Appendicitis In The Elderly

3.1. Epidemiology and Clinical Relevance

Appendicitis in the elderly is associated with a higher mortality rate, approximately 10% in patients 70 and older, when compared with the general population (13,14). Although the incidence is more common in the second and third decade of life, appendicitis still accounts for 15% of all surgical emergencies in the elderly (15). Prompt diagnosis, followed by definitive surgical treatment, reduces morbidity and mortality in this age group.

The diagnosis of appendicitis may not be as simple as in the young adult and this may delay treatment. The classic findings of nausea, vomiting, anorexia, fever, right lower-quadrant pain, and leukocytosis may not all be found in the elderly patient. Furthermore, the symptoms and signs of acute appendicitis are similar to other disease processes common in the older patient, resulting in the delayed diagnosis of appendicitis (see Table 2). Physical examination will indicate tenderness to palpation, involuntary guarding, and/or rebound tenderness in the right lower quadrant, which are similar in the younger patient. Typical physical findings in younger patients, which may not be present in the elderly patient, are fever, leukocytosis, abdominal distention, psoas sign, decreased bowel sounds, and/or rectal tenderness.

3.2. Diagnostic Tests

Radiographic studies can be used to help confirm the diagnosis of appendicitis or exclude other causes of the patient's symptoms. Plain radiographs are not sensitive or specific; however, plain abdominal radiographs may show appendiceal fecaliths, gas in the appendix, localized paralytic ileus, loss of right psoas shadow, and/or free air. It

Table 2

Difference in Presentation of Acute Appendicitis in 366 Patients >50 Yr Old and 1970 patients <50 Yr Old From the OMGE Series

Table 2

Difference in Presentation of Acute Appendicitis in 366 Patients >50 Yr Old and 1970 patients <50 Yr Old From the OMGE Series

Clinical feature

Patients < 50 yr old (%)

Patients > 50 yr old (%)

Generalized pain

2.2

13.1

Pain duration >24 h

57.2

75.4

Previous surgery

3.2

21.0

Distention

6.2

23.8

Generalized tenderness

2.1

14.2

Rigidity

18.9

40.1

Decreased bowel sounds

19.0

38.0

Mass

4.0

12.1

OMGE = Organisation Mondiale de Gastroenterologie. From ref. (26)

OMGE = Organisation Mondiale de Gastroenterologie. From ref. (26)

is more useful in excluding other illness common to the elderly. Ultrasonography can be used in the evaluation of acute appendicitis and is associated with 85% sensitivity and 92% specificity (16). The two primary criteria used for ultrasonic diagnosis of appendicitis are noncompressible appendix with a diameter of 7 mm or greater or appendicolithiasis. Findings of gas bubbles in the appendicial lumen, localized fluid collection, and/or periappendiceal abscess are also suggestive of the diagnosis. CT scan may also be used in the diagnosis of acute appendicitis. This study has a higher sensitivity and similar specificity as ultrasonography. Presence of pericecal inflammation or fluid collections are suggestive of appendicitis on CT scans.

3.3. Treatment

The treatment of acute appendicitis in the elderly is emergent appendectomy. This should be undertaken within 24 h of symptoms because of the increased risk of perforation past this time frame. If the diagnosis is unclear, diagnostic laparoscopy may be used in the elderly patient to avoid untimely delays in diagnosis (17,18). This procedure can include laparoscopic appendectomy when the diagnosis is made intra-operatively.

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Responses

  • Armi Otila
    How are the symptoms of appendicitis different in the elderly?
    6 months ago
  • janette
    Do elderly people still have appendix?
    4 months ago

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