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Introduction - Abdominal Pain in the Elderly

Mel Herbert, MD MBBS FAAEM, Stuart Swadron, MD FAAEM, Mizuho Spangler, DO, and Jessica Mason, MD
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07:03
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No me gusta!

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C3 - Elderly Abdominal Pain - Written Summary 540 KB - PDF

Abdominal pain is the third most common complaint in patients over 65, after chest pain and shortness of breath with millions of ED patient encounters each year.

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Elizabeth P., MD -

I'd like to suggest a correction to your discussion of bedside aortic ultrasound. You mentioned measuring the aorta in both the transverse and longitudinal direction. This is not correct. You only measure the aorta in transverse -- measuring in the longitudinal direction is not a good idea, as your probe may slide off to one side or the other of the aorta (particularly if it is large in diameter), and if your probe is not directly in the center, you may measure the "diameter" of the side of the aorta, not the exact middle, giving a falsely low diameter. While it is important to view the entire length of the aorta in the longitudinal dimension (to look for dissection flaps and saccular aneurysms), it is not the proper way to measure it. Measurements should be done in transverse only, so you can make sure you are measuring the exact center, at its largest dimension.

Mizuho S. -

Thanks Elizabeth for listening, and even more for submitting the inquiry. We double-checked with our E-Ultrasound gurus who gave us this information. "The ACEP Policy Statement on Emergency Ultrasound Guidelines still recommends measuring the maximal aortic diameter in both the longitudinal and transverse planes when measuring the aorta and iliac arteries. The listener is alluding to a common problem sonographers run into when their ultrasound beam goes rogue/tangent, and the probe inadvertently moves “off center.” This results in the beam measuring the aorta in the parasagittal plane, and this can result in either A)you mistakenly measuring the wrong vessel (the IVC if the probe sweeps to the patient’s right); or B) An erroneously small diameter measurement of the aorta. This problem however, can also occur in the transverse plane if your probe is placed at an angle on the aorta anything other than 90 degrees to the walls of the aorta. Therefore it is best to measure in both the longitudinal and transverse planes to verify measurements in two planes are consistent. "
https://www.acep.org/clinical---practice-management/focus-on--bedside-ultrasound-of-the-abdominal-aorta/

From these practice management guidelines, it seems that if you measure the long axis incorrectly you underestimate the diameter. If you measure the short axis incorrectly you overestimate the diameter. In my opinion, better to overestimate than underestimate the diameter of the aorta, not to mention it is harder to screw up measurements of the transverse because it is easier to measure, so in general, people like to measure TV planes only, but everyone recommends to measure both.
I think this is what you are also saying. So I hope this answer is acceptable to you. thanks again for keeping us on our toes! :) ~miz

Alan S. -

I wanted to add one comment regarding screening utility of abdominal x-ray and KUB. I agree that generally they are less than helpful but in the elderly patient I will often add one or teach my resident to add one as a screen for volvulus if a patient comes in with abdominl pain distention and or vomiting. I think they are useful to engage a surgical consult early if there's any hint of sigmoid volvulus especially in older debilitated nursing home patients

Mizuho S. -

Absolutely agree! Great point! Thanks Alan for listening! ~Miz

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C3 - Elderly Abdominal Pain Full episode audio for MD edition 70:24 min - 98 MB - M4AIntroduction - Abdominal Pain in the Elderly C3: Continuous Core Content 7:03 min - 10 MB - MP3Abdominal Pain Causes C3: Continuous Core Content 15:57 min - 22 MB - MP3Initial Approach C3: Continuous Core Content 10:49 min - 15 MB - MP3Expanding the Differential C3: Continuous Core Content 12:48 min - 18 MB - MP3Summary C3: Continuous Core Content 4:48 min - 7 MB - MP3Cases C3: Continuous Core Content 18:59 min - 26 MB - MP3C3 2017 January Board Review Answers 155 KB - PDFC3 2017 January Board Review Questions 214 KB - PDFC3 - Elderly Abdominal Pain - MP3 Files 91 MB - ZIPC3 - Elderly Abdominal Pain - Written Summary 540 KB - PDF