A reappraisal of appendicitis in the elderly

Influence of sarcopenia and frailty in the management of elderly patients with acute appendicitis

In developed countries, the average life expectancy has been increasing and is now well over 80 years. Increased life expectancy is associated with an increased number of emergency surgical procedures performed in later age groups. Acute appendicitis is one of the most common surgical diseases, with a lifetime risk of 8%. A growing incidence of acute appendicitis has been registered in the elderly population and in the oldest groups (> 80 years). Among patients > 50-year-old who present to the emergency department for acute abdominal pain, 15% have acute appendicitis. In these patients, emergency surgery for acute appendicitis is challenging, and some important aspects must be considered. In the elderly, surgical treatment outcomes are influenced by sarcopenia. Sarcopenia must be considered a precursor of frailty, a risk factor for physical function decline. Sarcopenia has a negative impact on both elective and emergency surgery regarding mortality and morbidity. Aside from morbidity and mortality, the most crucial outcomes for older patients requiring emergency surgery are reduction in function decline and preoperative physical function maintenance. Therefore, prediction of function decline is critical. In emergency surgery, preoperative interventions are difficult to implement because of the narrow time window before surgery. In this editorial, we highlight the unique aspects of acute appendicitis in elderly patients and the influence of sarcopenia and frailty on the results of surgical treatment.

The Emergency Surgery Frailty Index (EmSFI) in Elderly Patients with Acute Appendicitis: An External Validation of Prognostic Score

BACKGROUND

Identification of reliable risk-stratification tools is critical for surgical decision making, particularly in frail and elderly. The aim of the study is to validate the Emergency Surgery Frailty Index (EmSFI), in over 65 years old patients operated on for acute appendicitis.

METHODS

An observational study was conducted enrolling elderly patients with diagnosis of acute appendicitis who underwent emergency appendicectomy or right colectomy, between 2016 and 2021. All patients were treated according to the last SIFIPAC/WSES/SICG/SIMEU guidelines.

RESULTS

Overall, 61 patients were analyzed. Complication rate was higher for patients in the second EmSFI risk Class. Moreover, ROC analyses identified 3 as the best cutoff value in predicting risk of adverse postoperative events. Complication rate was higher in oldest elderly patients-over 80 years-(42.9 vs 22.5%; p 0.05) and was mainly related to medical complications (42.9 vs 12.5%, p 0.007). However, intestinal obstruction, peri-appendicular abscess on preoperative CT, peritonitis and a longer duration of surgery are related with increased risk of complications in the group of patients under 80 years.

CONCLUSION

The EmSFI score results a valid prognostic marker for frailty status, and it may support the surgeon in emergency setting for acute appendicitis. Patients aged 80 years or older have a higher risk of complications, independent from those factors which relate to increased morbidity in younger elderly patients. Age alone is not a reliable indicator of the real surgical risk, but it must encourage the adoption of multidisciplinary collaborative models of care for this group of patients.

Characteristics of Patients Presented with Complicated Appendicitis in Adama, Ethiopia: A Cross-Sectional Study

BACKGROUND

Complicated appendicitis (CA) is defined as perforated appendicitis, peritonitis, peri-appendicular abscess, or appendicular mass. One-third of patients who develop appendicitis are diagnosed with CA at presentation. Studies regarding the prevalence of CA are lacking in low-income countries, and the characteristics of patients presented with CA are incoherently identified.

OBJECTIVE

To assess the prevalence and the significant characteristics associated with CA among patients admitted with the diagnosis of acute appendicitis at Adama Hospital Medical College.

METHODS

A cross-sectional study was conducted from January 1, 2018, up to December 31, 2019. From a total of 1043 patients during the study period, the charts of 431 patients were selected using a systematic random sampling technique. Data were collected by a structured checklist. Bivariate and multivariable binary logistic regression analyses were employed to assess the association of patients' characteristics with CA.

RESULTS

Out of 431 patients, 157 (36.4%) had CA. Characteristics of patients having a significant association with CA were found to be generalized abdominal tenderness (AOR: 27.48, 95% CI: 4.03, 187.24), diagnosis with peritonitis (AOR: 14.87, 95% CI: 4.05, 54.54), right lower quadrant (RLQ) abdominal mass (AOR: 7.79, 95% CI: 2.02, 29.99), shock (10.37, 95% CI: 3.18, 33.76), white blood cell (WBC) count >11,000 (AOR: 2.16, 95% CI: 1.02, 4.61), onset to visit interval of 8-14 days (AOR: 10.45, 95% CI: 2.4, 45.52) and ultrasound report of acute appendicitis (AOR: 0.33, 95% CI: 0.13, 0.85), appendiceal abscess (AOR: 5.05, 95% CI: 1.48, 17.31), and appendiceal mass (AOR: 6.04, 95% CI: 1.45, 25.14).

CONCLUSION

The prevalence of CA was very high. Generalized abdominal tenderness, RLQ abdominal mass, shock, WBC count, onset to visit interval, abdominopelvic ultrasound report, and clinical diagnosis of peritonitis were significantly associated with CA.

Comparison of Clinical Features and Outcomes of Appendectomy in Elderly vs. Non-Elderly: A Systematic Review and Meta-Analysis

Background

The objective of this study is to compare clinical and surgical outcomes of appendectomy among elderly and non-elderly subjects.

Methods

A systematic search was conducted on PubMed, Scopus, and Google academic databases. Studies, observational in design, that compared peri-and postoperative outcomes of appendectomy, in patients with acute appendicitis, between elderly and non-elderly/younger subjects were considered for inclusion. Statistical analysis was performed using STATA software.

Results

A total of 15 studies were included. Compared to non-elderly patients, those that were elderly had an increased risk of complicated appendicitis [relative risk (RR), 2.38; 95% CI: 2.13, 2.66], peritonitis [RR, 1.88; 95% CI: 1.36, 2.59], and conversion from laparoscopic to open appendectomy [RR, 3.02; 95% CI: 2.31, 3.95]. The risk of overall postoperative complications [RR, 2.59; 95% CI: 2.19, 3.06], intra-abdominal abscess [RR, 1.84; 95% CI: 1.15, 2.96], wound infection [RR, 3.80; 95% CI: 2.57, 5.61], and use of postoperative drainage [RR, 1.14; 95% CI: 1.09, 1.19] was higher among the elderly. The risk of readmission (30 days) [RR, 1.61; 95% CI: 1.16, 2.24] and mortality (30 days) [RR, 12.48; 95% CI: 3.65, 42.7] was also higher among elderly.

Conclusions

Findings suggest an increased risk of peri-and postoperative complications among elderly subjects undergoing appendectomy, compared to non-elderly subjects.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021286157.

The Risk of Alzheimer's Disease After Acute Appendicitis With or Without Appendectomy

OBJECTIVE

Previous epidemiologic studies have suggested an association between appendectomy and Parkinson's disease. The aim of the current study was to examine the risk of Alzheimer's disease (AD) and other types of dementia following appendicitis or appendectomy for appendicitis.

DESIGN

Population-based cohort study.

SETTING AND PARTICIPANTS

We used claims data from the Taiwan National Health Insurance Research Database. Participants aged ≥45 years with acute appendicitis or who received appendectomy for appendicitis were enrolled and followed up for more than 15 years. Cases and controls underwent 1:1 matching by age, sex, index date, and dementia-related comorbidities.

METHODS

The primary outcome was AD, and secondary outcomes included other dementia types. Adjusted hazard ratios (aHRs) were calculated, and a competing risk regression model was created. The E value for causality of evidence was calculated.

RESULTS

Patients developing appendicitis (0.6% vs 0.1%, P = .005) and those receiving appendectomy for appendicitis (0.4% vs 0.1%, P = .003) had higher incidences of AD than the controls during the follow-up period. A Cox regression analysis with adjustment for potential confounders showed that patients with appendicitis [aHR 6.68, 95% confidence interval (CI) 1.84-24.48] and those receiving appendectomy for appendicitis (aHR 5.01, 95% CI 1.33-18.85) were more likely to develop AD than the controls. These 2 groups also had higher risks for unspecified dementia and all types of dementia but not for vascular dementia than the controls. The age at dementia diagnosis was 88.51 years in the controls; however, among people who developed dementia following appendicitis, the mean age at diagnosis was 70.18 years, and dementia occurred 5.84 years after appendicitis. The competing risk regression models and the E values support the study findings.

CONCLUSIONS AND IMPLICATIONS

After recovery from appendicitis, these patients should be followed up for signs of AD.

Chronological Changes in Appendiceal Pathology Among Patients Who Underwent Appendectomy for Suspected Acute Appendicitis

BACKGROUND

Given recent advances in imaging and the development of diagnostic parameters, the rate of unnecessary appendectomy (i.e., negative appendectomy) has been decreasing. However, the incidence of acute appendicitis (AA) in elderly patients is rising due to the aging of society. We aimed to identify chronological changes in demographics and appendiceal pathology among patients who underwent appendectomy for suspected AA.

METHODS

Data from 881 patients who underwent appendectomy for suspected AA between January 2006 and December 2017 were analyzed. The final diagnosis was based on intraoperative findings, pathological reports, and clinical course. Negative appendectomy was defined as the absence of appendiceal diseases including inflammation, fibrosis, and neoplasm. We compared demographics and appendiceal pathology between early (2006-2011) and late study phases (2012-2017).

RESULTS

The mean age of patients with pathologically proven AA (n = 761) was significantly greater in the late phase than in the early phase (38.6 ± 19.8 years vs. 44.0 ± 20.3 years, p = 0.0002), and the ratio of patients with AA aged ≧ 75 years was also increased (from 5.6 to 8.6%, p = 0.1120). The incidences of complicated appendicitis (defined as perforated or gangrenous appendicitis) and appendiceal diverticulitis (AD) were increased in the late phase compared to those in the early phase (61.3% vs. 77.2% and 3.7% vs. 6.6%, respectively). The negative appendectomy rate was significantly reduced in the late phase compared to that in the early phase (10.0% vs. 2.5%, p < 0.0001).

CONCLUSIONS

During a 12-year period, the mean age of patients with AA and the incidences of complicated appendicitis and AD increased, whereas the negative appendectomy rate decreased.

Appendiceal neoplasm incidence and mortality rates are on the rise in Australia

OBJECTIVES

The study aimed to examine the incidence and mortality rates of appendiceal neoplasms (ANs) in Australia.

METHODS

A retrospective analysis was performed on national data obtained from the Australian Institute of Health and Welfare (AIHW) from 1982 to 2013. Changes to the incidence, and the cancer-specific mortality following the diagnosis of ANs were analyzed over this time period, with stratification performed for histological subtype, gender, and age groups (<50y and ≥50y).

RESULTS

Incidence and mortality rates of ANs increased significantly across both genders and age groups. Incidence rates increased by 415%, from 0.40/100 000 population in 1982 to 2.06/100 000 in 2013. Overall mortality rates increased by 130%, from 0.057/100 000 during 1982-1985 to 0.131/100 000 during 2010-2013. Controlling for age group and gender, the incidence rates increased by 20% every four years (Incidence rate ratio (IRR) = 1.20, 95% confidence interval (CI): 1.17, 1.23, global P value<0.0001), and controlling for age, the mortality rates increased by 8% every four years (IRR = 1.08, 95% CI: 1.00, 1.17, global P-value = 0.0401).

CONCLUSION

The increasing use of CT scanning, improvements in pathological assessment of the appendix, and the growing aging population may have contributed in part to the apparent rise in the incidence of ANs.

Geriatric patients undergoing appendectomy have increased risk of intraoperative perforation and/or abscess

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Evaluation of the predictive power of laboratory markers in the diagnosis of acute appendicitis in the elderly

OBJECTIVE

The aim of this study was to analyze the predictive value of preoperative laboratory findings in acute appendicitis in geriatric patients aged >65 years.

METHODS

We enrolled a total of 4121 patients. A retrospective evaluation of the demographic features was made using preoperative laboratory values such as the white blood cell (WBC), neutrophil, and lymphocyte counts; platelet counts; the mean platelet volume and bilirubin values; and postoperative pathological data of the patients from the electronic file system. The neutrophil-to-WBC and neutrophil-to-lymphocyte ratios were calculated. Patients were divided into two groups, as geriatric (≥65 years old, n=140) and non-geriatric (<65 years old, n=3981).

RESULTS

The white blood cell and lymphocyte counts, and the neutrophil-to-WBC ratio, were significantly higher in the non-geriatric group (p<0.001, p=0.013, and p=0.021, respectively). The neutrophil and platelet counts were higher in the non-geriatric group, but this difference was not statistically significant (p=0.073 and p=0.072, respectively). A higher neutrophil-to-lymphocyte ratio was determined in the geriatric group, but the difference was not significant (p=0.176). According to the optimumal cutoff value of 12.11×103/µL for WBC, specificity and sensitivity values of 65.4% and 57.9% were calculated, respectively; the AUC value was 0.632±0.024 (p<0.001). A receiver operating characteristic (ROC) analysis was used to calculate the optimum cutoff values of neutrophil-to-WBC ratio, lymphocyte, and the mean platelet volume, but the diagnostic accuracy of these tests was inadequate with an AUC of <0.6.

CONCLUSION

WBC values >12.11×103/µL were predictive of acute appendicitis in geriatric patients. The other parameters were not predictive, and further studies are required.

In-hospital perforation risk in acute appendicitis: Age matters

BACKGROUND

Controversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis.

METHODS

We evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon.

RESULTS

Of 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms >24 h (aOR = 2.23, 95% CI = 1.33-3.72, p < 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04-10.06, p < 0.001) was also associated with higher risk that increased with increasing age.

CONCLUSION

Time to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.

Changing Epidemiology of the American Population

The changing epidemiology of the geriatric population in the United States has diverse social, medical, and financial implications that will continue to expand over the next few decades. According to the US Census Bureau, 20% of the US population will be 65 years or older by 2030 and more than 50% will eventually belong to a minority group. These changes are expected to be accompanied by several effects on the geriatric population's demographics, injury characteristics, surgical interventions, and the cost of caring for the geriatric population, which will ultimately broaden the financial burden.

Outcomes of appendectomy in elderly veteran patients

BACKGROUND

Some studies indicate that noncomplicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy. This study was undertaken to assess outcomes in elderly veterans and to determine if operative intervention would lead to substantial complications such that a nonoperative strategy should be investigated.

METHODS

A retrospective, single-institution analysis was conducted of patients who underwent an appendectomy at the VA North Texas Health Care System over a period of 12 years (from July 2005 to June 2017). Patients who underwent an appendectomy for cancer, interval appendectomy, exploratory laparotomy for perforated appendicitis, or appendectomy as part of another major operation were excluded from the study. Patients were then grouped as elderly (≥60 years old) and young (<60 years old), and differences in outcome were assessed. Univariate and multivariate analyses were also performed to determine if age and comorbid conditions were independent predictors of complications in both cohorts.

RESULTS

Of patients who underwent an appendectomy for acute appendicitis (n = 257, male = 90.7%, age = 45.4 ± standard deviation 15.6 years, body mass index = 30.3 ± 6.3 kg/m²), 195 were young (38.7 ± 11.2 years old) and 62 elderly (66 ± 5 years old). More patients were male in the elderly cohort (98.4% vs 88%; P = .01). The incidence of gangrenous and perforated appendicitis was greater in elderly patients (11.3% and 14.4% vs 24 % and 40%, P < .01 each). Diabetes and hypertension, as well as a history of cardiac, pulmonary, and renal diseases, were more than 2-fold greater in older patients. Complications and 30-day readmission rates were similar in both groups (young vs elderly: 7.2% and 9% vs 9.7% and 11%, P > .5 each). Logistic regression analysis showed that age and American Society of Anesthesia level were not independent predictors of complications. A history of cardiac disease and open operation independently predicted complications regardless of age. Unexpected malignancy was 3% in the elderly and 1.5% in the young cohort (P = .6) CONCLUSION: Complicated appendicitis is more common in elderly patients. Appendectomy in elderly veteran patients has a low rate of complications similar to younger patients and the private sector. Operative intervention in this group of patients is not prohibitive. Further studies are needed to determine if nonoperative intervention is noninferior to an appendectomy in this high-risk patient population.

Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy

INTRODUCTION

The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population.

METHODS

From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality.

RESULTS

Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls.

CONCLUSIONS

Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.

The Utility of the Alvarado Score in the Diagnosis of Acute Appendicitis in the Elderly

Clinical scores determining the likelihood of acute appendicitis (AA), including the Alvarado score, were devised using a younger population, and their efficacy in predicting AA in elderly patients is not well documented. This study's purpose is to evaluate the utility of Alvarado scores in this population. A retrospective chart review of patients >65 years old presenting with pathologically diagnosed AA from 2000 to 2010 was performed. Ninety-six patients met inclusion criteria. The average age was 73.7 ± 1.5 years and our cohort was 41.7 per cent male. The average Alvarado score was 6.9 ± 0.33. The distribution of scores was 1 to 4 in 3.7 per cent, 5 to 6 in 37.8 per cent, and 7 to 10 in 58.5 per cent of cases. There was a statistically significant increase in patients scoring 5 or 6 in our cohort versus the original Alvarado cohort (P < 0.01). Right lower quadrant tenderness (97.6%), left shift of neutrophils (91.5%), and leukocytosis (84.1%) were the most common symptoms on presentation. In conclusion, our data suggest that altering our interpretation of the Alvarado score to classify elderly patients presenting with a score of ≥5 as high risk may lead to earlier diagnosis of AA. Physicians should have a higher clinical suspicion of AA in elderly patients presenting with right lower quadrant tenderness, left shift, or leukocytosis.

Delta neutrophil index: A reliable marker to differentiate perforated appendicitis from non-perforated appendicitis in the elderly

BACKGROUND

Delta neutrophil index (DNI) is a new inflammatory marker and the present study aimed to evaluate the predictive value of the DNI for the presence of a perforation in elderly with acute appendicitis.

METHODS

This retrospective observational study was conducted on 108 consecutive elderly patients (≥65 years old) with acute appendicitis treated over a 24-month period.

RESULTS

Sixty-nine of the 108 patients (median, IQR: 72, 67-77 years) were allocated to the perforated appendicitis group (63.9%) and 39 to the non-perforated appendicitis group (36.1%). WBC, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and DNI were significantly higher in the perforated group. In multiple logistic regression analyses, initial DNI was the only independent marker that can significantly predict the presence of perforation in multiple regression [odds ratio 9.38, 95% confidence interval (2.51-35.00), P=.001]. Receiver operator characteristic curve analysis showed that DNI is a good predictor for the presence of appendiceal perforation at an optimal cut-off for DNI being 1.4% (sensitivity 67.7%, specificity 90.0%, AUC 0.807).

CONCLUSION

Clinicians can reliably differentiate acute perforated appendicitis from non-perforated appendicitis by DNI level of 1.4 or more in elderly patients.

Should Oral Contrast Be Omitted in Patients with Suspected Appendicitis?

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies. Our study evaluated patients given the diagnosis of appendicitis and reviewed their workup and clinical outcomes. We specifically focused on the use of oral contrast followed by appendectomy.

METHODS

We retrospectively reviewed all adult patients given an ICD-9 code for appendicitis at Northwestern Memorial Hospital between January 2000 and September 2010. Complication rates, time to the operating room, and length of hospital stay were compared between patients who received a CT scan and those who did not during the hospitalization for appendicitis.

RESULTS

Average time from Emergency Department to the operating room was found to be statistically longer for patients who underwent a CT scan (10 h: 3, 1548) versus those who did not (6 h: 2, 262) (p < 0.0001). There were 19 patients who had the complication of pneumonia and 4 patients who were diagnosed with acute respiratory distress syndrome postoperatively. Patients who underwent a CT scan and received oral contrast had a statistically higher number of both complications (p < 0.0001).

CONCLUSIONS

The use of oral contrast is not necessary for an accurate diagnosis of appendicitis and may be associated with higher complication rates, longer hospital stays, and poor outcomes.

A lower neutrophil to lymphocyte ratio is closely associated with catarrhal appendicitis versus severe appendicitis

PURPOSE

Catarrhal appendicitis (CA) could be treated effectively with antibiotics in some patients because of the milder inflammation associated with this form of appendicitis. Although several trials have compared surgery with antibiotic therapy for acute appendicitis (AA), the indications for antibiotic therapy remain controversial.

METHODS

The subjects of this study were 342 patients who underwent appendectomy at our hospital between January, 2000 and March, 2013. The patients were divided into two groups based on the severity of their appendicitis: Group A comprised patients with severe appendicitis and Group B comprised patients with CA. Statistical analyses were performed to assess the clinical features associated with CA.

RESULTS

Multivariate analysis of the eight clinical features correlated with CA according to univariate analysis revealed that the neutrophil to lymphocyte ratio (NLR) (<5/>5), age (<38/>38 years), fever (<38/>38 °C), white blood cell count (<11.5/>11.5 × 10³/mm³) and serum level of C-reactive protein (<110/>110 mg/L) were significantly associated with CA. The NLR (<5/>5) (OR 0.421; 95 % CI 0.218-0.811; P = 0.010) was the most useful predictor of CA, because the area under the ROC curve of NLR was the lowest of all these features.

CONCLUSION

The preoperative NLR in patients undergoing appendectomy is closely associated with CA.

The Role of Digital Rectal Examination for Diagnosis of Acute Appendicitis: A Systematic Review and Meta-Analysis

BACKGROUND

Digital rectal examination (DRE) has been traditionally recommended to evaluate acute appendicitis, although several reports indicate its lack of utility for this diagnosis. No meta-analysis has examined DRE for diagnosis of acute appendicitis.

OBJECTIVES

To assess the role of DRE for diagnosis of acute appendicitis.

DATA SOURCES

Cochrane Library, PubMed, and SCOPUS from the earliest available date of indexing through November 23, 2014, with no language restrictions.

STUDY SELECTION

Clinical studies assessing DRE as an index test for diagnosis of acute appendicitis.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted study data and assessed the quality, using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Bivariate random-effects models were used for the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR) as point estimates with 95% confidence intervals (CI).

MAIN OUTCOMES AND MEASURES

The main outcome measure was the diagnostic performance of DRE for diagnosis of acute appendicitis.

RESULTS

We identified 19 studies with a total of 7511 patients. The pooled sensitivity and specificity were 0.49 (95% CI 0.42-0.56) and 0.61 (95% CI 0.53-0.67), respectively. The positive and negative likelihood ratios were 1.24 (95% CI 0.97-1.58) and 0.85 (95% CI 0.70-1.02), respectively. The DOR was 1.46 (0.95-2.26).

CONCLUSION AND RELEVANCE

Acute appendicitis cannot be ruled in or out through the result of DRE. Reconsideration is needed for the traditional teaching that rectal examination should be performed routinely in all patients with suspected appendicitis.

[Recognition of infections in elderly emergency patients]

BACKGROUND

Elderly patients represent an increasing population in the emergency department (ED) and physicians often have to deal with multimorbidity and complexity. Infections are one of the major reasons for ED presentations of older patients and the main cause of mortality; however, infections are often difficult to diagnose in older patients.

AIM

This article provides a review of important indicators for infections, diagnostic tools and limitations in elderly patients.

MATERIAL AND METHODS

A literature search was carried out using PubMed in the period 1990-2015 and in addition own published data are presented.

RESULTS AND CONCLUSION

Infections in the elderly are difficult to assess in the emergency department due to atypical symptoms. Even subtle changes need to be recognized. For the diagnosis of infections in older ED patients unspecific symptoms, vital parameters, laboratory parameters, including C-reactive protein (CRP) and procalcitonin levels, cognitive function and functionality of the patient need to be taken into account.

Acute right lower abdominal pain in women of reproductive age: Clinical clues

AIM: To study possible gynecological organ pathologies in the differential diagnosis of acute right lower abdominal pain in patients of reproductive age.

METHODS: Following Clinical Trials Ethical Committee approval, the retrospective data consisting of physical examination and laboratory findings in 290 patients with sudden onset right lower abdominal pain who used the emergency surgery service between April 2009 and September 2013, and underwent surgery and general anesthesia with a diagnosis of acute appendicitis were collated.

RESULTS: Total data on 290 patients were obtained. Two hundred and twenty-four (77.2%) patients had acute appendicitis, whereas 29 (10%) had perforated appendicitis and 37 (12.8%) had gynecological organ pathologies. Of the latter, 21 (7.2%) had ovarian cyst rupture, 12 (4.2%) had corpus hemorrhagicum cyst rupture and 4 (1.4%) had adnexal torsion. Defense, Rovsing’s sign, increased body temperature and increased leukocyte count were found to be statistically significant in the differential diagnosis of acute appendicitis and gynecological organ pathologies.

CONCLUSION: Gynecological pathologies in women of reproductive age are misleading in the diagnosis of acute appendicitis.

Journal club: Acute abdominal pain in elderly patients: effect of radiologist awareness of clinicobiologic information on CT accuracy

OBJECTIVE

The purpose of this study was to assess whether the availability of clinicobiologic findings would affect the diagnostic performance of CT of elderly emergency department patients with nontraumatic acute abdominal pain.

MATERIALS AND METHODS

The cases of 333 consecutively registered patients 75 years old or older presenting to the emergency department with acute abdominal pain and who underwent CT were retrospectively reviewed by two radiologists blinded or not to the patient's clinicobiologic results. Diagnostic accuracy was calculated according to the level of correctly classified cases in both the entire cohort and a surgical subgroup and was compared between readings performed with and without knowledge of the clinicobiologic findings. Agreement between each reading and the reference diagnosis and interobserver agreement were assessed with kappa statistics.

RESULTS

In both the entire cohort (87.4% vs 85.3%, p = 0.07) and the surgical group (94% vs 91%, p = 0.15), there was no significant difference in CT accuracy between diagnoses made when the radiologist was aware and those made when the radiologist was not aware of the clinicobiologic findings. Agreement between the CT diagnosis and the final diagnosis was excellent whether or not the radiologist was aware of the clinicobiologic findings.

CONCLUSION

In the care of elderly patients, CT is accurate for diagnosing the cause of acute abdominal pain, particularly when it is of surgical origin, regardless of the availability of clinical and biologic findings. Thus CT interpretation should not be delayed until complete clinicobiologic data are available, and the images should be quickly transmitted to the emergency physician so that appropriate therapy can be begun.

Acute appendicitis in the elderly: risk factors for perforation

BACKGROUND

Acute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.

METHODOLOGY

The medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.

RESULTS

During the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient's pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.

CONCLUSION

Acute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

Unspecific clinical presentation of bowel ischemia in the very old. Digitalis treatment - a reason for higher mortality?

BACKGROUND AND AIMS

Ischemic bowel disease predominantly affects the elderly (>65 years). Early diagnosis and treatment are of vital importance for the outcome. The vague symptoms of ischemic bowel disease entail a risk of delayed diagnosis, with a subsequent risk of increased mortality. The aims of this retrospective study were to identify symptoms and prodromes, to study factors associated with mortality in ischemic bowel disease, and to describe the influence of age, by comparing patients <80 and > or = 80 years.

METHODS

The subjects of the study were 135 patients, mean age 77 years, admitted to Malmö University Hospital, Sweden, between 1987 and 1996, with a ICD-9 diagnosis of acute or chronic splanchnic ischemia.

RESULTS

Patients aged 80 years or more presented with a significantly higher prevalence of confusion (29% vs 12%), hematemesis (57% vs 14%), vomiting (82% vs 65%) and dehydration (58% vs 36%) at admission compared with patients aged under 80 years, and presented a higher mortality (87% compared with 65%, p=0.003). The prevalence of digitalis treatment was 34%, which was high compared with other Swedish cohort studies. Digitalis, adjusted for age, congestive heart failure and atrial fibrillation, was associated with increased mortality (odds ratio 4.6, 95% CI 1.3-16.1). Prodromal signs predicted poor outcome, and were found in one out of 4 patients, without any age differences.

CONCLUSIONS

Bowel ischemia in the very old is associated with a different clinical presentation and a higher mortality compared with younger patients. Digitalis treatment seems to be associated with increased mortality in ischemic bowel disease. Prodromal signs are prognostically unfavorable.

Does laparoscopic appendectomy impart an advantage over open appendectomy in elderly patients?

BACKGROUND

The use of laparoscopy in the elderly has been increasing in recent years. The data comparing laparoscopic (LA) with open appendectomy (OA) in elderly patients are minimal. We evaluated outcomes of LA versus OA in perforated and nonperforated appendicitis in elderly patients (aged ≥ 65 years).

METHODS

Using the Nationwide Inpatient Sample database, clinical data of elderly patients who underwent LA and OA for suspected acute appendicitis were evaluated from 2006 to 2008.

RESULTS

A total of 65,464 elderly patients underwent urgent appendectomy during this period. The rate of perforated appendicitis was twice as high in elderly patients (50 vs. 25%, p < 0.01) and rate of LA in elderly patients was lower (52 vs. 63%, p < 0.01) compared with patients younger than aged 65 years. Utilization of LA increased 24% from 46.5% in 2006 to 57.8% in 2008 (p < 0.01). In elderly patients with acute nonperforated appendicitis, LA had lower overall complication rate (15.82 vs. 23.49%, p < 0.01), in-hospital mortality (0.39 vs. 1.31%, p < 0.01), hospital charges ($30,414 vs. $34,095, p < 0.01), and mean length of stay (3.0 vs. 4.8 days, p < 0.01) compared with OA. Additionally, in perforated appendicitis in elderly patients, LA was associated with lower overall complication rate (36.27 vs. 46.92%, p < 0.01), in-hospital mortality (1.4 vs. 2.63%, p < 0.01), mean hospital charges ($43,339 vs. $57,943, p < 0.01), and shorter mean LOS (5.8 vs. 8.7 days, p < 0.01).

CONCLUSIONS

Laparoscopic appendectomy can be performed safely with significant advantages compared with open appendectomy in the elderly and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.

Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania

Background

Decision-making in patients with acute appendicitis poses a diagnostic challenge worldwide, despite much advancement in abdominal surgery. The Modified Alvarado Scoring System (MASS) has been reported to be a cheap and quick diagnostic tool in patients with acute appendicitis. However, differences in diagnostic accuracy have been observed if the scores were applied to various populations and clinical settings. The purpose of this study was to evaluate the diagnostic value of Modified Alvarado Scoring System in patients with acute appendicitis in our setting.

Methods

A cross-sectional study involving all patients suspected to have acute appendicitis at Bugando Medical Centre over a six-month period between November 2008 and April 2009 was conducted. All patients who met the inclusion criteria were consecutively enrolled in the study. They were evaluated on admission using the MASS to determine whether they had acute appendicitis or not. All patients underwent appendicectomy according to the hospital protocol. The decision to operate was the prerogative of the surgeon or surgical resident based on overall clinical judgment and not the MASS. The diagnosis was confirmed by histopathological examination. Data was collected using a pre-tested coded questionnaire and analyzed using SPSS statistical computer software.

Results

A total number of 127 patients were studied. Their ages ranged from eight to 76 years (mean 29.64 ± 12.97). There were 37 (29.1%) males and 90 (70.9%) females (M: F = 1:2.4). All patients in this study underwent appendicectomy. The perforation rate was 9.4%. Histopathological examination confirmed appendicitis in 85 patients (66.9%) and the remaining 42 patients had normal appendix giving a negative appendicectomy rate of 33.1% (26.8% for males and 38.3% for females). The sensitivity and specificity of MASS in this study were 94.1% (males 95.8% and females 88.3%) and 90.4% (males 92.9% and females 89.7%) respectively. The Positive Predictive Value and Negative Predictive Value were 95.2% (males 95.5% and females 90.6%) and 88.4% (males 89.3% and females 80.1%) respectively. The accuracy of MASS was 92.9% (males 91.5% and females 87.6%).

Conclusion

The study shows that use of MASS in patients suspected to have acute appendicitis provides a high degree of diagnostic accuracy and can be employed at Bugando Medical Centre to improve the diagnostic accuracy of acute appendicitis and subsequently reduces negative appendicectomy and complication rates. However, additional investigations may be required to confirm the diagnosis in case of atypical presentation.

Design and instrumentation of new devices for performing appendectomy at colonoscopy (with video)

BACKGROUND

There is increasing interest in natural orifice surgery (NOS). Because the lumen of the appendix is connected to the cecum, a minimally invasive method for removing the appendix by colonoscopy may be feasible.

OBJECTIVES

Our purpose was to design, develop, and test new devices for inverting and removing the appendix by colonoscopy.

DESIGN

Prospective prototype development program.

SETTING

University-based study in 25 colons from adult human cadavers.

INTERVENTIONS AND METHODS

Various prototypes were evaluated by inserting them into the appendiceal orifice to its luminal tip, with the intent to invert the appendix in a controlled fashion into the lumen of the cecum. The advantage of using a tubular structure as a counterforce to aid inversion of the appendix was evaluated. When inversion was incomplete, the growing tissue strain was relieved by endoluminal incision of the mesenteric side of the appendix. Closure methods with endoloops or ligating loops were studied. Appendiceal resection was completed by snare diathermy, leaving an inverted intraluminal stump.

MAIN OUTCOME MEASUREMENT

Ability to invert the appendix into the cecum.

RESULTS

The mean appendix length and luminal diameter were 84 +/- 23 mm and 4.9 +/- 1.2 mm, respectively. It was possible to advance various types of inversion devices to the tip of the appendiceal lumen. Partial inversion of the appendix was successful in 22 of 25 tests. Mesenteric tissue tension, tissue volume, and device slippage were the main reasons for incomplete inversion. The complete inversion was achieved with a combination of vacuum, tip grip, counterforce at the appendix base, and eventually endoluminal incision.

CONCLUSIONS

The inversion of the human appendix by colonoscopy seems feasible and may be an alternative approach to conventional appendectomy.

Perforation of a retrocaecal appendix presenting clinically as a right lumbar abscess

Presentations of acute appendicitis represent an ongoing challenge to surgeons. This case of retrocaecal perforated appendicitis presented clinically as a right lumbar abscess, with the concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male. This case emphasises the importance of an abdominal CT scan in any patient presenting with unusual sepsis near the abdomen.

[Acute appendicitis in a femoral hernia]

INTRODUCTION

Acute appendicitis in a femoral hernia is an uncommon condition that can be serious. Complications are more frequent if the diagnosis is delayed and surgery is not performed on time.

CASE REPORT

We present a 71-year-old man with a painful swollen mass. The patient presented with fatigue and loss of appetite, while body temperature was normal. The abdomen was not painful, and peristaltic was normal. All laboratory findings were normal. After anamnesis and physical examination, the presumed diagnosis was incarcerated femoral hernia and the patient was sent to the operating room. Intraoperative findings revealed an incarcerated femoral hernia within a phlegmonous inflammated appendix. Appendectomy and McVay hernioplastics were done. The postoperative course was without complications.

CONCLUSION

It is very important to bear in mind that right femoral hernia with signs of incarceration and inflammation may contain an acutely inflamed appendix. Delayed diagnosis and misdiagnosis cause greater morbidity and mortality.

Acute appendicitis in the setting of Clostridium difficile colitis: case report and review of the literature

A 72-year-old man was hospitalized for exacerbation of chronic obstructive pulmonary disease and was treated with oral prednisone and 7 days of moxifloxacin. Five days after completing the antibiotic course, he developed watery diarrhea and diffuse, crampy abdominal pain. On presentation he was afebrile, and abdominal examination revealed diffuse tenderness without peritoneal signs. Stool tested positive for Clostridium difficile toxin A by enzyme-linked immunosorbent assay. Despite starting oral metronidazole, the patient developed a fever of 101.2 degrees F 36 hours after his initial episode of diarrhea, 12 hours after admission. His abdominal pain intensified and became localized to the right and left lower quadrants. Computed tomography scan revealed both a thickened cecal wall and an edematous appendix with ileocecal stranding consistent with appendicitis. Appendectomy was performed, and the appendix was found to be suppurative in appearance and nonperforated. The cecum had mild edema and erythema, whereas the colon and rectum were grossly unaffected. Pathology examination revealed exudative material in the appendiceal lumen and a diffuse transmural inflammatory cell infiltrate. The patient had an uneventful recovery and continued to improve on oral metronidazole. Although Clostridium difficile colitis and appendicitis are each very common independently, C. difficile as an etiology of appendicitis is exceedingly rare. A review of the literature revealed 2 prior cases. We speculate that this association is underdiagnosed, because milder cases might respond to antibiotic therapy alone, and severe cases might involve the entire colon and require total colectomy. In each scenario, the involvement of the appendix might be overlooked.

First case of villous adenoma of the appendix leading to acute appendicitis presenting as strangulated femoral hernia: changes in management owing to concurrent adenoma

A 78-year-old lady presented with signs and symptoms of a strangulated femoral hernia. Peri-operatively she was found to have appendicitis within the hernia sac. Appendicectomy and non-mesh hernia repair were performed. Histology revealed acute inflammation and a villous adenoma of the appendix. Villous adenomas of the vermiform appendix are extremely rare tumours of the gastrointestinal tract. This is the first case combining two very rare pathologies--acute appendicitis presenting as strangulated femoral hernia and villous adenoma of the appendix. Early diagnosis and surgery are required to avoid high morbidity of perforated appendicitis within a femoral hernia. First, we discuss the diagnosis and surgical treatment of acute appendicitis within a femoral hernia. Second, the presence of an adenoma changes the aetiology of appendicitis. More importantly, changes in surgical management of acute appendicitis presenting as a strangulated femoral hernia owing to a co-existing adenoma are discussed.

Appendicitis in the elderly: a change in the laparoscopic era

BACKGROUND

Appendicitis in elderly patients is associated with significant morbidity and mortality. Early and correct diagnosis together with minimally invasive surgery can lead to more favorable outcomes than occurred in the prelaparoscopic era.

METHODS

A retrospective review of 116 elderly patients (age > 60) from 1999 to 2004 is compared with the authors' previously published studies from 1978 to 1988 (n = 96) and from 1988 to 1998 (n = 113), respectively.

RESULTS

In our current series (1999-2004), more cases were managed laparoscopically (n = 68) than with open surgery (n = 48). Perforated appendicitis cases resulted in significantly longer hospital stays, more complications, and longer operating time than nonperforated cases. The laparoscopic cases had significantly shorter lengths of hospital stay and fewer complications than open cases, and comparable operating times. As compared with our previous studies from 1978 to 1988) and from 1988 to 1998, the current series (1999-2004) consists of patients presenting with fewer classical symptoms. Computed tomography (CT) scanning was more accurate in the current study and more routinely used. The patients in the current series had more correct preoperative diagnoses. Perforated appendicitis was encountered less frequently and associated with fewer complications. The 4% mortality rate in the previous two series decreased to less than 1% in this series.

CONCLUSION

Minimally invasive surgery combined with increased use and accuracy of preoperative CT scans has changed the clinical management of acute appendicitis in elderly patients, leading to decreased lengths of stay, decreased mortality, and more favorable outcomes.

Quantifying the usefulness of CT in evaluating seniors with abdominal pain

OBJECTIVES

(1) Determine if older patients with abdominal pain who receive emergency department (ED) abdominal CT have changes in diagnosis and/or disposition more often than similar patients without CT; (2) compare physician confidence in diagnosis and disposition for patients with versus without CT; (3) document factors that most influence physician's decision to order abdominal CT in this population.

METHODS

ED patients 60 years of age or older, with acute non-traumatic abdominal pain were enrolled over a 6-week period. Physicians documented a preliminary and final ED diagnosis and disposition, along with pre- and post-evaluation confidence levels. Decision to order CT, along with clinical information most influencing that decision, was noted. Physician confidence levels and percent change in diagnosis and disposition were compared for patients with versus without CT.

RESULTS

One hundred and twenty-six patients comprised study sample. Abdominal CT rate was 59% (95%CI, 50-67%). CT was associated with an increased change in diagnosis (46%; 95%CI, 4-58% versus 29%; 95%CI, 16-42%), but no change in disposition between patients with versus without CT. Preliminary diagnostic confidence was lower for EPs who ordered a CT than for those who did not (p<0.001). Patient history most influenced ordering CT, whereas prior lab/imaging results most influenced not ordering CT.

CONCLUSION

Patients with CT had a change in diagnosis more often than those without. Preliminary diagnostic confidence was lower in CT group. Percent change in disposition did not differ between groups. Physicians most often ordered CT based on history and did not order CT when other diagnostic evaluation supported a specific diagnosis.

Length of Stay by Route of Contrast Administration for Diagnosis of Appendicitis by Computed-tomography Scan

OBJECTIVES

Studies show equivalent accuracy of abdominal computed tomography (CT) using rectal contrast compared with oral contrast for diagnosing appendicitis. The authors evaluated whether emergency department (ED) length of stay and satisfaction differed by route of contrast administration for abdominal CT.

METHODS

This before-and-after intervention evaluated adult patients in an urban academic ED who were undergoing abdominal CT to screen for suspected appendicitis. Phase 1 subjects had a CT after oral contrast. Phase 2 patients had a CT after rectal contrast infused by gravity drip. Patients were interviewed after CT scan to assess satisfaction and discomfort. The primary outcome was ED length of stay. Medians, 95% binomial confidence intervals (CI), and Wilcoxon rank sum test of differences were calculated.

RESULTS

One hundred twelve patients were enrolled; half received rectal contrast. There was a significant decrease in length of stay for patients who were administered rectal contrast (261 min, 95% CI = 236 to 305 min) vs. oral contrast (332 min, 95% CI = 299 to 362 min), p = 0.009. Although subjects in the rectal-contrast group waited 65 minutes longer than did oral-contrast patients before receiving contrast after the CT order, the time from contrast administration to CT was 13 minutes, vs. 150 minutes for patients receiving oral contrast (p < 0.001). Patient satisfaction and discomfort did not differ by route of contrast administration.

CONCLUSIONS

Rectal contrast for patients undergoing abdominal CT to rule out appendicitis reduced ED length of stay by more than an hour and did not affect patient satisfaction or discomfort. Rectal-contrast administration for abdominal CT may significantly shorten patient throughput time for individuals undergoing evaluation for appendicitis.

Retrocecal Appendix Location and Perforation at Presentation

Retrocecal appendicitis has been theorized to follow a more insidious course than other anatomic variants. To determine the influence of retrocecal anatomy on clinical course of appendicitis, 200 adult patients treated at a major university medical center with the diagnosis of appendicitis from 2001 to 2004 were retrospectively studied. Computed tomography (CT) scans of adult patients with an ultimate diagnosis of appendicitis were analyzed to determine an association between retrocecal appendix and perforation of the appendix at presentation. A higher perforation rate in the retrocecal group would imply patient delay in presentation from more tolerable symptoms. CT scans were examined for retrocecal location and perforation. No significant association was found between retrocecal anatomy and perforation rates at presentation (chi-square = 2.1, P = 0.15, odds ratio = 1.6, 95% confidence interval [0.8–3.0]). However, the risk of perforation was 60 per cent higher in the retrocecal group. By regression analysis, age and the presence of a fecalith on CT scan were predictors of appendix perforation. Appendix location was not. In this study, we found no significant association between retrocecal appendix anatomy and perforation at presentation.

Assessment and differential diagnosis of abdominal pain

Abdominal pain as a chief complaint can present a significant diagnostic challenge in the primary care setting. It is incumbent upon the primary care provider to have a thorough understanding of the many potential causes of abdominal pain, as well as a methodical, comprehensive, yet concise approach to its assessment.

Advantages of Laparoscopic Appendectomy in the Elderly

Laparoscopic appendectomy (LA) has gained in popularity in recent years. The number of elderly patients undergoing appendectomy has increased as that segment of the population has increased in number; however, the utility and benefits of LA in the elderly population are not well established. We hypothesized that LA in the elderly has distinctive advantages in perioperative outcomes over open appendectomy (OA). We queried the 1997 to 2003 North Carolina Hospital Association Patient Data System for all patients with the primary ICD-9 procedure code for OA and LA. Patients ≥65 years of age (elderly) were identified and reviewed. Outcomes including length of stay (LOS), charges, complications, discharge location, and mortality were compared between the groups. There were 29,244 appendectomies performed in adult patients (>18 years old) with 2,722 of these in the elderly. The annual percentage of LA performed in the elderly increased from 1997 to 2003 (11.9–26.9%, P < 0.0001). When compared with OA, elderly patients undergoing LA had a shorter LOS (4.6 vs 7.3 days, P = 0.0001), a higher rate of discharge to home (91.4 vs 78.9%, P = 0.0001) as opposed to a step-down facility, fewer complications (13.0 vs 22.4%, P = 0.0001), and a lower mortality rate (0.4 vs 2.1%, P = 0.007). When LA was compared with OA in elderly patients with perforated appendicitis, LA resulted in a shorter LOS (6.8 vs 9.0 days, P = 0.0001), a higher rate of discharge to home (86.6 vs 70.9%, P = 0.0001), but equivalent total charges ($22,334 vs $23,855, P = 0.93) and mortality (1.0 vs 2.98%, P = 0.10). When elderly patients that underwent LA were compared with adult patients (18–64 years old), they had higher total charges ($16,670 vs $11,160, P = 0.0001) but equivalent mortality (0.37 vs 0.15%, P = 0.20). The use of laparoscopy in the elderly has significantly increased in recent years. In general, the safety and efficacy of LA is demonstrated by a reduction in mortality, complications, and LOS when compared with OA. The laparoscopic approach to the perforated appendix in the elderly patient has advantages over OA in terms of decreased LOS and a higher rate of discharge to home as opposed to rehabilitation centers, nursing homes, or skilled nursing care. When compared with all younger adults, the laparoscopic approach in the elderly was associated with equal mortality rates even though hospitalization charges were higher. Laparoscopy may be the preferred approach in elderly patients who require appendectomy.

Abdominal Pain in the Elderly

Elderly patients who have abdominal pain remain one of the most challenging patient populations. Signs and symptoms of serious disease are often nonspecific. Atypical presentations are common in elderly patients. In addition, the higher incidence of serious pathology in this population requires emergency physicians to be vigilant and thorough in their work-up. Vascular catastrophes are more likely to be seen in this population, and a broad differential diagnosis needs to be considered.

An unusual case of appendicitis

BACKGROUND

Acute appendicitis in elderly patients often presents late and atypically. Presentation as an incarcerated femoral hernia is rare.

AIM

To describe the management of an elderly patient presenting with acute appendicitis in an incarcerated femoral hernia.

METHODS

The femoral canal was explored and the hernia repaired. Formal appendicectomy was performed via a midline laparotomy incision.

RESULTS

Histological examination confirmed the diagnosis of acute appendicitis.

CONCLUSION

Unusual clinical presentations of acute appendicitis represent an interesting diagnostic challenge.

Role of Leukocyte Count, Neutrophil Percentage, and C-Reactive Protein in the Diagnosis of Acute Appendicitis in the Elderly

Leukocyte count, neutrophil percentage, and C-reactive protein (CRP) have been shown to give valuable information in the diagnosis of acute appendicitis. However, whether these laboratory tests have the same clinical applicability in the elderly as in young patients remains unclear. This retrospective study aimed to clarify the role of these tests in the diagnosis of acute appendicitis in patients aged 60 years or over. Eighty-five consecutive elderly patients underwent appendectomy for suspected acute appendicitis during a 30-month period. Histologically verified appendicitis was found in 77 of the 85 patients (90.6%). There was no significant difference in leukocyte counts or CRP values between patients with acute appendicitis and those with a normal appendix. The sensitivities of leukocyte count, neutrophil percentage, and CRP in the diagnosis of acute appendicitis were 71.4 per cent, 88.3 per cent, and 90 per cent, respectively, while the specificities were 37.5 per cent, 25 per cent, and 37.5 per cent, respectively. Of 77 patients with acute appendicitis, only two had all three tests simultaneously normal. In conclusion, patients with normal results in all three tests are highly unlikely to have acute appendicitis and should be evaluated with extra caution before surgery.