What have we learned over the past 20 years about appendicitis in the elderly?

doi:10.1016/S0002-9610(02)01390-9

The American Journal of Surgery

Volume 185, Issue 3, March 2003, Pages 198-201

https://doi.org/10.1016/S0002-9610(02)01390-9 Get rights and content

Abstract

Background

This study evaluates appendicitis in the elderly, comparing our findings to those previously published a decade earlier.

Methods

Comparison of appendicitis in the elderly (aged 60 years and older) from 1978 to 1988 with the following 10 years, 1988 to 1998.

Results

Overall (1978–1998) 26% of patients presented typically, one third delayed seeking care, with only half diagnosed correctly on admission. Computed tomograhy (CT) use increased (44% versus rarely in the previous decade). Perforation rates declined (72% first group versus 51% second group) with a concomitant drop in complications from 32% to 21% respectively. Overall, three fourths of complications occurred in patients with perforated appendicitis. Mortality rates remained constant.

Conclusions

Appendicitis in the elderly is a difficult problem with delays in medical care, nontypical presentation resulting in incorrect diagnosis, relatively high rates of perforation often with associated postoperative complications and mortality. A higher index of suspicion with liberal early utilization of CT in uncertain cases may result in more appropriate management.

Section snippets

Patients and methods

The medical records of 113 consecutive elderly patients who underwent appendectomy from 1988 to 1998 at Akron General Medical Center were retrospectively reviewed and compared with our data from the preceding decade [5]. In both our ordinal as well as the present study all patients were examined and evaluated by attending surgeons and house staff. Emergency physician evaluation was not consistently available and therefore not included. As in our previous study, all patients were initially

Results

A total of 113 consecutive patients over the age of 60, diagnosed with appendicitis over a 10-year period from 1988 to 1998 were retrospectively analyzed. There were 55 men and 58 women with a mean age of 71.8 years (range 60 to 98). Age, sex, and comorbidities—diabetes (DM), coronary artery disease (CAD), pulmonary disease, and hypertension (HTN)—were compared with incidence of significant complications. Complications were defined as postoperative ileus requiring more than 5 days to resolve (n

Comments

Appendicitis is often thought of as a disease of the young. With increasing life expectancy, so too has the incidence of appendicitis increased among the elderly. Appendicitis is the most common cause of acute surgical abdomen [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. Both the incidences of perforation and complications are increased in the elderly [3], [7], [8]. Despite our medical advances the lifetime risk of appendicitis has remained unchanged at approximately 7% with

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Cited by (145)

Fibrinogen as a Marker of Overall and Complicated Acute Appendicitis: A Systematic Review and Meta-Analysis
2022, Journal of Surgical Research
We performed a systematic review and meta-analysis to evaluate the diagnostic value of fibrinogen (FB) for acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.
A search of electronic information sources was conducted to identify all studies reporting FB in patients with clinical suspicion or confirmed diagnosis of acute appendicitis. We considered two comparisons: (1) appendicitis versus no appendicitis and (2) uncomplicated appendicitis versus complicated appendicitis. To assess the diagnostic value of FB, sensitivity, specificity, diagnostic odds ratios, summary receiver operating characteristic curves, area under the curve, and 95% confidence intervals (95% CIs) were estimated.
Seven studies (917 confirmed appendicitis and 1026 controls) for overall appendicitis and eight studies (602 complicated appendicitis and 1386 uncomplicated appendicitis) for complicated appendicitis were identified. The pooled sensitivity and specificity of FB for the diagnosis of appendicitis were 0.62 (95% CI: 0.58-0.65) and 0.79 (95% CI: 0.77-0.82), respectively. FB was more accurate in diagnosing complicated appendicitis, with a pooled sensitivity of 0.74 (95% CI: 0.69-0.78), specificity of 0.76 (95% CI: 0.73-0.78), and the area under the curve was 0.84.
As per this meta-analysis, FB has a potential diagnostic value in overall appendicitis and that it has a higher diagnostic value in the diagnosis of complicated appendicitis. Future well-designed prospective studies are needed to corroborate the findings.
A new approach to the management of acute appendicitis: Decision tree method
2022, American Journal of Emergency Medicine
It is important to distinguish between complicated acute appendicitis (CAA) and noncomplicated acute appendicitis (NCAA) because the treatment methods are different. We aimed to create an algorithm that determines the severity of acute appendicitis (AA) without the need for imaging methods, using the decision tree method.
The patients were analyzed retrospectively and divided into two groups as CAA and NCAA. Age, gender, Alvarado scores, white blood cell values (WBC), neutrophil/lymphocyte ratios (NLR), C-reactive protein value (CRP), albumin value and CRP/Albumin ratios of the patients were recorded.
In the algorithm we created, the most important parameter in the distinction between CAA and NCAA is CRP. NLR is predictive in patients with a CRP value of ≤107.565 mg/L, and the critical value is NLR 2.165. In patients with a CRP value of >107.565 mg/L, albumin is the determinant and the critical value is 2.85 g/dL. Age, gender, alvarado score and CRP/albumin ratio have no significance in distinguishing between CAA and NCAA. In the statistical analysis, there were significant differences between NCAA and CAA groups in terms of age (39.56 years vs 13,675 years), gender (48.1% male vs 71.4% male), WBC (13,891.10/mL vs 11,614.76/mL), CRP (27 mg/L vs 127 mg/L), albumin (3 g/dL vs 3 g/dL) and CRP/albumin (9.50 vs. 41).
Thanks to the algorithm we created, CAA and NCAA distinction can be made quickly. In addition, by avoiding unnecessary surgical procedures in NCAA cases, patients' quality of life can be increased and morbidity rates can be minimized.
Appendicitis and related abdominal pain
2021, Features and Assessments of Pain, Anesthesia, and Analgesia
Appendicitis, the most common cause of acute abdomen, affects people of any age, but especially between the ages of 10 and 20, with an overall lifetime risk of 7% to 8%. It is a complex disease with a probably multifactorial etiology, although obstruction is considered the main factor involved. Lower abdominal pain is the main symptom, clinically implying a broad differential diagnosis. There are no physical signs or inflammatory markers that definitively confirm the diagnosis, and imaging tests such as ultrasound or computed tomography have achieved greater diagnostic accuracy. Surgery continues to be the dominant management strategy, and laparoscopy is the increasingly recommended approach. In recent years, new concepts are changing many of the classic ideas about this disease, such as the possible immune function of the appendix, the alternative model of natural history, with milder forms that resolve spontaneously and the effective and safe nonsurgical treatment of some cases.
Geriatric patients undergoing appendectomy have increased risk of intraoperative perforation and/or abscess
2020, Surgery (United States)
The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission.
The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis.
From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01–2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12–1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79–8.25, P = .116), compared with the younger cohort.
Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy.
Pre-hospital management and patient-related factors affecting access to the surgical care of appendicitis–a survey study
2024, Scandinavian Journal of Primary Health Care
A different way to diagnosis acute appendicitis: machine learning
2024, Polski Przeglad Chirurgiczny/ Polish Journal of Surgery

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Scientific paperWhat have we learned over the past 20 years about appendicitis in the elderly?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Results

Comments

Am J Surg

Surg Clin North Am Feb

Surg Clin North Am

Surg Clin North Am

Emerg Med Clin North Am

Acute appendicitisreview and update

Am Fam Phys

Perforated appendicitisis it truly a surgical urgency?

Am Surg

The natural history of appendicitis in adults, a prospective study

Ann Surg

Scientific paper
What have we learned over the past 20 years about appendicitis in the elderly?