Introduction

The evaluation of the elderly patient presenting with right lower abdominal pain poses a difficult challenge to the surgeon. The usual diagnosis of acute appendicitis is not common in the elderly, with only 10% occurring in the elderly¹ and therefore the diagnosis is commonly overlooked.

Elderly patients may present differently from their younger counterpart, they may delay in seeking for help and have diminished sensorium and therefore present with vague symptoms and signs². This may also allow pathology to advance before symptoms and signs develop. Some patient present with completely misleading symptoms and diagnosis has to be based on imaging studies³. Because of this, many elderly patients are misdiagnosed and necessary surgery delayed leading to increased incidence of perforation⁴. Compounding these is usually the presence of co-morbidity that increases surgical and anesthetic risk for these patients.

Acute appendicitis is commoner in the younger population with only 5-10% occurring in the elderly, but with the increasing life span, the incidence is likely to be on the increase^5,6. The purpose of this study is to look at the presentation and outcomes of acute appendicitis in the elderly as seen in a Private hospital in Nigeria.

Patients and Methods

This is a retrospective study done in a busy private hospital in Warri, Nigeria. Lily Clinic/Hospital is a 45 bed hospital in the center of Warri and receives referrals from other hospitals within Warri and its environs.

The names of all patients who had appendectomy in the hospital between March 2007 and February 2011 were gotten from the operation register. The names of patients more than 60 years old were selected and their records retrieved. The bio-data, clinical presentation and co-morbidity, findings at surgery and post-operative course were noted. The results were analyzed using simple percentages.

Results

There were one hundred and thirty-nine cases of appendectomy during the study period; and seventeen were in the elderly constituting 12.23% of all cases operated for appendicitis. There were 15 males (88.24%) and 2 females (11.76%); age/sex distribution is shown in table 1. The mean age for the males was 64.4 years ± 5.2SD, and the mean age for females was 76 years ± 2 SD.

Table 1: Age/Sex Distribution.

All presented with abdominal pain with 11 patients localizing the pain in the right lower abdomen and the others presenting with diffuse abdominal pain. The pain has been recurrent for more than 24 months in 4 of the male patients and both female patients and they had been evaluated in different hospitals for this complaint. The other patients had sudden onset abdominal pain within 72 hours of presentation. Anorexia was present in all patients, but none had nausea or vomiting.

Physical examination elicited right iliac fossa tenderness in four patients and generalized tenderness in the others. Fever was only present in 6 (35.29%) of the patients with generalized tenderness. One of the female patients had a palpable mass in the right iliac fossa.

All patients were evaluated with abdominal scan which diagnosedacute appendicitis in all patients (appendix >6mm in diameter, non-compressible), with presence of peritoneal fluid in 6 patients and an appendix mass in one.Leucocytosis was present in 9 patients (52.94%).

Co-morbidity was present in eleven patients (64.71%). Five of the patients had hypertension, three patients had diabetics and three others had both co-morbidities.

The lady with the appendix mass was initially managed conservatively but had to have drainage after 48 hours. The other patients had surgery within 24 hours of admission.  Intra-operative findings are shown in table 2.

Table 2: Intra-Operative Findings.

There were five complications in this series (29.41%), four patients had wound infection that required opening the wound and one had residualintraperitoneal abscesses that had to be drained. There was no mortality.

The patient with the intussuscepted appendix was found out on histology to have mucinous adenocarcinoma of the appendix. He was counseled to have a right hemicolectomy but he declined and has since been lost to follow up.

Discussion

The elderly patient made up 12.23% of all patients operated on for acute appendicitis over the study period. This is close to the 10% incidence reported in literature^5,6. There was a predominance of male in this study, with male making 88.24% of the cases, while previous reports have reported a slight male predominance or an even sex distribution⁷. The reason for this male predominance in this study is not clear and will have to be investigated in a larger study.

The diagnosis of acute appendicitis is usually made on history and clinical examination, but the elderly patients presenting with abdominal pain are often misdiagnosed^5,8. A high index of suspicion for appendicitis should be had by doctors when evaluating elderly patients with abdominal pain. The presence of right lower abdominal tenderness has been suggested to be the most sensitive physical finding in acute appendicitis⁹. Six of the patients were evaluated over 24 months for recurrent abdominal pain, this highlights the reluctance of doctors to make a diagnosis of appendicitis in the elderly.

The use of abdominal scan in the diagnosis of acute appendicitis has been found to be effective and this is shown in our study^10,11. The use of CT scan has been shown to have high specificity and sensitivity in diagnosing acute appendicitis^12,13. The high cost and lack of availability of computerized tomography scan in the country makes doctors reluctant to request this imaging for making a diagnosis of acute appendicitis as majority of patients cannot afford it.

The elderly patient is believed to present more with complicated appendicitis, with 70 -90% of elderly patients presented with perforated appendicitis^14,15. Majority of the patient in this study had perforated appendicitis (70.59%), and only one presented with an uncomplicated appendicitis (5.88%). This result was comparable to published data.

Mortality rate in the elderly with appendicitis range from 2% to 32%^5,9,16,17. There was no mortality in this study and this is likely due to the relatively small study population. There were five complications in this series (29.41%) which is similar to previous reports of 28-60% complication rate^5,17. The complications were are septic complications and this is explained by the high incidence of perforated appendix.

Conclusion

With increasing lifespan in the country, more elderly patients will be presenting to the doctor with abdominal pain. A careful history, physical examination and abdominal ultrasound scan can help make the diagnosis of acute appendicitis earlier. This will eventually translate to a reduction in morbidity and mortality.

References

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