For patients over the age of 80, what are the typical presenting signs and symptoms of appendicitis? What is their typical outcome?

Submitted by James Warneke, MD

Response by Carol Howe, MD, MLS

Available studies looking at appendicitis in the elderly are, with some exceptions (see Kraemer et al. [2000]), mostly retrospective—and involve extensive reviews of medical records during specific periods of time. Of the six studies that I found to be the most helpful, none looked exclusively at the oldest old—those over age 80. One--Hui et al. (2002) used age 70 and above as a cut off for the definition of elderly; three --Horattas et al. (1990); Lee et al. (2000); and Storm-Dickerson & Horattas (2003) used age 60 as a cut off; and two—(Kraemer et al. (2000) and Gurleyik and Gurleyik (2003), considered a cutoff of age 50 [sic!] as being reflective of the elderly population.

Signs and symptoms of acute appendicitis are similar in older and younger patients with fever, nausea/ vomiting/anorexia, abdominal pain, and leukocytosis being the most common. Unlike the presentation in younger patients, it is rare for all four features to be present in older patients. Horattas et al. (1990) found that “Only 20% presented classically with anorexia, fever, right lower quadrant pain, and an elevated white blood cell count”(abstract). Localization of the abdominal pain to the right lower quadrant is also less common. Lee et al. (2000) found that in their study population of 130:

Only 43 patients (33.1%) were febrile; 34 patients (26.1%) had a history of vomiting and six patients (12.3%) had diarrhoea. All but one patient presented with abdominal pain. The classical site of pain in the right lower quadrant was present only in 90 (69%) patients. The other sites included the epigastrium (n=2); central abdomen (n=14); lower abdomen (n=11); right abdomen (n=8); and generalized abdomen (n=4). [pp.593-4)

Hui et al. (2002) compared two groups of patients aged ≥70 years (47 patients in the four years between 1991 and 1995 with 48 patients in the four years between 1996 and 2000) at Cedars-Sinai Medical Center, Los Angeles, CA who underwent appendectomy. In their study:

Symptoms included abdominal pain in 90 patients (95%), nausea in 41 patients (43%), and emesis in 19 patients (20%). Signs included right lower quadrant tenderness in 79 patients (83%), leukocytosis in 68 patients (72%), fever in 29 patients (31%), and leukopenia in 1 patient (1%). No patients had hypothermia. There were no statistically significant differences for any of the presenting signs or symptoms between the 2 groups.

Robert McNamara, writing in Emergency Medicine: a Comprehensive Study Guide-6th Ed. (2004) notes:

The abdominal pain is generally reported to be in the right lower quadrant; however, the description may be vague or the pain poorly localized. Migration has been reported from a low of 5 percent to as high as 64 percent of elderly patients with appendicitis. Anorexia, an expected finding in younger patients, may be lacking (reported in 19 to 44 percent), while nausea and vomiting are reported in roughly half of elderly patients with appendicitis. Diarrhea and urinary tract symptoms do not exclude the disease.

Fever may be absent in one-third or more. Tenderness in the right lower quadrant is a frequent finding occurring in 80 to 90 percent. The presence of rigidity and rebound tenderness ranges from 20 percent to more than 80 percent. Laboratory assessment is potentially misleading, as most studies indicate that 20 percent or more will have a white blood cell count below 10,000. Up to 17 percent of the elderly with appendicitis have hyperbilirubinemia.12 (Chapter 73)

Although less likely to be clustered together, therefore, signs and symptoms of appendicitis in the elderly are not dissimilar to those in younger populations. Its diagnosis in the elderly, however, is disproportionately more likely to be missed—causing much higher morbidity and mortality when compared with outcomes in younger patients. There are several reasons for this.

First, appendicitis is not typically a disease of the elderly. According to Horattas et al (1990), “5% to 10% of all cases of appendicitis occur in the elderly” (p. 291). Similarly, Lee et al. (2000) state:

It is estimated that one in 15 individuals in the general population will develop acute appendicitis in their lifetime. Although the peak incidence of acute appendicitis occurs in the 15–24-years age group, 5–10% of all appendicitis occurs in the elderly (i.e. those over 60 years of age) and this accounts for 5% of all acute abdominal conditions in the aged. (p.593)

Because it is relatively rare in the aged, appendicitis is not a diagnosis that immediately comes to mind when evaluating abdominal pain in an elderly patient. Also, “diagnosis may be hampered by atypical presenting signs and symptoms as well as any associated confusion or dementia in a sick older patient” (Horattas et al, 1990, p. 292). A majority of elderly patients have comorbid diseases further clouding the diagnostic picture. Hui et al. (2002) found that:

Associated illness occurred in 71 patients (75%). The average number of associated illnesses was 2.3 per patient and was similar in both groups. Hypertension was present in 42 patients (44%), cardiac disease in 30 patients (32%), diabetes mellitus in 13 patients (14%) chronic obstructive lung disease in 7 patients (7%), renal insufficiency in 3 patients (3%), and myeloma in 1 patient (1%). [p. 996]

Even in the absence of known chronic diseases, older patients have accumulated many more reasons to have abdominal pain-- with small bowel obstruction and diverticular disease leading the list. Older patients themselves are much more likely than younger patients to attribute their early symptoms to ailments that are familiar to them such as constipation and indigestion (Horattas et al, 1990). This in turn leads to the consistent finding across the literature that older patients present at a much later stage in their disease with a consequently much higher incidence of perforation and its complications.

Horattas et al. (1990) and Lee et al. (2000) identify the same contributing factors as leading to this unfortunate delay in seeking care:

Only two thirds of our patient population presented within 48 hours of the onset of symptoms. Contributing factors may include reluctance in seeking help or living alone, economic factors (being unable to afford care), dislike of hospitalization or its association with death, and an altered perception of symptoms or attributing them to them to other causes (i.e. constipation or indigestion). [Horattas et al., 1990, p. 292]

In addition to delays in presentation and difficulties with diagnosis, several authors also mention a natural tendency for the appendix to be more prone to rupture with age. Hui et al (2002) for example, note: “Some believe that the physiology differs in the elderly and that the progression to perforation is more rapid owing to decreased lymphoid tissue or blood supply” (p.998). Lee et al. (2000) similarly state that

With age, the blood supply to the appendix is affected by atherosclerosis: the wall of the appendix is weakened by fibrosis and fatty infiltration. Thus, even with a mild increase in luminal pressure during the early phase of appendicitis, these changes may predispose the appendix to perforate. (p.595)

The studies by Lee et al. and by Gurleyik and Gurleyik also discuss the fact that, given presentations that are both more toxic in appearance and more uncertain as to etiology, older patients are more likely to receive midline or paramedian incisions rather than right lower quadrant incisions at the time of surgery. These larger and more central incisions are then themselves more likely to be associated with higher wound infections and longer hospital stays. Gurleyik and Gurleyik then make a case for diagnostic laparoscopy, which can “identify abnormal findings and improve outcomes in the majority of selected cases. If a precise diagnosis of appendicitis can be made by diagnostic laparoscopy, the infected appendix can be removed laparoscopically or by right lower quadrant transversal incision, thus avoiding a vertical laparotomy” (p.202).

Interestingly, Hui et al. (2002) tried specifically to tease out the effects of computed tomography (CT) as a diagnostic tool and laparoscopic appendectomy as a therapeutic tool in reducing morbidity and mortality in elderly patients with appendicitis. By dividing “all patients aged 70 years and older who underwent appendectomy for appendicitis between January 1, 1991 and December 31, 2000” into two groups—as described above, they hoped to test their hypothesis that “recent changes in the diagnosis and management of appendicitis in elderly patients [CT and laparoscopy] might affect the outcome” (abstract). Unfortunately, they found that “the use of CT and laparoscopy has increased significantly but no differences in the frequency of complicated appendicitis, time from the hospital admission to operation, length of hospitalization, and morbidity and mortality rates were observed (p. 998). In the “Discussion” section, which follows this Archives of Surgery paper, note is made by one reviewer, (Waxman, p. 999), that that the retrospective design of the study might lead toward a negative bias. Another reviewer, Peck, (p.999) felt that the CTs in this particular cohort were simply done too late. One of the original authors, Margulies--in the context of his reply (p.1000)-- also summarized:

Many other questions brought out how it was really the delay in presentation from these patients that established the rate of perforation, the high rate of complications, and their ultimate outcome, and therefore, very little could be done, even if the diagnosis had been made initially. This is true, is one of the main findings, and points to an area for improvement. (p. 1000)

Storm-Dickerson and Horattas (2002) did a study very similar in design to that of Hui et al. (2002). Storm-Dickerson and Horattas also compared cohorts of elderly patients with appendicitis within two time periods 1978-1988 and 1988-1998. On a positive note, they found a drop in perforation rates from 72% to 51%, which they thought might “be the result of earlier use of CT in the diagnosis of more seriously ill patients” (p. 201). Nonetheless, they note that “while CT has proven a useful tool especially in elderly patients with equivocal findings, it was employed in less than half of such cases in our institution” (p.201). They found that

Failure to correctly diagnose appendicitis was seen in more than 50% of elderly patients. Bowel obstruction was the most common misdiagnosis (24%) in those who perforated whereas diverticulitis was the most common misdiagnosis in the nonperforated group (21%). The correct diagnosis was missed more often (62%) in perforated appendicitis than in nonperforated appendicitis (45%). Delayed surgical referrals and refusal on the part of the patient to seek prompt medical attention may further contribute to the problem. (p.201)

Their overall conclusions are very much in keeping with Hui et al. (2002) and also consistent, as they themselves note, with the general literature on this subject:

Remarkably little has changed in the diagnosis and treatment of appendicitis over the past 20 years. However, in our institution we have seen a decline in perforation rates from (72% to 51%), while mortality rates have remained constant (4%). Over the past several years, we have seen increasing use of diagnostic laparoscopy and laparoscopic appendectomy but it is too early to see the impact of this approach in our series. Our data are consistent with that reported in the literature. The morbidity and mortality rates reflect the impact of sepsis and surgical trauma in an already frail population.

Acute appendicitis needs to be considered in the differential diagnosis of all patients with abdominal pain. A high index of suspicion is necessary to guard against misdiagnosis, especially in the elderly. Delays in presentation and diagnosis are associated with higher rates of perforation and hence higher morbidity. Early abdominal and pelvic CT may be useful in equivocal cases to facilitate appropriate and timely surgical intervention. (p.201)

In summary, the individual presenting signs and symptoms of appendicitis are similar in the elderly when compared with younger patients. The elderly are thus likely to have fever, to complain of loss of appetite, nausea and vomiting, to have abdominal pain—often, but not always, localized to the right lower quadrant, and to have an elevated white blood count. When compared with younger patients, however, the elderly are less likely to have all, or even most of these features in a convenient “diagnostic package” (McNamara, 2004).

The elderly almost always have comorbid conditions such as diabetes or heart disease which can divert the physician’s thinking away from the diagnosis of appendicitis—which is unlikely to be at the top of his or her differential diagnosis in any case because of its relative rarity. Additionally, findings such as elevated liver function tests and abdominal pain which is diffuse—neither uncommon in the elderly with appendicitis-- may be much more suggestive of—for example, hepatobiliary disease.

Older patients are far more likely to present at a much later stage in their appendicitis—either for psychosocial, economic, or indirectly—medical reasons. They may be so accustomed to feeling less than 100% that symptoms that many attribute to common ailments such as constipation or indigestion—simply fail to alarm them. Unfortunately, by the time they do present, they are much more likely to have a perforated appendix. Their very toxicity may lead the physician to consider illnesses such as small bowel obstruction, or even colon cancer before considering appendicitis. As a result, many patients undergo exploratory laparotomies involving midline or paramedian incisions with significant complications.

The use of CT scans, which is highly specific, has great potential to aid in diagnosis—though one study (Hui et al. 2002), saw no obvious improvement – and also mentioned (but did not specifically reference) another “study that has shown that routine use of CT may lead to delay in definitive management” (p.998). Storm-Dickerson and Horattas (2003) saw an improvement in rates of perforation “with a concomitant drop in complications from 32% to 21% respectively” (abstract), which was thought to be related to the use of CT. The jury is still out as to whether laparoscopy—either as diagnostic or therapeutic tool, or both, will have a positive impact. The importance of perioperative antibiotic use is stressed in much of the literature.

Almost without exception authors writing about appendicitis in the elderly conclude with the overarching message that a high index of suspicion and expeditious surgery are the keys to minimizing morbidity and mortality.

References

Gurleyik, G., & Gurleyik, E. (2003). Age-related clinical features in older patients with acute appendicitis. European journal of emergency medicine: official journal of the European Society for Emergency Medicine, 10(3), 200-203.

Horattas, M. C., Guyton, D. P., & Wu, D. (1990). A reappraisal of appendicitis in the elderly. American Journal of Surgery, 160(3), 291-293.

Hui, T. T., Major, K. M., Avital, I., Hiatt, J. R., & Margulies, D. R. (2002). Outcome of elderly patients with appendicitis: Effect of computed tomography and laparoscopy. Archives of surgery (Chicago, Ill.: 1960), 137(9), 995-8; discussion 999-1000.

Jaffe, B.M. & Berger, D.H. “Acute Appendicitis in the Elderly,” Schwartz’s Principle of surgery- 8th Ed. (2005) [electronic version] retrieved March 23, 2007 from Stat!Ref Database provided by the Arizona Health Sciences Library http://www.ahsl.arizona.edu/

Kraemer, M., Franke, C., Ohmann, C., Yang, Q., & Acute Abdominal Pain Study Group. (2000). Acute appendicitis in late adulthood: Incidence, presentation, and outcome. results of a prospective multicenter acute abdominal pain study and a review of the literature. Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie, 385(7), 470-481.

Lee, J. F., Leow, C. K., & Lau, W. Y. (2000). Appendicitis in the elderly. The Australian and New Zealand Journal of Surgery, 70(8), 593-596.

McNamara, R. “Abdominal Pain in the Elderly:Appendicitis.” In emergency medicine: A Comprehensive Study Guide- 6th Ed. (2004) [electronic version]. Retrieved march 23, 2007 from Stat!Ref Database provided by the Arizona Health Sciences Library http://www.ahsl.arizona.edu/

Storm-Dickerson, T. L., & Horattas, M. C. (2003). What have we learned over the past 20 years about appendicitis in the elderly? American Journal of Surgery, 185(3), 198-201.