Acute appendicitis in the elderly patient

Acute Appendicitis in the Elderly Patient: Diagnostic Problems, Prognostic Factors and Outcomes
Sorinel Lunc1, George Bouras2, Narcis Sandy Romedea1 1) Emergency Surgical Clinic, University of Medicine and Pharmacy Gr. T. Popa, Iai, Romania. 2) IRCAD/EITS, University of Medicine Louis Pasteur Strasbourg, France

Abstract
Background and aims. Acute appendicitis (AA) in the elderly (over 60 year-old) continues to pose diagnostic problems and carries a high morbidity and mortality rate. The aim of this article is to present our experience and outcomes and to evaluate influencing factors. Methods. During a period of 5 years 63 patients with a definitive pathological diagnosis of AA were retrospectively analyzed. Results. The primary admission diagnosis was established correctly in 44 patients (69.8%). Nineteen patients (30.1%) required further diagnostic investigations and the mean time to final diagnosis was 26 hours. For 3 patients (4.8%), the final diagnosis was established intraoperatively. The perforation rate was 31.8% (20 patients). Thirty-eight patients (63.3%) had associated co-morbidities. The overall mean duration of pre-hospitalization symptoms was 2.7 days, 2.3 days for non-perforated cases and 3.8 days for perforated AA (p=0.0025). The complication rate was 34.9% (22 patients), complications occurred in 75% of perforated appendicitis and in 16.2% of non-perforated cases (p=0.00001). Overall mortality rate was 6.3%, 15% in the perforated case group and 2.3% in the group with nonperforated appendicitis (p=0.0003). The mean hospital stay was significantly longer for cases with perforated AA (7.2 days) than non-perforated AA (5.1 days) (p=0.0056), and for patients developing complications (9.6 days) than those without complications (5.6 days) (p=0.0031). Conclusions. Advanced age adversely affects clinical diagnosis, the stage of the disease and the outcomes. Late presentation, delayed diagnosis, presence of perforation and co-morbidities are associated with a poor outcome from surgery.
Romanian Journal of Gastroenterology December 2004 Vol.13 No.4, 299 - 303 Address for correspondence: Dr. Sorinel Lunc 1 Place de lHpital 67091 Strasbourg France E-Mail: slunca@hotmail.com

Key words
Acute appendicitis - elderly - diagnostic - prognostic factors - outcomes

Rezumat
Introducere. Apendicita acut (AA) la btrni (>60 ani) continu s pun probleme de diagnostic i s se nsoeasc de morbiditate i mortalitate crescut. Scopul acestui studiu este de a prezenta experiena i rezultatele noastre i de a evalua factorii prognostici. Material i metod. aizeci i trei de pacieni cu diagnostic definitiv anatomo-patologic de AA au fost analizai retrospectiv pe o perioad de 5 ani. Rezultate. Diagnosticul corect la internare a fost stabilit n 44 de cazuri (69,8%). Un numr de 19 pacieni (30,1%) au necesitat investigaii suplimentare pentru stabilirea diagnosticului, timpul mediu pentru aceasta fiind de 26 de ore. La 3 (4,8%) dintre acetia diagnosticul final a fost stabilit intraoperator. Rata perforaiei a fost de 31,8% (20 pacieni). Treizeci i opt de pacieni (63,3%) au prezentat afeciuni medicale asociate. Durata medie a simptomelor pn n momentul spitalizrii a fost de 2,7 zile, fiind de 2,3 zile pentru cazurile de AA neperforat i 3,8 zile pentru cei cu AA perforat (p=0,0025). Complicaii au fost nregistrate n 34,9% din cazuri (22 pacieni), n 75% din cazurile de AA perforat i n 16,2% din cazurile neperforate (p=0,00001). Rata mortalitii a fost de 6,3%: 15% n grupul cu AA perforat i 2,3% n grupul cu AA neperforat (p=0,0003). Durta medie de spitalizare a fost semnificativ mai lung pentru cazurile de AA perforat (7,2 zile) comparativ cu pacienii cu AA neperforat (5,1 zile) (0,0056) precum i pentru cazurile cu complicaii postoperatorii (9,6 zile) fa de cei cu evoluie simpl postoperatorie (5,6 zile) (p=0,0031). Concluzii. Vrsta naintat influeneaz negativ diagnosticul clinic, stadiul bolii i rezultatele postoperatorii. Prezentarea tardiv la medic, diagnosticul ntrziat, prezena perforaiei i afeciunilor asociate influeneaz negativ rezultatele operatorii.

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Introduction
Acute appendicitis (AA) is the most common acute surgical abdominal condition (1). The lifetime risk of AA is 7% in the general population, 90% of cases occurring in children and young adults (peak 10-30 years) and up to 10% being in the elderly over 60 years (2,3). The diagnosis of AA is difficult and remains one of the most challenging diagnostic issues in surgery. Despite developments in diagnostic imaging (ultrasonography, computed tomography) the diagnostic accuracy of AA remains poor (4,5). The risk of perforation in the elderly population is high, reaching levels of up to 70% in some reports (3,6,7). Progress has been made in the treatment of AA. In 1944, the mortality of AA was 2.4%, today this figure is less than 1% in the general population (3,8-10). Despite such progress, morbidity and mortality in elderly remains significant at 2860% and 10% respectively (6,8-12). The aim of this study was to evaluate the outcomes following appendectomy for AA in the elderly and to identify possible prognostic factors associated with this condition.

(57.1%) and 27 women (42.9%), the mean age being 65.1 years (range 60-82 years). Co-morbidity was present in 38 patients (60.3%), the details of whom are given in Table I.
Table I Co-morbidities in elderly patients with acute appendicitis
Co-morbidities Arterial hypertension Ischemic coronary disease Atrial fibrillation Diabetes mellitus Bronchopulmonary disease Pulmonary fibrosis Malignancy Number of patients 33 31 14 12 3 1 2

Material and methods

During a study period from January 1998 to December 2003, patients aged over 60 years with the diagnosis of AA who underwent appendectomy in the Emergency Hospital of Iasi were retrospectively analysed. Information obtained included demographic data, co-morbidities, time from onset of symptoms to admission, symptoms, diagnosis at admission, diagnostic investigations, timing of surgery, operative findings, hospital stay, morbidity and mortality. For most of the patients, the primary admission diagnosis was established in the emergency department by a senior resident surgeon, the diagnosis being subsequently confirmed by a more senior surgeon. For the remainder, the primary admission diagnosis was established by the experienced surgeon. Only patients with the diagnosis of AA confirmed on histopathological analysis were included in the study, such evaluation definitively confirming the presence or absence of perforation. The presence of neutrophils within the submucosa and mucosal ulceration defined catarrhal appendicitis. The suppurative (phlegmonous) appendicitis was characterised by transmural inflammation with neutrophilic infiltrate of muscularis propria, extensive ulceration, intramural abscesses and vascular thrombosis. When areas of necrosis were identified we established the diagnosis of gangrenous (necrotizing) appendicitis. Statistical analysis was performed using the Student t-test for continuous variables and chi-squared and Fischer exact tests for categorical data. A value of p<0.05 was considered statistically significant.

Results
During the study period, 63 patients over the age of 60 years underwent appendectomy for AA. There were 36 men

The mean duration of pre-operative symptoms was 2.7 days. For the patients with perforated AA, the mean preadmission duration of symptoms was 3.8 days, more than that of patients with non-perforated AA (2.3 days) the difference being statistically significance (p=0.0025). The primary admission diagnosis was established correctly in 44 patients (69.8%), further diagnostic investigations were required in 16 patients (25.4%) and the correct diagnosis was only established intra-operatively in 3 patients (4.8%). During the same period of time another 9 patients were operated on for the suspicion of AA (12.5% false positive diagnostic of AA). Among these 9 patients there were four normal appendices on pathological examinations. As for the other 5 cases, two caecal tumours, one right ovarian mass, one sigmoid tumour and renal pathology in one case were found. All the patients had pain as the predominant presenting symptom. This was in the right iliac fossa in 26 patients (41.3%), lower abdomen in 11 patients (17.5%), right hemiabdomen in 7 patients (11.1%) and diffuse in 19 patients (30.1%). In terms of associated gastrointestinal symptoms, 19 patients had vomiting (30.1%), 31 patients had nausea (49.2%), 20 patients had constipation (31.8%) and 9 patients had diarrhoea (14.3%). Clinical examination revealed right iliac fossa tenderness in 38 patients (63.3%), diffuse abdominal tenderness in 22 patients (34.9%), and 3 patients had tenderness in the right upper quadrant, left iliac fossa and in the right lumbar region respectively (1.6% each). For the 19 patients with an incorrect primary admission diagnosis, the pre-operative diagnosis was subacute or acute intestinal obstruction, suspicion of malignancy, acute cholecystitis, peptic ulcer, urinary disease in decreasing order of frequency. Leucocytosis (>10, 000/ml) was present in 39 patients (69.1%), and fever (t>37.8C) 31 patients (49.2%). Ultrasound examination established the diagnosis of AA (vermiform appendix over 6 mm wide) in 34 out of 48 patients examined. Other pre-operative diagnostic investigations included contrast enema in 5 patients, abdomino-pelvic computed tomography in 3 patients and colonoscopy in 2 patients. This led to the establishment of the diagnosis of AA in a further 16 cases. For three patients, the pre-operative diagnosis remained unclear, two caecal

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tumours and a right parauterine mass of genital origin being suspected before operation. Among the 63 patients with proved AA on pathology, a pseudo-tumoral form of AA, suggesting potential malignant pathology, was present in four cases. Twenty-three patients were operated within the first 6 hours after hospital admission (36.5%) - within this group, 11 patients had perforated appendicitis (47.8%). Twenty-two patients (34.9%) were operated between 6-12 hours following admission with 4 cases of perforation (18.2%). Seventeen patients were operated on after 12 hours and within 3 days of admission (mean 1.8 days), 4 cases of which were perforations (23.5%). One patient operated on the 5th day after admission proved to have a perforated AA. The mean time from hospital admission to operation was shorter for non-perforated cases compared to perforated cases, 17.6 vs. 18.1 hours. If we exclude the patient who was operated on the 5th day after admission for a perforated AA, we noticed that the time admission-operation was longer for the non-perforated group than for the perforated case group, 17.6 vs. 12.7 hours. When non-complicated AA or localized peritonitis was suspected, a right lower abdominal incision was made. When a generalized peritonitis was suspected, a midline laparotomy incision was performed. Only patients with perforated AA were drained. If local peritonitis was present a Douglas drain was placed and if generalised peritonitis was found multiple drains were left in place. Twenty-two patients developed complications giving an overall rate of 34.9% (Table II).
Table II Post-operative complications
Complication Wound infection Intraabdominal abscess Generalised peritonitis Urinary tract infection Pneumonia Deep venous thrombosis Respiratory distress Evisceration Digestive fistula Pressure sore Number of patients 8 3 2 3 4 3 2 1 1 1

generalized peritonitis in 2 cases and localized peritonitis in 1 case. The mean hospital stay was 5.1 days (4-9 days) for cases with non-perforated AA, and 7.2 days (6-23) for cases of perforated AA (p=0.0056). Patients developing complications had a significantly longer hospital stay (9.6 days) than those without complications (5.6 days) (p=0.0031).

Discussion
The incidence of AA in the elderly population (>60 years) is between 5-10% (2,6). Despite the relatively simple nature of this diagnosis, it still remains a challenge for the elderly patient. This is due to specific physiological alterations, comorbidities and socio-behavioral factors which are associated with this group of patients. The physiological changes seen in the elderly affect almost every organ system and influences the presentation of the disease and the response to intervention. The perception of pain and its localization is altered due to the modification of neural mechanisms and diminished immune function. The T-cell function is decreased, autoantibodies levels are raised, bone marrow capacity is reduced and the inflammatory response is dampened. Frequently, the bacteriemic elderly patient does not develop fever and may have hypothermia instead (13,14). The vermiform appendix of the elderly patient develops vascular sclerosis, narrowing of the lumen by fibrosis, the muscular layer is infiltrated with fat and there is a structural weakness with tendency towards early perforation. Co-morbidities frequently imply that symptomatology for acute appendicitis may be confused with already existing symptoms making the clinical diagnosis more difficult. In addition, concurrent medication may further complicate this issue and further compromise the elderly physiology increasing susceptiblity to other conditions. The elderly patient frequently refuses medical care and this can impede appropriate management. The diagnosis of AA is usually based on history and clinical examinatinon. In the elderly patients, the history is frequently incomplete and confused, they have atypical and subtle clinical features and multiple co-morbidities. Furthermore, the morbidity rate associated with acute abdominal pain increases with age, being 15% over the age of 50 years and more than 70% over the age of 80 years (15). Less than half of the elderly patients with AA present with the classical signs and symptoms including nausea, vomiting, loss of appetitie, migrating pain and localized tenderness (16). The pain usually lasts longer and is accompanied by abdominal distention, reduced bowel sounds and occasionally a palpable mass. As opposed to the classical migration of pain from the epigastrium to the right iliac fossa, elderly patients may more frequently have localized pain in the right iliac fossa from the onset (16). For our patients, the pain was perceived in the right iliac fossa in only 57.1% and on clinical examination, tenderness was elicited in the right iliac fossa in 60.3%, additional symptoms

The majority of complications were present in the patients with perforated AA (15 patients, 75%) and in those with co-morbidities (20 patients, 90.9%). The presence of perforation or co-morbidity was found to significantly increase the risk of complications (p=0.00001 and respectively p=0.0003). Of the 15 abdominal complications, 12 patients had perforated AA and 3 had non-perforated AA, the risk of abdominal complications increasing with the presence of perforation (p=0.00001). There were 4 deaths (6.3%) - 2 patients developed multiple organ failure following post-operative generalized peritonitis, 1 patient died from a major pulmonary embolism and 1 patient died from myocardial infarction. All 4 patients presented with significant co-morbidities, 3 of them had perforated AA with

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being present in less than half of the cases. On the other hand, constipation was present in about one-third of our patients. The correct diagnosis was established in only 69.8% of cases. For the other patients, additional investigations were necessary and this led to a delay of definitive surgical treatment. The main causes of acute abdominal pain in the elderly patient, in order of frequency, are cholecystitis, bowel obstruction, appendicitis, peptic ulcer disease, pancreatitis and diverticulitis (15,16). AA is the main cause of acute abdominal pain in young people while acute cholecystitis is the most frequent aetiology in the elderly. In our patients, the primary admission diagnosis of acute cholecystitis was made in 3 patients, the most frequent initial diagnosis being sub-acute intestinal obstruction with suspected neoplastic disease in 9 patients (14.3%). Malignancy represents another frequent diagnosis which has to be always considered in elderly people. It is advised that in the elderly, urgent investigations are necessary to reach a definitive diagnosis early. However, such investigations are often time-consuming and can delay the diagnosis thus increasing the risk of perforation thereby increasing morbidity and mortality (17,18). In our series, 19 patients had supplementary investigations (30.1%), the diagnosis being reached in 16 of them. The mean time to definitive diagnosis was 26 hours. The elderly have the tendency to present late (17-22), the reasons of this being: living in rural areas, living alone, fear of hospitals, low regard for new symptomatology, higher threshold for pain and co-medication which often conceals symptoms. The majority of our patients presented 48 hours after the onset of symptoms (mean 2.7 days). For perforated cases, the time from onset of symptoms was 1.1 days longer than the overall mean and 1.4 days longer than for nonperforated cases these differences (p=0.0025). Elderly people often present to hospitals in an advanced stage of the disease (19-22). In young people, the perforation rate of AA is less than 20% while this can be 70% (6,7,17) or even as high as 90% (23-25) in elderly people. The reasons behind this could be explained by the late presentation, the age-specific physiological alteration, atypical presentation and delay in diagnosis. In our series, 20 patients (31.7%) had a perforated AA, a rate which is similar to what is found in the literature (5,6,12,23,27). Advanced age is associated with a high risk of morbidity and mortality (6,11,26) following surgery for infectious diseases (6,12). The overall complication rate of 34.9% in our series is similar to previous reports of 28-60% (5,12,24,27,28). The morbidity is higher for perforated cases; Girleyk found the incidence to be 6 times higher than for non-perforated cases (5). In our series, the incidence of complications was significantly higher for perforated cases (p=0.00001). When considering patients with postoperative abdominal complications only (15 patients), 14 were in the perforated group. There was a statistically significant difference between perforated and non-perforated patients here as well, only one patient developing an abdominal complication in the non-perforated group (p=0.00001).

Co-morbidities were present in 20/22 patients with complications, the correlation between the two variables being also statistically significant (p=0.0003). The mortality rate in elderly patients with AA is between 4-10% (1,5,11,28), a higher incidence being reported for cases with perforated AA and for those over the age of 70 years (25-32%) (6,20). Death is often directly related to intraabdominal sepsis and in most cases to septic complications from perforation augmented by associated severe comorbidities (6,12). In our series, the mortality rate was 6.3%, two deaths were due to septic complications, three patients having perforated appendicitis and all four having comorbidities. Mortality was 10% for patients with perforated AA and 3% for non-perforated cases, the difference being statistically significant (p=0.0034). In conclusion, AA in the elderly remains a challenge for practicing surgeons and continues to be associated with a high morbidity and mortality. With increasing life expectancy, more such cases are likely to be encountered in the future. A careful examination of elderly people presenting with atypical abdominal pain and the avoidance of delayed diagnosis for a septic abdomen are extremely important in the prevention of severe morbidity and mortality. Repeated clinical examination by a senior surgeon, a high index of suspicion and urgent investigations are necessary for a correct and rapid diagnosis. The incidence of perforation remains higher than in the young population. A significant morbidity rate was associated with perforation, peritonitis and septic shock. In the elderly, the advanced stage of disease at presentation is the main cause of high morbidity and mortality. Late presentation, delayed diagnosis, presence of perforation and co-morbidities are associated with a poor outcome from surgery.

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