Appendicitis in Mature Patients

Abstract

All patients greater than 50 years of age (N = 96) admitted with a pre- or postoperative diagnosis of acute appendicitis from 1971 to 1980 were reviewed. A comparative series of 91 patients aged 25 to 50 years was similarly reviewed. Noninflammatory diseases of the appendix and incidental appendectomies were excluded. Detailed study of symptoms, clinical presentation, laboratory evaluation, radiographic evaluation, concomitant diseases, hospital course, surgical findings, complications, and mortality were completed. Comparison of patients aged 25 to 50 to patients older than 50 years revealed a statistically significant increased incidence of perforation in the older group (p less than 0.0001). Sixty-five per cent of the older group showed greater incidence of perforation. Further analysis of this series yields the hypothesis that the increased incidence of perforation is related to a significant decrease in the frequency of classic presentation in the greater-than-50 age group, a significant decrease in frequency of correct admission diagnosis and a significant delay between admission and surgical procedure in the older group. A more rapid pathophysiologic progression of appendicitis with increasing age was noted. A much higher percentage of older patients was undiagnosed until the surgical procedure. In this group, there was a longer duration of symptoms, less frequent classic presentation, and decreased frequency of right lower quadrant guarding and tenderness as compared to patients with correct diagnosis prior to surgery. Complications were much more frequent in older patients and higher still in those with perforation. Analysis of findings by decade of life revealed an anticipated high incidence of perforated appendicitis in patients greater than 50, but also showed a continuation of the high incidence of perforation into the decade 40 to 50. There were three deaths in the entire study group (1.6%) all occurring in the older age group with postoperative sepsis.

False‐negative and False‐positive Errors in Abdominal Pain Evaluation Failure to Diagnose Acute Appendicitis and Unnecessary Surgery

“…[14][15][17][18][19] Investigators have found a correlation between the extent of out-of-hospital symptoms and the development of perforation. A weakness of these analyses was the failure to examine how much of the delay occurred after the patient sought medical care.…”

“…A weakness of these analyses was the failure to examine how much of the delay occurred after the patient sought medical care. 15,[17][18][19] Brender et al differentiated patient failure to seek medical care delay from the initial examining physician failure to refer the patient to a surgeon delay. 10 Patient/ family delay in the decision to seek medical care did not correlate with risk of perforation.…”

“…We found an increased rate of perforation in younger and older patients, in agreement with findings of previous investigators. 10,14,19,28 This has been postulated as due to a higher rate of false-negative decisions, 19 higher rate of inhospital delay, 19 and longer duration of symptoms before presentation. 1 Since both extremes of age had increased rates of adverse outcomes, the clinician's suspicions should be increased for these patients, with consideration of observation of these patients at a lower threshold than in the adult patient.…”

Comparison of perforation risk among physicians, other medical professionals and general adults with acute appendicitis in Taiwan

“…Variations in case mix, staffing levels, and performance characteristics of hospitals and surgeons may have an effect on appendiceal perforation rates 9,10,16,38 .…”

“…With appropriate treatment, overall mortality rates for appendicitis have dropped to less than 1 per cent 4,7 , but appendiceal perforation results in a significantly higher mortality rate and prolonged hospital stay 8,9 . Demographic characteristics of patients, medical technology, and delay in diagnosis and surgery are associated with appendiceal perforation 10 -18 .…”