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

Background: Acute appendicitis is the second most common cause of surgical abdominal disease in late adulthood. it is a serious condition: major error s in management are made frequently and the condition is associated with si gnificant morbidity and mortality. Data collected within a multicenter pros pective trial and a literature review were used to analyze diagnostic and t herapeutic difficulties in detail. methods: In a multicenter intervention s tudy (MEDWIS A 70) data from 2,280 patients with acute abdominal pain were collected prospectively. Patients with histologically proven acute appendic itis, aged 50 years and older (n=102), were compared with younger patients (n=417) to determine differences in presentation, clinical course, and outc ome. The basis for the literature review was a Medline search for appendici tis 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: Pa tients aged 50 years and older with acute abdominal pain had a significantl y 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 presentatio n of appendicitis in younger patients was far more ambiguous. There were no significant differences in outcome between older and younger patients as r egards perforations. Perforations are directly associated with treatment de lay. Overall delay is a result of late presentation of older patients to ho spital and postadmission delay. Conclusions: Appendicitis in late adulthood is characterized by a delay in treatment, high perforation rates, and unfa vorable outcome parameters, all mutually correlating. Older patients with a cute abdominal pain are high-risk patients, unlike their younger counterpar ts. They have to be clinically evaluated by experienced surgeons within a n arrow time margin. The problem of late presentation and/or referral should be addressed, perhaps by education of primary care physicians and the publi c.