Yaşlılarda Karın Ağrısı
Özet
Yaşlı popülasyonda karın ağrısı, acil servis başvurularının önemli bir bölümünü oluşturur ve genç erişkinlere kıyasla üç ila dört kat daha yüksek morbidite ve mortalite ile seyretmektedir. Bu bölümde, yaşlılarda karın ağrısının epidemiyolojisi, yaşlanmaya bağlı fizyopatolojik değişiklikler, atipik klinik prezentasyonlar, sık karşılaşılan etiyolojik nedenler, tanısal yaklaşım ve tedavi prensipleri güncel literatür eşliğinde ele alınmıştır. Yaşlanma sürecinde periferik ve santral sinir sistemindeki nörodejeneratif değişiklikler ağrı eşiğini yükseltirken, immün yaşlanma (immünosenesens) nedeniyle ateş, lökositoz ve taşikardi gibi klasik enfeksiyon bulgularının baskılanması tanısal süreci güçleştirmektedir. Polifarmasi hem semptomları maskeleyerek hem de gastrointestinal yan etkileriyle karın ağrısının bağımsız bir nedeni olarak karşımıza çıkmaktadır. Akut kolesistit, bağırsak tıkanıklığı, divertikülit, peptik ülser perforasyonu, mezenterik iskemi, abdominal aort anevrizması rüptürü ve apandisit gibi yaşamı tehdit eden patolojiler, bu yaş grubunda sıklıkla atipik prezentasyonlarla ortaya çıkmaktadır. Tanısal değerlendirmede bilgisayarlı tomografi en yüksek doğruluğu sağlarken, laboratuvar bulgularının yorumlanmasında yaşa özgü fizyolojik değişikliklerin dikkate alınması gerekmektedir. Tedavi yaklaşımında erken resüsitasyon, bireyselleştirilmiş analjezi, kırılganlık değerlendirmesine dayalı cerrahi karar verme ve kapsamlı geriatrik değerlendirme perspektifinden multidisipliner yönetim ön plana çıkmaktadır. Yaşlı hastada karın ağrısı, düşük belirtili ancak yüksek riskli bir tablo olarak ele alınmalı ve tanısal gecikmeyi en aza indirmek için düşük eşikli görüntüleme stratejisi benimsenmelidir.
Abdominal pain in the elderly constitutes a substantial proportion of emergency department visits and is associated with three- to four-fold higher morbidity and mortality compared to younger adults. This chapter reviews the epidemiology, age-related pathophysiological changes, atypical clinical presentations, common etiological causes, diagnostic approach, and management principles of abdominal pain in older patients in light of the current literature. Neurodegenerative changes in the peripheral and central nervous systems elevate pain thresholds with aging, while immunosenescence suppresses classic infection markers such as fever, leukocytosis, and tachycardia, thereby complicating the diagnostic process. Polypharmacy both masks clinical findings and independently contributes to abdominal pathology through gastrointestinal adverse effects. Life-threatening conditions including acute cholecystitis, bowel obstruction, diverticulitis, peptic ulcer perforation, mesenteric ischemia, ruptured abdominal aortic aneurysm, and appendicitis frequently present with atypical features in this population. Computed tomography provides the highest diagnostic accuracy, while interpretation of laboratory findings requires consideration of age-specific physiological alterations. Management priorities include early resuscitation, individualized analgesia, frailty-guided surgical decision-making, and multidisciplinary care within a comprehensive geriatric assessment framework. Abdominal pain in older adults should be regarded as a low-symptom yet high-risk condition, and a low-threshold imaging strategy should be adopted to minimize diagnostic delay.
Referanslar
Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. American Family Physician. 2006;74(9):1537-1544.
Ragsdale L, Southerland L. Acute abdominal pain in the older adult. Emergency Medicine Clinics of North America. 2011;29(2):429-448. doi:10.1016/j.emc.2011.01.012.
Martinez JP, Mattu A. Abdominal pain in the elderly. Emergency Medicine Clinics of North America. 2006;24(2):371-388. doi:10.1016/j.emc.2006.01.010.
Brooks D, Smiles JP, Murphy AP, et al. Assessment and management of older patients with abdominal pain in the emergency department. Emergency Medicine Australasia. 2024;36(1):149-158. doi:10.1111/1742-6723.14361.
Mert DK, Durak VA, Özdemir F, et al. The Comparison of Patients with Abdominal Pain in Emergency Department at the Age of 45-64 with 65 and 65+ and the Evaluation of the Relationship Between the Diagnosis and Physiological Changes. Journal of Uludağ University Medical Faculty. 2017;43(1):7-12.
Li D. Emergency surgical conditions in geriatric patients: current research landscape. International Journal of Emergency Medicine. 2025;18(1):269. doi:10.1186/s12245-025-01074-0.
Leuthauser A, McVane B. Abdominal pain in the geriatric patient. Emergency Medicine Clinics of North America. 2016;34(2):363-375. doi:10.1016/j.emc.2015.12.009.
Spangler R, Van Pham T, Khoujah D, et al. Abdominal emergencies in the geriatric patient. International Journal of Emergency Medicine. 2014;7:43. doi:10.1186/s12245-014-0043-2.
Richter V, Kienle P, Büchler MW. Abdominal pain in the geriatric patient. Therapeutische Umschau. 2011;68(10):591-595. doi:10.1024/0040-5930/a000192.
Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emergency Medicine Clinics of North America. 2003;21(4):937-969. doi:10.1016/s0733-8627(03)00072-5.
Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2005;60(8):1071-1076. doi:10.1093/gerona/60.8.1071.
Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. The Clinical Journal of Pain. 2004;20(4):227-239. doi:10.1097/00002508-200407000-00004.
Tinnirello A, Mazzoleni S, Santi C. Chronic Pain in the Elderly: Mechanisms and Distinctive Features. Biomolecules. 2021;11(8):1256. doi:10.3390/biom11081256.
Pawelec G, Goldeck D, Derhovanessian E. Inflammation, ageing and chronic disease. Current Opinion in Immunology. 2014;29:23-28. doi:10.1016/j.coi.2014.03.007.
Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797. doi:10.2147/IJGM.S25936.
Bhutto A, Morley JE. The clinical significance of gastrointestinal changes with aging. Current Opinion in Clinical Nutrition and Metabolic Care. 2008;11(5):651-660. doi:10.1097/MCO.0b013e32830b5d37.
Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emergency Medicine Clinics of North America. 2016;34(3):559-574. doi:10.1016/j.emc.2016.04.008.
Dundar ZD, Ergin M, Karamercan MA, et al. Abdominal pain in older patients. In: Geriatric Emergency Medicine. Springer; 2018:169-180. doi:10.1007/978-3-319-19318-2_15.
Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2022;17(1):54. doi:10.1186/s13017-022-00443-x.
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922. doi:10.1016/S0140-6736(13)60688-1.
Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opinion on Drug Safety. 2014;13(1):57-65. doi:10.1517/14740338.2013.827660.
Pilotto A, Franceschi M, Maggi S, et al. Optimal management of peptic ulcer disease in the elderly. Drugs & Aging. 2010;27(7):545-558. doi:10.2165/11537380-000000000-00000.
2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052-2081. doi:10.1111/jgs.18372.
Bonomo RA, Edwards MS, Abrahamian FM, et al. 2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intraabdominal Infections: Diagnostic Imaging of Suspected Acute Cholecystitis and Acute Cholangitis in Adults, Children, and Pregnant People. Clinical Infectious Diseases. 2024;79(Suppl 3):S104-S108. doi:10.1093/cid/ciae349.
Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). Journal of Hepato-Biliary-Pancreatic Sciences. 2018;25(1):41-54. doi:10.1002/jhbp.515.
Kimura Y, Takada T, Kawarada Y, et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. Journal of Hepato-Biliary-Pancreatic Surgery. 2007;14(1):15-26. doi:10.1007/s00534-006-1152-y.
Ozturk E, van Iersel M, Stommel MWJ, et al. Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care. World Journal of Emergency Surgery. 2018;13:48. doi:10.1186/s13017-018-0208-z.
Frago R, Ramirez E, Millan M, et al. Current management of acute malignant large bowel obstruction: a systematic review. The American Journal of Surgery. 2014;207(1):127-138. doi:10.1016/j.amjsurg.2013.07.027.
Halabi WJ, Jafari MD, Kang CY, et al. Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Annals of Surgery. 2014;259(2):293-301. doi:10.1097/SLA.0b013e31828c88ac.
Hall JK, Supiano MA, Cohan JN. Diverticulitis in older adults: a review of etiology, diagnosis, and management. Journal of the American Geriatrics Society. 2025;73(5):1598-1607. doi:10.1111/jgs.19388.
Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery. 2020;15:3. doi:10.1186/s13017-019-0283-9.
Hocaoglu N, Atilla MK, Ors F, et al. Low-back pain in geriatric patients: remember abdominal aortic aneurysm! JCR: Journal of Clinical Rheumatology. 2007;13(6):345-346. doi:10.1097/RHU.0b013e318065489c.
Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2022;80(24):e223-e393. doi:10.1016/j.jacc.2022.08.004.
Fugazzola P, Ceresoli M, Agnoletti V, et al. The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition). World Journal of Emergency Surgery. 2020;15(1):19. doi:10.1186/s13017-020-00298-0.
Omari AH, Khammash MR, Qasaimeh GR, et al. Acute appendicitis in the elderly: risk factors for perforation. World Journal of Emergency Surgery. 2014;9:6. doi:10.1186/1749-7922-9-6.
Samaras N, Chevalley T, Samaras D, et al. Older patients in the emergency department: a review. Annals of Emergency Medicine. 2010;56(3):261-269. doi:10.1016/j.annemergmed.2010.04.015.
Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “There’s got to be a happy medium”. JAMA. 2010;304(14):1592-1601. doi:10.1001/jama.2010.1482.
Dadeh A-A, Uppakarnnuntakul W. Factors associated with serious abdominal conditions in geriatric patients visiting the emergency department. BMC Emergency Medicine. 2024;24(1):16. doi:10.1186/s12873-024-00934-x.
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Referanslar
Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. American Family Physician. 2006;74(9):1537-1544.
Ragsdale L, Southerland L. Acute abdominal pain in the older adult. Emergency Medicine Clinics of North America. 2011;29(2):429-448. doi:10.1016/j.emc.2011.01.012.
Martinez JP, Mattu A. Abdominal pain in the elderly. Emergency Medicine Clinics of North America. 2006;24(2):371-388. doi:10.1016/j.emc.2006.01.010.
Brooks D, Smiles JP, Murphy AP, et al. Assessment and management of older patients with abdominal pain in the emergency department. Emergency Medicine Australasia. 2024;36(1):149-158. doi:10.1111/1742-6723.14361.
Mert DK, Durak VA, Özdemir F, et al. The Comparison of Patients with Abdominal Pain in Emergency Department at the Age of 45-64 with 65 and 65+ and the Evaluation of the Relationship Between the Diagnosis and Physiological Changes. Journal of Uludağ University Medical Faculty. 2017;43(1):7-12.
Li D. Emergency surgical conditions in geriatric patients: current research landscape. International Journal of Emergency Medicine. 2025;18(1):269. doi:10.1186/s12245-025-01074-0.
Leuthauser A, McVane B. Abdominal pain in the geriatric patient. Emergency Medicine Clinics of North America. 2016;34(2):363-375. doi:10.1016/j.emc.2015.12.009.
Spangler R, Van Pham T, Khoujah D, et al. Abdominal emergencies in the geriatric patient. International Journal of Emergency Medicine. 2014;7:43. doi:10.1186/s12245-014-0043-2.
Richter V, Kienle P, Büchler MW. Abdominal pain in the geriatric patient. Therapeutische Umschau. 2011;68(10):591-595. doi:10.1024/0040-5930/a000192.
Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emergency Medicine Clinics of North America. 2003;21(4):937-969. doi:10.1016/s0733-8627(03)00072-5.
Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2005;60(8):1071-1076. doi:10.1093/gerona/60.8.1071.
Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. The Clinical Journal of Pain. 2004;20(4):227-239. doi:10.1097/00002508-200407000-00004.
Tinnirello A, Mazzoleni S, Santi C. Chronic Pain in the Elderly: Mechanisms and Distinctive Features. Biomolecules. 2021;11(8):1256. doi:10.3390/biom11081256.
Pawelec G, Goldeck D, Derhovanessian E. Inflammation, ageing and chronic disease. Current Opinion in Immunology. 2014;29:23-28. doi:10.1016/j.coi.2014.03.007.
Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797. doi:10.2147/IJGM.S25936.
Bhutto A, Morley JE. The clinical significance of gastrointestinal changes with aging. Current Opinion in Clinical Nutrition and Metabolic Care. 2008;11(5):651-660. doi:10.1097/MCO.0b013e32830b5d37.
Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emergency Medicine Clinics of North America. 2016;34(3):559-574. doi:10.1016/j.emc.2016.04.008.
Dundar ZD, Ergin M, Karamercan MA, et al. Abdominal pain in older patients. In: Geriatric Emergency Medicine. Springer; 2018:169-180. doi:10.1007/978-3-319-19318-2_15.
Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2022;17(1):54. doi:10.1186/s13017-022-00443-x.
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922. doi:10.1016/S0140-6736(13)60688-1.
Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opinion on Drug Safety. 2014;13(1):57-65. doi:10.1517/14740338.2013.827660.
Pilotto A, Franceschi M, Maggi S, et al. Optimal management of peptic ulcer disease in the elderly. Drugs & Aging. 2010;27(7):545-558. doi:10.2165/11537380-000000000-00000.
2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052-2081. doi:10.1111/jgs.18372.
Bonomo RA, Edwards MS, Abrahamian FM, et al. 2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intraabdominal Infections: Diagnostic Imaging of Suspected Acute Cholecystitis and Acute Cholangitis in Adults, Children, and Pregnant People. Clinical Infectious Diseases. 2024;79(Suppl 3):S104-S108. doi:10.1093/cid/ciae349.
Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). Journal of Hepato-Biliary-Pancreatic Sciences. 2018;25(1):41-54. doi:10.1002/jhbp.515.
Kimura Y, Takada T, Kawarada Y, et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. Journal of Hepato-Biliary-Pancreatic Surgery. 2007;14(1):15-26. doi:10.1007/s00534-006-1152-y.
Ozturk E, van Iersel M, Stommel MWJ, et al. Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care. World Journal of Emergency Surgery. 2018;13:48. doi:10.1186/s13017-018-0208-z.
Frago R, Ramirez E, Millan M, et al. Current management of acute malignant large bowel obstruction: a systematic review. The American Journal of Surgery. 2014;207(1):127-138. doi:10.1016/j.amjsurg.2013.07.027.
Halabi WJ, Jafari MD, Kang CY, et al. Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Annals of Surgery. 2014;259(2):293-301. doi:10.1097/SLA.0b013e31828c88ac.
Hall JK, Supiano MA, Cohan JN. Diverticulitis in older adults: a review of etiology, diagnosis, and management. Journal of the American Geriatrics Society. 2025;73(5):1598-1607. doi:10.1111/jgs.19388.
Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery. 2020;15:3. doi:10.1186/s13017-019-0283-9.
Hocaoglu N, Atilla MK, Ors F, et al. Low-back pain in geriatric patients: remember abdominal aortic aneurysm! JCR: Journal of Clinical Rheumatology. 2007;13(6):345-346. doi:10.1097/RHU.0b013e318065489c.
Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2022;80(24):e223-e393. doi:10.1016/j.jacc.2022.08.004.
Fugazzola P, Ceresoli M, Agnoletti V, et al. The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition). World Journal of Emergency Surgery. 2020;15(1):19. doi:10.1186/s13017-020-00298-0.
Omari AH, Khammash MR, Qasaimeh GR, et al. Acute appendicitis in the elderly: risk factors for perforation. World Journal of Emergency Surgery. 2014;9:6. doi:10.1186/1749-7922-9-6.
Samaras N, Chevalley T, Samaras D, et al. Older patients in the emergency department: a review. Annals of Emergency Medicine. 2010;56(3):261-269. doi:10.1016/j.annemergmed.2010.04.015.
Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “There’s got to be a happy medium”. JAMA. 2010;304(14):1592-1601. doi:10.1001/jama.2010.1482.
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