老年患者非创伤性急腹症诊治共识
本共识由中华医学会急诊医学分会、中国老年医学学会急诊医学分会及北京医学会急诊医学分会联合制定，旨在规范老年非创伤性急腹症的诊治。老年急腹症患者常表现不典型、起病隐匿、合并症多、病死率高，需早期识别高危因素。共识强调结构化诊断流程、合理影像检查选择、规范镇痛镇痉治疗、优化容量管理、及时手术干预及术后并发症预防。推荐使用生物标志物辅助诊断、风险预测模型评估预后，并建议多学科协作以改善老年患者结局。
要点
- 老年急腹症患者症状常不典型，需高度警惕严重腹腔内病变，避免漏诊延误手术时机导致病死率升高
- 推荐使用结构化诊断流程，结合病史、体格检查、实验室检查（包括乳酸、降钙素原、D-二聚体、心肌肌钙蛋白等生物标志物）及影像学检查快速评估
- 手术延迟与老年急腹症患者预后不良相关，一旦明确外科指征应尽早手术干预
- 老年患者容量管理需谨慎，推荐个体化补液策略；高剂量静脉对乙酰氨基酚可降低老年急腹症患者谵妄风险
- 术后需重视肺部并发症预防、营养支持及脓毒症相关性脑病的早期识别与处理
适用人群与场景
- 适用于急诊科就诊的老年非创伤性急腹症患者
- 老年患者常表现为起病隐匿、症状不典型、合并基础疾病多、病死率高
- 排除创伤性急腹症
诊断标准与关键阈值
- 推荐使用结构化诊断流程进行评估
- 生物标志物辅助诊断：乳酸、降钙素原（PCT）、D-二聚体、心肌肌钙蛋白（高敏肌钙蛋白T升高与急腹症患者不良预后相关）
- 血浆D-二聚体对以腹痛为首发症状的老年患者具有诊断意义
- APACHE II评分、早期乳酸曲线下面积、N末端脑钠肽前体水平联合可预测老年脓毒性休克患者病死率
- 可应用机器学习风险预测模型分析急腹症高危患者危险因素
处置流程与药物剂量
- 第一步：快速病史采集、体格检查及生命体征评估
- 第二步：实验室检查包括血常规、生化、凝血功能、乳酸、PCT、D-二聚体、心肌标志物等
- 第三步：影像学检查（根据临床情况选择超声、CT或MRI）
- 镇痛镇痉治疗：推荐规范使用解痉镇痛药物；高剂量静脉对乙酰氨基酚可降低老年急腹症患者谵妄风险
- 容量管理：推荐个体化补液策略，避免过度或不足补液
- 外科干预：明确外科指征后应尽早手术，手术延迟与预后不良相关
- 脓毒症患者可考虑连续性血液净化治疗（可降低血清HNL、IL-6、PCT水平）
- 术后管理：重视肺部并发症预防（与患者自控镇痛相关）、营养支持（参照中国老年患者肠内肠外营养指南）、脓毒症相关性脑病的早期识别
红旗征与不能漏的情况
- 老年患者症状不典型易漏诊，需警惕严重腹腔内病变如肠梗阻、肠缺血、穿孔、腹主动脉瘤破裂等
- 手术延迟显著增加老年急腹症患者病死率，明确外科指征应尽早手术
- 需警惕急性心肌梗死以腹痛为首发表现（高敏肌钙蛋白T升高提示不良预后）
- 老年急腹症合并脓毒症或脓毒性休克时需早期识别并积极处理
- 术后谵妄风险高，需预防性镇痛管理
研究设计与关键结果
- 共识由中华医学会急诊医学分会、中国老年医学学会急诊医学分会、北京医学会急诊医学分会联合制定
- 引用文献包括：手术延迟对老年急腹症患者预后影响的单中心研究；高敏肌钙蛋白T与急腹症患者预后关联的研究；高剂量静脉对乙酰氨基酚降低谵妄风险的回顾性队列研究；中国ICU脓毒症流行病学全国横断面调查
- APACHE II评分、早期乳酸曲线下面积、N末端脑钠肽前体水平联合预测老年脓毒性休克患者病死率的研究
- 机器学习模型用于急腹症高危患者风险预测的前瞻性观察研究
- 老年急腹症术后肺部并发症与患者自控镇痛相关性研究
证据类型、等级与局限
- 证据类型：专家共识
- 引用文献包括：回顾性队列研究、单中心经验、前瞻性观察研究、全国横断面调查、指南（日本急腹症初级诊疗指南2015、中国老年患者肠内肠外营养指南、中国成人急性腹痛解痉镇痛药物规范使用专家共识、中国老年上消化道出血急诊专家共识、中国老年脓毒症相关性脑病诊治急诊专家共识）
- 局限性：原文未提及证据分级体系及各推荐条款的推荐强度
对床旁实践的改变
- 老年急腹症患者需采用结构化诊断流程，常规检测乳酸、PCT、D-二聚体、心肌标志物等生物标志物辅助诊断与风险分层
- 明确外科指征后应尽早手术，避免因等待进一步检查或观察而延误手术时机
- 镇痛管理可考虑使用高剂量静脉对乙酰氨基酚以降低谵妄风险
- 容量管理需个体化，参照中国老年危重症容量管理急诊专家共识
- 术后需加强肺部并发症预防、营养支持及脓毒症相关并发症监测
- 部分老年急性阑尾炎患者可尝试非手术治疗
- 多学科协作（急诊科、普外科、ICU、老年医学科）可改善老年急腹症患者预后
指南或共识出处
- 共识名称：老年患者非创伤性急腹症诊治共识
- 制定机构：中华医学会急诊医学分会、中国老年医学学会急诊医学分会、北京医学会急诊医学分会
- 发布年份：2026年
- 引用指南：日本急腹症初级诊疗指南2015（Practice guidelines for primary care of acute abdomen 2015）；中国老年患者肠内肠外营养指南2020；中国成人急性腹痛解痉镇痛药物规范使用专家共识2021；中国老年上消化道出血急诊专家共识2024；中国老年危重症容量管理急诊专家共识2024；中国老年脓毒症相关性脑病诊治急诊专家共识2025；中国老年缺血性结肠炎诊治临床指南2023
原文图文 · 图 3 张
World Journal of Emergency Medicine ›› 2026, Vol. 17 ›› Issue (5): 412-415.doi: 10.5847/wjem.j.1920-8642.2026.092
Consensus on the diagnosis and treatment of non-traumatic acute abdomen in elderly patients
), Jie Zhong1, Xingbang Pan1, Jinsheng Ye2, Guoqiang Zhang3, Chuanzhu Lyu4, Yuefeng Ma5, Miaorong Xie6, Wei Guo2, Chinese Society of Emergency Medicine, Emergency Medicine Branch of the Chinese Geriatrics Society, Emergency Medicine Branch of the Beijing Medical Association
1 Department of Emergency Medicine, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing 100022, China
2 Department of Emergency Medicine, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing 100010, China
3 Department of Emergency Medicine, China-Japan Friendship Hospital, Beijing 100029, China
4 Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
5 The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
6 Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
Wei Gu, Email: banditgu@163.com
1. 探讨2016版国际胰瘘研究小组定义和分级系统对胰腺术后患者胰瘘分级的影响.PDF(500KB)
Wei Gu, Jie Zhong, Xingbang Pan, Jinsheng Ye, Guoqiang Zhang, Chuanzhu Lyu, Yuefeng Ma, Miaorong Xie, Wei Guo, Chinese Society of Emergency Medicine, Emergency Medicine Branch of the Chinese Geriatrics Society, Emergency Medicine Branch of the Beijing Medical Association. Consensus on the diagnosis and treatment of non-traumatic acute abdomen in elderly patients[J]. World Journal of Emergency Medicine, 2026, 17(5): 412-415.
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