Acute appendicitis in late adulthood: incidence, presentation, and outcome. Results of a prospective multicenter acute abdominal pain study and a review of the literature

Abstract

Background: Acute appendicitis is the second most common cause of surgical abdominal disease in late adulthood. It is a serious condition: major errors in management are made frequently and the condition is associated with significant morbidity and mortality. Data collected within a multicenter prospective trial and a literature review were used to analyze diagnostic and therapeutic difficulties in detail.

Methods: In a multicenter intervention study (MEDWIS A 70) data from 2,280 patients with acute abdominal pain were collected prospectively. Patients with histologically proven acute appendicitis, aged 50 years and older (n=102), were compared with younger patients (n=417) to determine differences in presentation, clinical course, and outcome. The basis for the literature review was a Medline search for appendicitis in late adulthood and in the elderly, covering the years 1980-1998. In addition, studies on clinical presentation of acute appendicitis in all age groups were also reviewed and appropriate data were extracted.

Results: Patients aged 50 years and older with acute abdominal pain had a significantly higher incidence of surgery. Fourteen percent had acute appendicitis (27% in younger patients), with an increased complication rate (20% vs. 8%) and mortality (3% vs. 0.2%). Significantly more signs and symptoms suggestive of acute abdominal disease and peritonitis were recorded among older patients, reflecting the higher perforation rate (35% vs. 13%). Clinical presentation of appendicitis in younger patients was far more ambiguous. There were no significant differences in outcome between older and younger patients as regards perforations. Perforations are directly associated with treatment delay. Overall delay is a result of late presentation of older patients to hospital and postadmission delay.

Conclusions: Appendicitis in late adulthood is characterized by a delay in treatment, high perforation rates, and unfavorable outcome parameters, all mutually correlating. Older patients with acute abdominal pain are high-risk patients, unlike their younger counterparts. They have to be clinically evaluated by experienced surgeons within a narrow time margin. The problem of late presentation and/or referral should be addressed, perhaps by education of primary care physicians and the public.