with delayed incision healing. When there is an increase in intraperitoneal pressure, abdominal wall rupture or incision hernia may occur suddenly, or even intestinal necrosis due to intestinal intussusception between the sutures. For prevention, blood or plasma transfusion can be administered in small amounts multiple times during the perioperative period. When liver and kidney function are normal, 500ml of compound amino acid solution can be infused intravenously daily to correct hypoproteinemia and promote incision healing. The incision must be sutured with 3 to 4 tension sutures and bandaged with an abdominal bandage. Postoperative prevention and treatment of severe coughing, abdominal distension, constipation, and urinary retention are necessary; sutures are generally removed around 2 weeks. If the incision ruptures, immediate reoperation should be performed, and the incision should be sutured according to the above steps. If there is intussusception with necrotic intestinal tissue, it should be excised together.
　　2. Anastomotic fistula
　　Elderly malnutrition, hypoproteinemia, atherosclerosis, insufficient blood supply to the intestinal tract often occur anastomotic fistula of the digestive tract, the incidence of colonic anastomosis is higher. Prevention can continue to correct hypoproteinemia, and follow the principle of late bed, late eating, late tube removal (abdominal drainage tube, gastric tube), lateral position to reduce the tension of the anastomosis, which can effectively prevent the occurrence of anastomotic fistula. If it occurs, mild cases can be observed strictly through the abdominal drainage tube in order to heal spontaneously: severe cases should be treated with early intestinal exteriorization fistula surgery.
　　3. Intractable hiccups
　　Elderly patients with postoperative gastrointestinal function recovery is slow, often leading to severe abdominal distension; the absorption capacity of the peritoneum and omentum decreases, which can lead to peritoneal effusion. Both can raise the diaphragm, stimulate diaphragmatic spasm and cause intractable hiccups, seriously affecting the patient's rest and causing incisional pain. Effective semi-recumbent position, maintaining the patency of abdominal drainage, taking traditional Chinese medicine compound Dacheng Decoction, can promote the recovery of gastrointestinal function, reduce the stimulation of the diaphragm; or use Fumin 2-4mg, 3 times a day, oral administration, or intramuscular injection of compound chlorpromazine 2ml, generally with good preventive and therapeutic effects.
　　4. Abdominal distension and constipation
　　After a major abdominal operation, abdominal distension and constipation often occur due to lying in bed, decreased gastrointestinal function, less eating, and the use of antibiotics. If there is no排气 and defecation for 72 hours after the operation, 2 to 3 enemas can be used to induce defecation by intrarectal injection. Generally, it can stimulate the rectum to defecate, and severe cases can take 3 to 6 doses of the traditional Chinese medicine 'Zengye Chengqi Decoction'. Prescription: Scrophularia 30g, Ophiopogon 24g, Prepared Rehmannia 24g, Dahuang 10g (added later), Mirabilitum 5g (to be pounded). It can achieve the effect of both invigorating the interior and nourishing the Yin, with the meaning of purging in tonifying, and has a good effect on relieving intestinal paralysis and preventing constipation.

　　A detailed medical history and a comprehensive and systematic physical examination with a focus on key aspects, combined with the results of auxiliary examinations, are helpful for the diagnosis of common acute abdominal pain.

　　1. Laboratory examination
　　4. Blood examination: The determination of hemoglobin and the total number of red blood cells has diagnostic and differential diagnostic value for anemia or internal hemorrhage; the determination of white blood cells is for the judgment of infection
　　It is of great significance in guiding treatment.
　　2. Urinalysis: The determination of formed elements (red blood cells, white blood cells, and casts) and unformed elements (protein, sugar, ketone bodies, amylase, pH) in urine has certain significance for the diagnosis of acute abdominal pain, identification of urinary system diseases, and judgment of renal function.
　　3. Stool examination: A large number of red blood cells are seen in lower gastrointestinal bleeding, colorectal cancer, and other conditions. A large number of white blood cells are seen in intestinal bacterial infections, and a positive occult blood test suggests diseases with upper gastrointestinal bleeding, such as gastric and duodenal ulcers, gastric cancer, and others.
　　4. Biochemical examination: Elevated serum amylase, decreased blood calcium, indicating acute pancreatitis, AFP increased indicating primary liver cancer.

　　Second, other auxiliary examinations
　　1. X-ray examination: Including fluoroscopy, plain film, and contrast examination, it can show special signs for acute abdominal pain, especially for some surgical acute abdominal pain. The diseases that can be diagnosed by X-ray examination in acute abdominal pain are: ① Obstructive diseases: various types of intestinal obstruction, cholelithiasis, pancreatic calculi, urinary system calculi, gastric volvulus, pyloric stenosis, etc. ② Rupture and injury diseases: abdominal trauma and intra-abdominal foreign bodies, liver or spleen rupture, kidney or bladder rupture, acute gastrointestinal perforation, etc. ③ Inflammatory diseases: acute pancreatitis, acute peritonitis, colonic diverticulitis, etc. ④ Diseases that can assist in diagnosis: acute appendicitis, acute cholecystitis, splenic embolism or acute splenomegaly, etc. Although X-ray examination is one of the important means of diagnosing acute abdominal pain, generally speaking, through fluoroscopy, abdominal plain film, and contrast observation of the direct and indirect signs of the lesion, combined with clinical findings, most acute abdominal pain can be diagnosed correctly. However, for some cases with atypical clinical symptoms and obvious X-ray signs, the preoperative diagnosis rate is still low, which needs to be paid attention to.
　　2. Ultrasound examination: This examination is one of the most common non-invasive examinations. Since the 1980s, the development of X-ray, CT, MRI, radionuclide, and ultrasound as the four major imaging technologies has been very rapid, each with its own advantages and complementing each other in the diagnosis of diseases. In the ultrasound examination of acute abdominal pain, there are different echographic manifestations, which have very specific diagnostic value for liver tumors, gallbladder calculi, gallbladder gangrene and perforation, acute obstructive empyema of the bile duct, acute pancreatitis, acute gastric dilatation, gastric and duodenal perforation, pyloric stenosis, intestinal obstruction, abdominal large blood vessel rupture, thrombosis, and abdominal trauma.
　　3. Endoscopic examination: Including gastroscopy, duodenoscopy, bile ductoscopy, laparoscopy, and fiberoptic colonoscopy, etc., which has important value for the diagnosis and treatment of digestive system lesions. However, it is contraindicated for elderly and weak patients, hemoglobin below 5g, severe systemic diseases such as cardiovascular and pulmonary dysfunction, unable to tolerate examination, and suspected gastric or intestinal perforation and patients with peritonitis. The attending physician can choose the examination according to the patient's general condition and the need for the disease.
　　4. CT, MRI: For some cases that cannot be diagnosed by examination, it can further provide diagnostic evidence.
　　5. Diagnostic peritoneal puncture: It often provides direct evidence for the diagnosis of ulcers. It is suitable for abdominal trauma, in the early stage of shock, suspected internal organ rupture or hemorrhage, acute abdominal pain, obvious peritoneal irritation signs, abdominal distension or disappearance of bowel sounds, unknown nature of peritoneal effusion, ascites with or without intra-abdominal mass.
　　6. Diagnostic peritoneal lavage and drainage: However, it should be strictly controlled for indications and contraindications.

　　Patients with acute abdominal pain in the elderly should pay attention to a reasonable diet after treatment, with light and fresh as the main principle, eating more fresh fruits and vegetables, and ensuring sufficient nutrition; avoid smoking, drinking, spicy food; avoid greasy, smoking, drinking; avoid eating cold and raw foods..

　　After detailed examination and diagnosis, elderly acute abdomen cases are mainly divided into two types: conventional medical treatment and surgical treatment.

　　1. General medical treatment
　　Open a venous access immediately, administer intravenous fluids, and maintain electrolyte and water balance. For patients with severe abdominal pain, analgesics should be avoided to prevent masking symptoms, and antispasmodics such as atropine, belladonna, and scopolamine can be used. For patients with high fever, in addition to selecting antibiotics according to the cause, physical methods of cooling (such as alcohol bath, head ice pack, hibernation) or the use of antipyretics can be adopted. For those suspected of having an acute surgical abdomen, an emergency consultation with a surgeon should be sought.
　　For patients with shock caused by various reasons, especially septic shock patients, due to differences in etiology, pathology, age, and overall conditions, emergency treatment and comprehensive treatment measures are often required. For common biliary shock, enteric shock, and pancreatic shock, necrotic tissue should be cleared, adequate drainage should be performed, infection foci should be eliminated, and the cause should be removed to completely counteract shock.
　　Surgical bacterial infections are related to the site of the lesion. Abdominal infections are mainly caused by Escherichia coli, Klebsiella, Proteus, Pseudomonas, and anaerobic bacteria. Such as Bacteroides fragilis, Enterococcus, etc., generally, cephalosporins and aminoglycoside antibiotics such as gentamicin and amikacin (butylamine kanamycin) are first selected. In addition, drugs against anaerobic bacteria such as metronidazole injection can be used.
　　The principle of medication should be large doses and combination therapy (biphasic or triphasic). For example, cefmetazole (先锋美他醇) 2g, intravenous infusion once every 6 hours, added with gentamicin 240,000 U, intravenous infusion once a day, plus 100 ml of 0.5% metronidazole, intravenous infusion once every 8 hours. If conditions permit, simultaneous cultures of lesion secretions and blood for aerobic and anaerobic bacteria, as well as antibiotic sensitivity tests, should be performed, and the type and dose of antibiotics should be adjusted according to the culture results. For suspected sepsis caused by Gram-negative bacteria, high-dose benzathine penicillin, oxacillin, cloxacillin (cloxacillin), gentamicin, or tobramycin, or cephalosporins combined with aminoglycoside antibiotics can be used.
　　The basic pathological changes of septic shock are divided into two stages: high output low resistance type and low output high resistance type. The former has a decrease in blood pressure, but little loss of blood volume, a decrease in peripheral vascular resistance, good capillary perfusion, warm limbs, known as warm shock. The latter has increased permeability of the capillary wall, with fluid components of the blood leaking into the tissue spaces, resulting in a decrease in blood volume, a sharp drop in blood pressure, an increase in peripheral vascular resistance, reduced capillary perfusion, decreased cardiac output, and cold limbs, known as cold shock. Volume expansion should be rapid at first and then slow, with sufficient fluid replacement within the first 2 hours to rapidly replenish effective blood volume, increase cardiac output, and relieve vasoconstriction in small vessels, preventing further progression of shock. Generally, 1500 to 2500 ml of balanced salt solution is administered within 2 hours, with warm extremities, maintaining urine output greater than 50 ml/h, and urine specific gravity less than 1.020. The rate of fluid administration can be maintained unchanged. The initial fluid should be crystalloid, with appropriate administration of colloids, such as hydroxyethyl starch (706 plasma substitute) if blood concentration is high.

　　
　　

　　Indications for surgical treatment include: ① Having the characteristics of

　　In summary, patients with acute abdomen syndrome are usually critically ill, with complex clinical manifestations that require immediate and decisive treatment. A careful understanding of the medical history, especially the initial clinical manifestations and evolution process, combined with signs and symptoms, and with necessary examinations, carefully considers the pathological changes, proposes possible diagnoses, and can obtain satisfactory therapeutic effects.