Why abdominal pain and vomiting in an older woman matters
In older people, abdominal pain with vomiting can hide serious disease behind mild signs. Yellow eyes point to the bile ducts, and waves of pain with vomiting also raise the question of a blockage further down the gut.
What to ask in the history
- How it started; waves of pain or constant
- What she vomits; is she passing wind or opening her bowels
- Swelling of the abdomen
- Fever, shivering
- Yellow eyes, urine and stool colour
- Previous bouts and any known gallstones
- Past operations
- Medicines, weight loss
Red flags
- Fever with jaundice and pain
- Confusion or low blood pressure
- No wind or stools with a swollen abdomen
- Rigidity or guarding
- Foul-smelling vomit
What to examine
- Observations, hydration
- Jaundice
- Abdomen: swelling, tenderness, scars, hernias, bowel sounds
- Rectal examination
First investigations
- Full blood count, CRP, liver function, amylase or lipase
- Kidney function, electrolytes, lactate
- Blood cultures
- Ultrasound of the abdomen
- Abdominal X-ray or CT
- MRCP or endoscopic tests as needed
Differential diagnosis of abdominal pain and vomiting in an older woman
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Bowel
- Obstruction from adhesions, a hernia, a gallstone or a tumour
Bile ducts and gallbladder
- Biliary colic
- Cholecystitis
- A stone in the common bile duct
- Cholangitis
Pancreas
- Gallstone pancreatitis
Other
- Mesenteric ischaemia
- A heart attack presenting as abdominal pain
Common mistakes
- Putting dark urine down to a urine infection.
- Missing sepsis in an older patient who has no high fever.
- Not looking for hernias.