acute abdomen in the elderly
Introduction
Introduction to acute abdomen in the elderly Senile acute abdomen is a frequently-occurring disease characterized by acute abdominal pain and accompanied by a series of manifestations such as acute systemic symptoms. It has the characteristics of acute onset, rapid development, serious illness, many changes and complicated etiology. It involves inflammation, obstruction, hemorrhage, circulatory disturbance, perforation, infection poisoning, body fluid disorder and shock in various system organs such as digestion, urinary and reproductive. The elderly have reduced responsiveness due to organ dysfunction and clinical manifestations. Typical, easy to cause misdiagnosis and mistreatment. Therefore, for the elderly acute abdomen, we must master its characteristics and changes in the condition of the disease to achieve early diagnosis and timely and effective treatment. basic knowledge The proportion of the disease: the incidence rate of the elderly over 50 years old is about 0.03% - 0.05% Susceptible people: the elderly Mode of infection: non-infectious Complications: shock, abdominal pain, upper gastrointestinal bleeding, upper gastrointestinal bleeding in the elderly, acute abdomen in the elderly, acute abdomen, diarrhea
Cause
The cause of acute abdomen in the elderly
Gastrointestinal tumors (20%):
Cancer is the second leading cause of death in the elderly after heart disease. Common ones are:
1 stomach cancer.
2 small bowel tumors, usually occurring in people aged 50 to 70 years, the most common is carcinoid, followed by adenocarcinoma, lymphoma and leiomyosarcoma.
3 Colon cancer, the incidence of colorectal cancer began to rise at the age of 40, the peak is 80 years old, rectal cancer is more common in men, and colon cancer is almost equal in men and women.
4 Pancreatic cancer, the incidence of more than 75 years old is 10 times that of the general population.
5 Liver tumors, the liver is the most common site of other tumor metastases. Primary liver cancer is rare in the United States and Western Europe, but is most common in Africa and Asia. 90% of primary liver cancer originates from liver cells, called hepatocytes. Cancer or liver cancer; 5% to 10% of cholangiocarcinoma originating from the bile duct, or two mixed types called bile duct hepatocellular carcinoma.
6 gallbladder tumors, gallbladder malignant tumors accounted for 0.2% to 5% of patients with cholecystectomy, most women between 60 and 70 years old, adenocarcinoma accounted for 80%, 20% of squamous cell carcinoma, various cancers In the late stage, it is mainly the obstruction of the organ or the rupture of the cancer itself, and the acute abdomen of different causes.
Peptic ulcer (20%):
With the rapid development of population aging, the incidence of peptic ulcer in the elderly has increased. However, due to its atypical clinical manifestations, obstruction and perforation are often the first symptom. The complications are serious and serious, which should be paid attention to.
Liver disease (10%):
Liver abscess, divided into bacterial abscess and amoebic abscess, amoebic abscess is the most common parenteral amebiasis, bacterial liver abscess is caused by purulent bacteria invading the liver, two liver abscesses such as Timely and effective treatment, abscess can be broken into the thoracic cavity to form pleurisy; broken into the abdominal cavity to form acute peritonitis.
Gastrolithic disease (10%):
Common in the elderly, especially after vagus nerve resection or subtotal gastrectomy, may be related to the reduction of gastric motility, and often occurs in elderly patients with diabetes, high blood obstruction can be caused when the stomach stone blocks the pylorus.
Stomach torsion (20%):
Older people are more common, and the ligaments supporting the stomach are loose and prone to gastric torsion.
Gallbladder and biliary tract disease (10%):
Acute cholecystitis often occurs on the basis of chronic lesions, more than 90% with cholelithiasis, and is induced by the incarceration of the cystic duct or gallbladder neck.
Pathogenesis
The etiology is complicated and the pathogenesis has not yet been elucidated.
Prevention
Elderly acute abdomen prevention
At present, although there is no very effective method for preventing the occurrence of acute abdomen in the elderly, according to its incentives, taking corresponding measures and actively preventing it will help improve the condition and reduce complications.
1. General preventive measures
Including the following aspects:
(1) Maintain mental health: The elderly often suffer from mental stress and unexpected stimulation, resulting in large fluctuations in mood and psychological imbalance, which seriously affect the physiological functions of the digestive system. Therefore, the elderly should focus on eliminating tension, anxiety, anxiety and pessimism, and self-adjusting emotions. Change, always maintain a psychological balance, in case of digestive system dysfunction caused by acute abdomen.
(2) pay attention to proper diet: the elderly often cause many acute abdomen due to improper diet, such as: overeating greasy can induce cholecystitis; alcoholism can cause pancreatitis; insufficient cellulose can cause constipation, often sigmoid torsion and feces Obstructive intestinal obstruction, so the elderly and avoid overeating and alcoholism, choose nutrient-rich foods that are easy to digest and absorb, to achieve regular quantitative, soft and hard, adequate protein, less fat, more drinking water, low sodium sugar control And make up the vitamins A, B, D, K, etc. to ensure smooth stool.
(3) Preventing excessive fatigue: The elderly are prone to fatigue, excessive fatigue can cause indigestion, metabolic disorders, and acute abdomen. Therefore, the elderly should maintain moderate labor and regularity to improve their disease resistance.
(4) Adaptation to weather changes: The weather changes in the elderly with sudden changes in sudden heat and cold, especially those with a history of abdominal surgery, often induce intestinal obstruction, so the elderly should focus on strengthening outdoor activities, adapt to hot and cold stimulation Keep warm, and don't catch cold, it has a certain significance to prevent acute abdomen.
(5) Regular health checkup: The vascular degeneration of the elderly with arteriosclerosis as the center is almost everywhere in the body, so the elderly should conduct regular health checkups, detect the lesions in time, and treat them early, so that they can be investigated. The combination of treatment and prevention prevents the occurrence of acute abdomen.
2. Prevention of postoperative complications
There are four common complications of severe acute abdomen in the elderly after surgery. It is preventable to take effective measures during the perioperative period:
(1) Incision rupture: the elderly have more anemia, hypoproteinemia, and the wound healing is later. When the intra-abdominal pressure is increased, the peritoneal tear often occurs, causing the incision to rupture or incisional hernia, even because the intestine is embedded in the intestine. Intestinal necrosis is caused between sutures. For prevention, a small amount of blood transfusion or plasma can be used during the perioperative period. When liver and kidney function is normal, 500 ml of compound amino acid can be intravenously administered every day to correct hypoproteinemia, which is beneficial for incision healing. It is necessary to add 3~4 needles of tension suture and bandage with abdominal band. After operation, it can prevent severe cough, abdominal distension, constipation and urinary retention. The suture is usually removed in about 2 weeks. Once it is split, it should be re-surgery immediately. Incarcerated necrotic intestines were removed.
(2) anastomotic leakage: elderly malnutrition, hypoproteinemia, arteriosclerosis, insufficient blood supply to the intestine, often occur in the digestive tract anastomotic leakage, the incidence of colon anastomosis is higher, prevention can continue to correct hypoproteinemia, And follow the rules of getting out of bed late, eating late, late extubation (abdominal drainage tube, stomach tube), lateral position, to reduce the tension of the anastomosis, can effectively prevent the occurrence of anastomotic leakage, if it happens, light, by Abdominal drainage tube is closely observed, in order to self-heal: in severe cases, early intestine external ostomy should be performed.
(3) stubborn hiccups: the recovery of gastrointestinal function in the elderly is slow, often causing severe abdominal distension; peritoneal, retinal absorptive capacity is reduced, can make peritoneal effusion, both can increase diaphragmatic muscles, stimulate diaphragmatic spasm Intractable hiccups, seriously affecting patients' rest and causing pain in the incision, can take effective semi-recumbent position, keep the abdominal cavity circulate smoothly, take Chinese medicine compound Dachengqi decoction, promote the recovery of gastrointestinal function, reduce the stimulation of diaphragm muscles; Static 2 ~ 4mg, 3 times / d, oral, or intramuscular compound chlorpromazine 2ml, the general control effect is better.
(4) bloating constipation: after abdominal surgery, often because of bedridden, gastrointestinal function, eating less, the use of antibiotics caused by abdominal distension and constipation, 72 hours after surgery, no defecation, you can use Kailu 2 to 3 anal injection into the anus, generally can stimulate the rectum and defecation, severe cases can take Chinese medicine to increase the liquid Chengqi soup 3 ~ 6, the prescription: Scrophulariaceae 30g, Ophiopogon 24g, rehmannia 24g, rhubarb 10g (after the next ), Glauber's salt 5g (rush), can be received both attacking and yin, diarrhea in the effect of supplement, to relieve intestinal paralysis, prevention and treatment of constipation has a good effect.
Complication
Elderly acute abdomen complications Complications shock abdominal pain upper gastrointestinal bleeding elderly upper gastrointestinal bleeding elderly acute abdomen acute abdomen diarrhea
Concurrent shock, multiple organ dysfunction syndrome and multiple system organ failure, bleeding, acid-base balance disorders.
Symptom
Elderly acute abdomen symptoms common symptoms shock gastrointestinal bleeding acute abdomen abdominal pain peritonitis abdominal muscle tension paroxysmal abdominal pain upper gastrointestinal bleeding intestinal perforation blood pressure drop
1. Pathophysiological characteristics
(1) Poor reaction ability: The elderly have decreased ability due to dysfunction of organs, and symptoms and signs are often inconsistent with pathological changes in acute abdomen. The local pathological changes are often heavy, but the symptoms and signs are not obvious, body temperature and white blood cell count changes. Not significant, the pain is not as heavy as that of young people. Because of abdominal muscle relaxation or excess fat, abdominal muscle tension is not obvious during peritonitis.
(2) hypotonic state (hyponatremia): because the elderly are more in a low-osmotic state, the electrolyte concentration and hydrogen ion concentration of the extracellular fluid are often on the margin of compensation, when suffering from acute abdomen or trauma, although no Significant loss of sodium, but can quickly enter a state of severe hyponatremia.
(3) vascular degeneration: the elderly often have vascular degeneration, suffering from acute abdomen disease is easy to cause organ blood flow disorders, prone to organ necrosis, such as gangrenous appendicitis, strangulated intestinal obstruction, etc. High, in addition to more common mesenteric thrombosis or thrombophlebitis of the lower extremities after surgery.
(4) Degenerative diseases: The elderly suffer from degenerative diseases such as cardiovascular disease, kidney disease, chronic lung disease, diabetes, etc. When the acute abdomen is complicated, the condition is more complicated, and the two are often confused and mutually The impact, leading to diagnosis and treatment difficulties, coupled with the elderly's tolerance to drugs, drug excretion, prone to adverse reactions, increased the severity of the problem, clinicians should master these pathophysiological characteristics.
2. Symptoms and signs
(1) Acute abdominal pain:
1 The part where most abdominal pain begins, that is, the part where the diseased organ is located. For example, the pain in the upper abdomen is mostly stomach, duodenum, pancreas and other diseases; but any part of the abdominal pain caused by large bowel disease begins under Abdominal, full abdominal pain at the beginning, more common in the abdominal cavity, sudden congestion, fluid filling, so that the peritoneum is widely stimulated, such as liver and spleen and other internal organs ruptured internal bleeding, ulcer disease perforation or abdominal abscess suddenly ruptured.
2 pain transfer site (metastatic abdominal pain), there are two common conditions, acute appendicitis: early pain mostly begins in the upper abdomen or around the umbilicus, after a few hours to ten hours, that is, turn and fix the appendix in the right lower abdomen Part or ectopic appendix; cavity organ perforation or substantial organ rupture, its contents rapidly spread along a certain part to the whole abdomen, that is, after local sudden pain, rapidly spread into total abdominal pain, such as stomach or ten Perforation of duodenal ulcer, gallbladder or liver rupture, its contents often descend along the transverse colon and ascending colon to the ileocecal area, rapidly spread to the whole abdomen, that is, from the right upper abdomen to the right abdomen, through the right lower abdomen or lower abdomen The cause of total abdominal pain, due to the cause of acute abdomen, the expression of abdominal pain is not the same, paroxysmal abdominal pain, mainly due to contraction of smooth muscle spasm, persistent abdominal pain, often abdominal organs and peritoneum Inflammation infection, chemical factors or stimulation of blood secretions and changes in the condition, persistent abdominal pain is aggravated, mostly indicating inflammation accompanied by obstruction or obstructive disease accompanied by blood Obstacles, while the elderly due to poor body reaction ability, slow feeling of pain, abdominal muscle atrophy, clinical manifestations and pathological changes often do not coincide, even if acute abdominal symptoms occur, its clinical manifestations are mild and concealed, need to cause the clinician height note.
(2) nausea and vomiting: nausea and vomiting precedes abdominal pain, more common in medical diseases, nausea and vomiting occurs after abdominal pain, more common in intra-abdominal inflammation and obstructive diseases, such as appendicitis, cholecystitis, pancreatitis, peritonitis, cholelithiasis, low position Intestinal obstruction, vomit is rotten egg smell or rot-like odor is more common in gastric emptying disorders, fecal vomiting is often low intestinal obstruction, advanced colonic obstruction or gastro-intestinal fistula, bilious vomiting, more common in Vater ampulla Duodenal obstruction below the level, high intestinal obstruction, etc., hematemesis, which is characteristic of upper gastrointestinal bleeding.
(3) fever: elevated body temperature, generally 38 ~ 39 ° C more suggestive of inflammatory disease or combined with infection, it should be noted that some patients with acute abdomen, especially the elderly, due to the reduction of the body's ability to respond, body temperature is not only Not high but decreased, often suggesting critical illness, such as gastrointestinal perforation, acute hemorrhagic pancreatitis, severe toxemia, advanced peritonitis, severe shock and so on.
(4) shock: shock is often accompanied by symptoms and signs of acute abdomen, and the appearance of shock indicates critical illness, severe abdominal injury, severe abdominal pain, intra-abdominal hemorrhage or acute gastrointestinal bleeding, fluid loss or acid-base balance disorders Intra-abdominal infection and toxin absorption and poisoning can cause shock. Acute abdomen shock can be divided into three types:
1 traumatic shock.
2 hemorrhagic shock.
3 toxic shock (this type of more common), its prominent clinical manifestations are blood pressure drop, small pulse compression, mental disorders, decreased urine output, peripheral circulatory disorders, cyanosis and wet and cold limbs and other syndromes.
In order to improve the correct rate of diagnosis of elderly patients with acute abdomen, in the absence of typical medical history and signs, we should pay attention to the main symptoms and master the clinical features, although the causes of acute abdomen are numerous, carefully ask the medical history and carry out a comprehensive system and A focused physical examination, combined with ancillary examination data, can make a correct diagnosis of common acute abdomen.
Examine
Elderly acute abdomen examination
1. Blood test: The determination of the total number of hemoglobin and red blood cells has the value of diagnosis and differential diagnosis for the presence or absence of anemia or internal bleeding; the determination of white blood cells is of great significance for the judgment of infection and guiding treatment.
2. Urine examination: Determination of urine forming components (red blood cells, white blood cells and casts) and non-formation (protein, sugar, ketone body, amylase, pH), etc. for the diagnosis of acute abdomen, identification of urinary system diseases The judgment of kidney function has certain significance.
3. stool examination: a large number of red blood cells, found in lower gastrointestinal bleeding, colorectal cancer, etc., a large number of white blood cells, found in intestinal bacterial infection, occult blood test positive for upper gastrointestinal bleeding, such as stomach, duodenal ulcer, stomach cancer, etc. .
4. Biochemical examination: serum amylase increased, blood calcium decreased, suggesting acute pancreatitis, AFP increased suggestive of primary liver cancer.
5. X-ray inspection
Including fluoroscopy, plain film and contrast examination, it can show special signs for acute abdomen, especially some surgical acute abdomen. In acute abdomen, the diseases it can diagnose are:
1 obstructive diseases: various types of intestinal obstruction, cholelithiasis, pancreatic stones, urinary calculi, gastric torsion, pyloric obstruction and so on.
2 damage rupture disease: abdominal trauma and intra-abdominal foreign body, liver or spleen rupture, kidney or bladder rupture, acute gastrointestinal perforation.
3 inflammatory diseases: acute pancreatitis, acute peritonitis, colonic diverticulitis.
4 can help diagnose the disease: acute appendicitis, acute cholecystitis, spleen embolism or acute splenomegaly, although X-ray examination is one of the important means of diagnosis of acute abdomen, in general, through fluoroscopy, abdominal plain film and contrast observation Direct and indirect signs of the disease, combined with clinical diagnosis of most acute abdomen, but for some cases lacking typical clinical symptoms and obvious X-ray signs, the preoperative diagnosis rate is still low, need to pay attention.
6. Ultrasound examination
This test is one of the most common non-invasive tests. Since the 1980s, X-ray, CT, MRI, radionuclide, and ultrasound have developed rapidly. They have their own advantages in disease diagnosis. Ultrasound examination of acute abdomen has different sonograms, liver tumors, gallstones, gallbladder gangrene and perforation, acute obstructive suppurative cholangitis, acute pancreatitis, acute gastric dilatation, gastroduodenal perforation, pylorus Obstruction, intestinal obstruction, rupture of large abdominal blood vessels, embolism and abdominal trauma have very specific diagnostic value.
7. Endoscopy
Including gastroscopy, duodenoscopy, choledochoscopy, laparoscopic and fiberoptic colonoscopy, etc., has important value for the diagnosis and treatment of digestive diseases, but is frail and elderly, hemoglobin is less than 5g, suffering from serious systemic diseases such as Cardiopulmonary insufficiency, intolerance, and patients with suspected stomach, intestinal perforation, and peritonitis are contraindicated. Clinicians can choose to check according to their condition and general condition.
8.CT, MRI
Further diagnosis can be provided for some cases that are not yet diagnosed.
9. Diagnostic abdominal puncture
It is often used as a direct basis for the diagnosis of ulcers. It is suitable for abdominal trauma. In the early stage of shock, suspected visceral rupture or hemorrhage, acute abdominal pain, obvious signs of peritoneal irritation, abdominal distension or bowel sounds disappear, unexplained ascites, ascites With or without an intra-abdominal mass.
10. Diagnostic peritoneal lavage drainage
However, indications and contraindications should be strictly controlled.
Diagnosis
Diagnosis and diagnosis of acute abdomen in the elderly
What needs to be identified is the identification of medical or surgical acute abdomen.
1. Internal medicine acute abdomen
Often have the following characteristics:
1 The original medical disease related to abdominal pain exists, and the abdominal pain is relieved after the original disease is controlled.
2 There is no evidence of surgical acute abdomen after thorough examination and dynamic observation.
3 abdominal pain can be light and heavy, abdominal signs are not obvious, abdominal tenderness points are not fixed without peritoneal irritation or only slight rebound and muscle tension, the condition will not change in a short time.
4 white blood cells are normal or slightly elevated.
2. Surgical acute abdomen often has the following characteristics:
(1) General abdominal pain has one of the following conditions:
1 Limitation of tenderness lasting for more than a few hours, especially over 6 hours.
2 persistent abdominal pain increased paroxysmal.
3 progressive pulse acceleration, the total number of white blood cells increased.
4 abdominal pain is the first and main symptoms, accompanied by digestive tract reaction and obvious abdominal signs.
5 fever after abdominal pain.
6 abdominal pain and tenderness sites are more fixed.
(2) severe abdominal pain has one of the following conditions:
1 sudden abdominal pain lasted for > 6h, various treatments can not be alleviated.
2 The general condition is getting worse and worse, with toxemia or shock.
3 accompanied by tender or fixed abdominal mass.
4 abdominal can be seen in the intestines, peristaltic waves, bowel sounds hyperthyroidism, gas over water or bowel sounds weakened or even disappeared.
5 obvious radiation pain.
6 Abdominal rejection or peritoneal irritation.
7 bilious vomiting, fecal vomiting or bloody vomiting.
8 accompanied by anal defecation exhaust stop.
9 Abnormal voiced area of the abdomen or the appearance of intra-abdominal mobility dullness.
(3) The peritoneal irritation sign is obvious and there is an expansion of the spread.
(4) progressive anemia, progressive blood pressure drop, accompanied by obstructive symptoms or abdominal masses.
(5) There is a positive finding in diagnostic abdominal or peritoneal lavage drainage.
(6) X-ray examination has one of the following acute abdomen conditions:
1 free gas under the armpit.
2 large intestine or small intestine accumulation of effusion.
3 gallbladder, pancreatic or ureteral area with stone shadows.
4 liver or spleen shadow enlargement, diaphragmatic elevation or limited movement.
5 chest has abdominal organs such as gastrointestinal signs.
6 The extraperitoneal fat layer disappeared.
7 intra-abdominal abnormalities.
There are various ideas for the diagnosis and differential diagnosis of acute abdomen. It is also feasible to analyze the cause of acute abdomen according to the location of abdominal pain. Abdominal pain in different parts suggests different diseases.
