INCREASED MORBIDITY OF APPENDICITIS WITH ADVANCING AGE

The early diagnosis of acute appendicitis before progression to gangre ne or abscess formation is recognized as important to minimize morbidi ty from this common disease process. As our population ages, the chall enge for expedient diagnosis and intervention in older age groups will become more significant. Prompted by recent unexpected complications occurring in elderly patients, we reviewed 100 consecutive admissions with the diagnosis of appendicitis to a tertiary Veterans Administrati on hospital. All patients were males and were arbitrarily divided into three age groups: less than 50, 50-70, and greater than 70 years of a ge. There were no patients less than 20 years old. Operative findings were classified as simple acute appendicitis, ruptured or perforated a ppendicitis, appendicitis associated with intra-abdominal abscess, and finally other when the operative diagnosis differed from appendicitis . Of the 37 patients less than 50 years of age, 28 were found to have simple acute appendicitis, making this by far the most common finding in this age group (P < 0.05). Only two of the 18 patients aged 50-70 w ith appendicitis demonstrated simple acute appendicitis, with the rema inder having progressed to perforation or abscess formation (P < 0.05) . Patients greater than 70 years of age were significantly more likely than any other age group to manifest appendicitis associated with int raabdominal abscess (10 of 19, P < 0.05). Eight patients died in this series, six of whom were more than 70 years of age. In most cases, mor tality was directly attributable to infectious complications of perfor ated appendicitis. There were no deaths in the under 50 age group. Amo ng variables examined, only the duration of symptoms correlated with t he incidence of complications and final outcome. Patients found to hav e simple acute appendicitis complained of symptoms lasting approximate ly 22 +/- 0.9 hours before presentation (average age 34 +/- 3 years). In those patients whose disease had progressed to ruptured appendix or appendicitis associated with abscess, there was a significantly longe r duration of symptoms, with the onset of illness 50 +/- 2.6 and 66 +/ - 2.4 hours before presenting to the hospital, respectively (P < 0.05) . The average age for complicated appendicitis was also significantly older (average age 61 +/- 4 years, P < 0.05). Finally, 82% of the diag nostic errors occurred in those patients greater than 50 years old (P < 0.05 compared to age < 50). We conclude that increasing age is direc tly associated with complicated appendicitis, fatal appendicitis, and errors in diagnosis. Furthermore, much of the difficulty in the manage ment of older males diagnosed with appendicitis appears not to be due to a difference in presentation, but rather to a delay in seeking medi cal attention, resulting in a more advanced stage of disease.