ACUTE APPENDICITIS IN THE

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1 Age and Ageing 87;:2-2 JAMES McCAUJON* Registrar GORDON P. CANNMGt Senior Registrar ACUTE APPENDICITIS IN THE Registrar Department of Pathology Stobhill General Hospital, Glasgow G2 Summary Acute appendicitis in elderly patients has not been studied extensively in the United Kingdom. Studies were performed prior to the regular use of broad spectrum antibiotics and tended to include younger patients. We studied retrospectively all elderly patients (n=, mean age=72 years) who presented in the years 8-8 and a younger gtoup (n=, mean age=2 years) who had a confirmed pathological diagnosis of appendicitis. We found a significant reduction in accurate pre-operative diagnoses, a longer duration of hospital stay and increased complication and mortality rates in the elderly group. Our study suggests that diagnostic accuracy, mortality and morbidity have not improved in comparision to earlier overseas studies. INTRODUCTION Acute appendicitis was first described by Reginald Fitz in 88 and is one of the most common of all surgical emergencies. Although the peak incidence (2./ population/year) occurs in the -2 age group, appendicitis can occur at any age and morbidity and mortality increase with advancing age [ ]. Previous studies in the elderly have been carried out mainly in the USA [2-7], and in these studies the elderly were usually defined as those aged over [, -8], and in two studies [2, ] those over age were used as the older group. All previous papers have noted an increased morbidity and mortality in their older groups. Thorbjarnarson and Loehr [] proposed diminished vascularity and mucosal atrophy of the appendix as causes of the increased perforation rate in the elderly. The aim of our study was to compare pathologically proven appendicitis in the elderly ( years and older) with a younger cohort with regard to presentation, management and outcome. We were particularly interested in whether current surgical and anaesthetic techniques had improved morbidity and mortality in the elderly. Downloaded from at Pennsylvania State University on March, 2 Methods We studied retrospectively all elderly patients with a pathologically proven diagnosis of appendicitis in the years 8-8. These patients presented to Stobhill Hospital which serves an elderly population of Address correspondence to Dr J. McCallion, Dryburn District General Hospital, Durham, t Present address: Southern General Hospital, Glasgow G TF.

2 McCALLION ET AL.: ACUTE APPENDICITIS IN THE ELDERLY 2 approximately 2 and were compared with a younger group. Statistical analysis was performed using chi squared with a Yates' correction factor. RESULTS There were elderly patients with an age range of -82 and a mean age of 72 years. These were compared to a sample of young subjects chosen randomly from the pathology records over the same period (age range -7; mean 2 years). Thus the incidence of appendicitis in the elderly was.2 cases/ population/year. Symptoms and signs were broadly comparable in both groups (Table I), in keeping with findings elsewhere that appendicitis presents in a similar fashion at all ages [2-8]. Altered bowel habit was noted more often in the elderly and, in particular, constipation was significantly more common (P<.2). So-called classical presentations of periumbilical pain progressing to pain over McBumey's point associated with anorexia, vomiting and altered bowel habit was not particularly common in either group, being noted in of the young and 2 of the elderly. Abdominal pain was present in all elderly patients with over 7 localizing this ta the right iliac fossa. In the younger age group, although there was a slightly lower incidence of right iliac fossa pain, most of the others had periumbilical pain and may have presented at an earlier stage in the pathological process. Right iliac fossa tenderness was common to both groups (Table II) and though Abdominal pain: R iliac fossa Periumbilical Diffuse Other Nausea Vomiting Anorexia Constipation Diarrhoea R iliac fossa tenderness Guarding Rebound Distension Mass Table I. Symptoms on presentation in young and elderly 22 Table II. 7 2 Abdominal signs on presentation P<.2 P<. / ) <.2 P<. P<. Downloaded from at Pennsylvania State University on March, 2

3 28 AGE AND AGEING VOL., NO. Temperature >7 C Leucocytosis: > >2 > Radiography (only in elderly) Small bowel fluid level Perforation Faecoliths Table III. Results of investigations ") \ J more prevalent in the younger cohort this was not statistically significant. Rebound tenderness was notably less frequent in the elderly group. A right iliac fossa mass was noted in 2 of the elderly patients on presentation, and was attributed wrongly to a caecal carcinoma in four of these six patients, thus delaying appropriate therapeutic measures. Investigations were not helpful in arriving at a diagnosis (Table III). Less than half of the elderly had a pyrexia compared to 7 of the young. This difference was not significant. Leucocytosis was present in 7 of the elderly and 77 of the young. This difference was not significant, nor was there a correlation between leucocytosis and pyrexia in either group. Abdominal radiography was performed in of the elderly and showed mainly nonspecific changes such as small-bowel fluid levels. There was a significant delay (P=.) in the time to presentation in the elderly group (Table IV) with one half having symptoms for more than 2 h before presentation (one third having symptoms for more than 8 h). In comparison, over half of the young group presented within 2 h and the majority within 2 h. Having noted this delay in presentation in the elderly group we also observed the longer admission to surgery interval with under half going to theatre within 2 h compared to 8 of the younger group (Table IV). These delays may be important when Table IV. <2h 2-2 h >2 h Onset of symptoms to presentation at hospital, and admission to surgery time intervals 8 Time to presentation Admission to surgery interval The trend towards later presentation in the elderly was significant at the P=. level Downloaded from at Pennsylvania State University on March, 2

4 McCALLION ET AL.: ACUTE APPENDICITIS IN THE ELDERLY 2 considering the perforation rate in the elderly. Thirty per cent of the elderly group had perforations, and all of these had a delay of greater than 2 h between onset of symptoms and surgery. Only one younger patient perforated, and this in less than 2 h. Part of the delay in commencing the surgical procedure in the elderly might be attributed to diagnostic difficulty, in that there was only a correct preoperative diagnostic rate in this group compared to in the young cohort (P<.). In those elderly patients with a preoperative diagnosis of acute appendicitis only half had an 'appendicitis incision' such as Lanz, grid iron or skin crease. The rest had either right paramedian or midline incisions allowing a wider variety of surgical procedures. The relevance of the incision choice is emphasized when analysing complications in the elderly group. All cases of postoperative pneumonia and wound dehiscence occurred in the subgroup who had a paramedian incision. A course of broad spectrum antibiotics was commenced preoperatively in of the elderly, and of the younger group. A single dose of metronidazole was prescribed in a further 7 of the elderly and of the young. However, postoperative infection was confined to the elderly, occurring in ( patients). Of these, seven had chest and six had wound infections, three having both. Seven of the patients were taking broad-spectrum antibiotics. Fifty-three per cent of the elderly had at least one complication whereas none occurred in the younger group. The mortality rate in our study () is somewhat higher than that found in other series [2-8]. With a relatively small number of patients and an older population, the significance is difficult to assess. The causes of death were myocardial infarction (one case), pulmonary thromboembolus (one case), and bronchopneumonia (two cases). The duration of hospital stay was considerably longer in the elderly with an average stay of days compared to days in the young. Even in those elderly patients with no noted complications the duration of stay was still days on average. DISCUSSION Incidental appendicectomies were excluded from our study, although it was interesting to note that more than of the total number of appendices removed in the over- age group were at other operations. This study demonstrates that the range and type of symptoms experienced in acute appendicitis were similar in both groups. There was also little difference in the findings on clinical examination between the two populations. However, rebound tenderness was much more common in our younger group whereas the presence of a caecal mass was confined to the elderly population. Despite similarities in presentation, the diagnosis of appendicitis was apparently more difficult to make with certainty in the elderly, probably because the range of differential diagnoses is greater. Delay in presentation and in surgery appears to be associated with an increased risk of perforation. The incision chosen was related to the incidence of postoperative chest problems. The mortality rate of in the elderly group was high, but there was no correlation between increasing age and increasing morbidity within the group. Downloaded from at Pennsylvania State University on March, 2

5 2 AGE AND AGEING VOL., NO. CONCLUSIO Appendicitis in the elderly is an uncommon condition,.2 cases/ population/year. Our study shows no improvement in morbidity and mortality from earlier studies. The main complications are still related to infection. REFERENCES. Soreide O. Appendicitis: a study of incidence, death rates and consumption of hospital resources. Postgrad hied J 8;:-. 2. Burns RP, Cochran JL, Russell WL, Bard RM. Appendicitis in mature patients. Ann Surg 8;2:-7.. Goldenberg IS. Acute appendicitis in the aged. Geriatrics ;:2-7.. Hubbell DS, Barton WK, Solomon OD. Appendicitis in older people. Surg Gynecol Obstet ;: Owens BJ, Horrit HF. Apendicitis in the elderly. Ann Surg 78;87:2-.. Thorbjarnareon B, Loehr WJ. Acute appendicitis in patients over the age of. Surg Gynecol Obstet 7;2: Yusuf MF, Dunn E. Appendicitis in the elderly: Learn to discern the untypical picture. Geriatrics 7;: Freind HR, Rubenstein E. Appendicitis in the aged: is it really different? Ann Surg 8;:-. Date accepted January 87 Downloaded from at Pennsylvania State University on March, 2