Đặc điểm lâm sàng các trường hợp viêm ruột thừa ở người cao tuổi tại bệnh viện Nguyễn Tri Phương

美美美美美美
美美美美美美美
美美美美

醫醫醫醫醫醫醫醫醫醫醫醫醫醫醫
CLINICAL MANIFESTATIONS OF
ACUTE APPENDICITIS AMONG
ELDERLY AT NGUYEN TRI PHUONG
HOSPITAL, HO CHI MINH CITY
醫 醫 醫醫Nguyen Thi Tuyet Mai
醫醫醫醫醫Professor. Neoh Choo Aun

美 美 美 美 x xx 美 xx 美
醫醫醫醫醫醫醫醫醫醫醫醫醫醫醫
CLINICAL MANIFESTATIONS OF ACUTE
1


APPENDICITIS AMONG ELDERLY AT NGUYEN TRI
PHUONG HOSPITAL, HO CHI MINH CITY

Graduate student:醫Nguyen Thi Tuyet Mai
Supervisor醫Professor. Neoh Choo Aun

Meiho University
Graduate Institute of Health care
Thesis
A thesis submitted to the Graduate Institute of Health Care of
Meiho University
In partial fulfillment of the requirement for the degree of

Master of Health Care

July 2014

2


Abstract
Background: Acute appendicitis (APP) is a less common cause of abdominal pain in
elderly patients than in younger patients, but the severity among elderly patients
appears to be higher. Diagnosing an elderly patient who presents with abdominal pain
due to APP is a difficult challenge due to atypical manifestations, comorbidities and
socio-behavioral factors which are associated with this group of patients. Therefore,
identification clinical presentation of patients with APP is crucial to improve
punctuation and accuracy of APP diagnosis. In Nguyen Tri Phuong Hospital, the
diagnostic procedure of APP although is available, the rate of misdiagnosis of APP in
the elderly is surprisingly up to 18%. The reason for misdiagnosis is largely due to the
fact that physicians are lack of experience of recognizing clinical presentations of APP
in elderly patients; nevertheless, there are not any studies identifying clinical
manifestations of APP in elderly in the hospital setting.
Objective: The primary purpose of the present study is to identify all medical history,
physical examinations and laboratory findings related to APP and their relationships
with the occurrence of APP in elderly patients who are hospitalized and treated at
Nguyen Tri Phuong Hospital.
Methods: A retrospective study was carried out at Nguyen Tri Phuong Hospital with a
total of 130 older patients with APP in Nguyen Tri Phuong Hospital. Medical records
of participants were reviewed to explore all clinical presentation of participants. The
significance of the results was assessed by Chi-Square test at p-value of 0.05 using
SPSS version 16.
Results: In this study female accounted for large portion of study population

(61.54%). The mean age of participants was 71.01 ± 7.4 with a range from 60 to 89.
Most of patients were unemployed or did not work at all (88.46%). Kinh was the
ethnic community predominant in the study (87.69%). More than half of patients
(57.69%) had finished elementary of secondary school, while only 3.85% had the
education of above high school. Regarding marital status, 67.69% patients had married
and 25.38% were widows or widowers.
The duration of symptom before admission to the hospital ranged from 1 to 14
days. Most of patients (84.62%) were indicated to operation of APP within 24 hours
1


after admission. Regarding clinical symptoms, all of patients complained about
abdominal pain, of whom right iliac fossa is the most common position of abdominal
pain (58.46%), followed by the abdominal pain at the epigastric position (45.38%).
There were 45.38% patients reported the pain shift. Other common symptoms
followed the abdominal pain were nausea or vomiting (15.38%) and diarrhoea (10%).
Mild fever was found in only 22.31% of total patients, while 92.31% had positive
Macburney’s point and 63.08% had tenderness. The mean WBC count was 13.93 ±
4.97 and the proportion of leukocytosis was 63.08%. The means of CRP was 51.41 ±
54.92. The proportion of glycaemia was 46.15%. The means of creatinine, SGOT,
SGPT were 87.05 ± 23.07, 30.00 ± 19.9, 27.91 ± 21.34, respectively. There were no
association had been found between clinical symptoms and background profile of
patients.
Conclusion: Among patients, hypertension and diabetes were two most common
comorbid diseases those patients had 50% and 11.54%. The most common symptoms
were abdominal pain (100%), nausea/votmitting (15.38%), and diarrhoea (10.00%).
Macburney’s point and tenderness were found to occure more frequent among patients
(92.31% and 63.08%) than fever (22.31%). Leukocytosis was identified in 63.08% of
patients, while other laboratory tests were not specific for APP diagnosis.
Recommendations: The findings showed that some common menifestations of APP

in elderly population treated at Nguyen Tri Phuong Hospital could be used to create a
set of criteria specific for diagnosis of APP in elderly. However, to make it come true,
a further study comparing the realibility and validity of the set and other established
scoring system such as Alvarado, Lintula must be carried out.
Key words: acute appendicitis, clinical manifestation, elderly

2


Acknowledgements
First and foremost, I would like to send from bottom of my heart my thanks to
my supervisor, Dr Neoh Choo Aun, for all encouragement, support and feedback you
gave to me. Secondly, I would like acknowledge the endeless and precious supports
from Dr. Yung Yu Su and Dr. Tich Chi Chung, who always facilitate me complete this
thesis.
I also would like to thank a lot to valuable supports by The Diretor Board of
Nguyen Tri Phuong Hospital during my studying and my thesis implimentation. For
all patients who had participants in this study I send my special thanks to all of you for
accepting me to use your information.

3


List of tables
Page

Table 1. The differences between classical history and history of appendicitis in
elderly...........................................................................................................................11
Table 2. The difference between classical signs and signs of appendicitis in the elderly
......................................................................................................................................12

Table 3. The differences between classical and specified lab findings in the elderly...13
Table 4. Demographic characteristics of patients (n=130)...........................................29
Table 5. History of use of alcohol, cigarette and betel nut (n=130)..............................31
Table 6. Pre-operative outcomes of patients (n=130)...................................................32
Table 7. History of comorbidities among patients (n=130)..........................................32
Table 8. Clinical manifestations of patients at admission (n=130)...............................33
Table 9. Laboratory investigations of patients (n=130)................................................34
Table 10. Operative outcomes of patients (n=130).......................................................35
Table 11. Post- operative outcomes of patients (n=130)...............................................35
Table 12. The relationship between position of abdominal pain and patient’s profile
(n=130)..........................................................................................................................36
Table 13. The relationships between other symptoms and patient’s profile (n=130)...37

List of figure
Page
Figure 1. Research framework of presentation of APP and contributable factors among
older patients.................................................................................................................23
Figure 2. The sampling procedure applied in the study................................................25

4


Contents
Page
Abstract...............................................................................................................................i
Acknowledgements..........................................................................................................iii
List of tables.....................................................................................................................iv
List of figure.....................................................................................................................iv
Chapter 1. Introduction...................................................................................................1
1.1. Statement of this research....................................................................................1

1.2. Significance of this research................................................................................2
1.3. Aim of this research.............................................................................................2
1.4. Chapter summary.................................................................................................3
Chapter 2. Literature Review.........................................................................................4
2.1. Introduction..........................................................................................................4
2.2. Epidemiology of appendicitis in elderly..............................................................4
2.3. Clinical presentations of acute appendicitis in the elderly................................10
2.4. Factors affecting clinical presentations of acute appendicitis in elderly...........13
2.5. The diagnosis of acute appendicitis in elderly in Nguyen Tri Phuong hospital.16
2.6. Review of relevant research...............................................................................17
2.7. Chapter summary...............................................................................................20
Chapter 3. Research methodology...............................................................................22
3.1. Introduction........................................................................................................22
3.2. Research design.................................................................................................22
3.3. Research framework..........................................................................................22
3.4. Sampling issues..................................................................................................23
3.5. Data management and data analysis strategy....................................................26
3.6. Ethic issues........................................................................................................27
3.7. Chapter summary...............................................................................................27
Chapter 4. Results..........................................................................................................28
4.1. Introduction........................................................................................................28
4.2. Demographic characteristic of patients..............................................................28
4.3. Pre-operative outcomes......................................................................................31
4.4. Operative outcomes...........................................................................................35
4.5. Post-operative outcomes....................................................................................35
1


4.6. Relation between clinical symptoms and patient’s characteristics....................36
4.7. Summary............................................................................................................38

Chapter 5. Discussion and conclusion.........................................................................39
5.1. Introduction........................................................................................................39
5.2. Discussing the significance results of findings..................................................39
5.3. The principal research findings..........................................................................48
5.4. Contributions and Implications..........................................................................49
5.5. Limitations.........................................................................................................49
5.6. Recommendation for further research...............................................................49
5.7. Conclusion.........................................................................................................50
Appendix 1. The questionnaire.....................................................................................62
Appendix 2. The informed consent..............................................................................66
Appendix 3. The list of participants.............................................................................67
Appendix 4. The Letter of permission of conducing study.......................................72

2


Chapter 1. Introduction
1.1. Statement of this research
Acute appendicitis (APP) is a less common cause of abdominal pain in elderly patients than
in younger patients, but the severity among elderly patients appears to be higher. There are
approximately 10% of cases of APP occur in patients older than 60 years and one half of all
deaths from appendicitis occur in this age group (Doria, Moineddin, & Kellenberger, 2006).
Studies have also confirmed a significant increase of perforation rates in patients older than 50
years, and progressively higher rates in patients older than 60 years (Koepsell, Inui, & Farewell,
1981).
Diagnosing an elderly patient who presents with abdominal pain due to APP is a difficult
challenge. In approximately 20% of all cases, the diagnosis is incorrect and patients undergo
surgery without having APP (McCallion, Canning, Knight, & McCallion, 1987). This is due to
atypical manifestations, comorbidities and socio-behavioral factors which are associated with
this group of patients. Indeed, more than half of the elderly patients with APP do not present with

the classical signs and symptoms such as fever, nausea and vomiting, migrating pain and
localized tenderness (McCallion, et al., 1987). Moreover, older patients with comorbidities also
have existing symptoms that may result in misdiagnosis of APP (Ghnnam, 2012). Finally, the
elderly patients frequently refuse medical care or neglect early symptoms of the disease and
those can delay diagnosis of APP.
From that point of view, a question emerges that how physicians can make an accurate early
diagnosis of appendicitis in the elderly so that rate of complications can be reduced. In a meta
analysis of diagnostic studies, Anderson concluded that diagnostic variables are better combined
to improve the diagnosis of appendicitis. Numerous diagnostic and clinical scores such as
Alvarado score, Lintula score etc have been developed to increase the accuracy of diagnosis of
APP and their validity has been demonstrated in many studies worldwide (Kailash, Shyam, &
Pinki, 2008; Khan & Rehmanur, 2005; Konan, Hayran, Kilic, Karadoc, & Kaynaroglu, 2011).
However, it does not mean that they can be adopted in all settings, especially in developing
countries where the elderly suffer not only chronic diseases but also communicable ones that
make diagnosis of APP more challenging. At least two Vietnamese studies found that the
1


sensitivity and specificity of Alvarado score in diagnosis of APP in elderly patients were not
quite high and reasons for that may be the differences in clinical presentations of Vietnamese
elderly (Duong & Chau, 2013; Lam, 2009). These suggest that for a given setting identification
of clinical characteristics of APP in an elderly population and then application of an available
diagnostic scoring system or development of a new diagnostic procedure are crucial to improve
punctuation and accuracy of APP diagnosis.

1.2. Significance of this research
In Nguyen Tri Phuong Hospital, there are approximately 851 cases with APP each year, of
those older patients account for 30% (Nguyen Tri Phuong Hospital, 2012). The problem is that
the diagnostic procedure of APP although is available, the rate of misdiagnosis of APP in the
elderly is surprisingly up to 18% (Nguyen Tri Phuong Hospital, 2012). The reason for

misdiagnosis is largely due to the fact that physicians are lack of experience of recognizing
clinical presentations of APP in elderly patients. Nevertheless, there are not any studies
identifying clinical manifestations of APP in elderly in the hospital setting. The aim of the
present study therefore is to identify all clinical manifestations related to APP in elderly patients.
The most common clinical findings will be used as predictors for confirmed diagnosis of APP in
the hospital and that will help physicians make diagnosis of APP in elderly more promptly and
precisely and that in turns will lower the risk of complications in elderly.

1.3. Aim of this research
The primary purpose of the present study is to identify all medical history, physical
examinations and laboratory findings related to APP and their relationships with the occurrence
of APP in elderly patients who are hospitalized and treated at Nguyen Tri Phuong Hospital. To
achieve this purpose, firstly we investigate background profile such as age, gender, ethnicity etc
and history of comorbidities of selected elderly with suspected APP at the time of hospital
admission. Secondly, we identify all signs and symptoms of selected elderly with suspected APP.
Thirdly, we identify laboratory findings of selected elderly with suspected APP at the time of
hospital admission. Finally we analyse the relationships between background profile, medical
history, clinical features and laboratory findings with the occurrence of APP in selected elderly
2


with suspected APP.

1.4. Chapter summary
APP although occurs with a lower rate in elderly patients compared to younger ones, the
complications of the disease are more severe and even death may occur occasionally.
Misdiagnosis of APP in elderly is now still a concern for physicians due to atypical symptoms of
the disease, comorbidities and bad behaviours of elderly. One way to magnify the accuracy in
diagnosing APP is to use scoring systems such as Alvarado score, Lintula score etc. However, the
application of these scoring systems into Vietnamese settings could not be completely

appropriate because of differences in clinical presentations of APP in Vietnamese elderly. Hence,
describing clinical presentations first and then adopting established scoring systems or
developing more proper diagnostic procedures may be the best approach to improve diagnosis of
APP in elderly.
There are about 255 elderly patients with suspected APP hospitalized and treated in Nguyen
Tri Phuong Hospital annually and the rate of misdiagnosis of APP in the elderly is up to 18%. At
the time of conducting this study, studies on clinical manifestations of APP in elderly at the
hospital are not available, so it is an urge to conduct this study. The main objectives of the study
are to examine medical history, clinical features and laboratory findings of APP in older cases.
The results of the study will be used as a baseline data from which new diagnostic procedure will
be developed to improve the accuracy of diagnosis of APP in elderly.

3


Chapter 2. Literature Review
2.1. Introduction
Firstly documented by Fitz in 1886, APP in elderly drew more concerns after that time.
While APP is largely a disease of the younger population, the incidence of APP in older patients
seems to be increasing with an increase in life expectancy. Researchers make efforts to explore
the causes of APP in elderly and they find that epidemiological characteristics in association with
anatomical and physiological changes are potential factors affecting the risk of acquiring APP in
the elderly.
In this chapter, the burden of APP in elderly is described in detail and risk factors that
could affect the incidence of APP in elderly also mentioned. Clinical features of APP in older
patients then will be depicted and factors that lead to the variability of clinical presentations of
APP in elderly are noted as well. A description of Nguyen Tri Phuong hospital and diagnosis of
older patients with APP are included in the chapter to give a clear picture about the place where
the present study takes place and the reason why the authors conduct the study. Finally some
researches on APP in elderly are reviewed to provide what earlier researchers have found in this

topic.

2.2. Epidemiology of appendicitis in elderly
2.2.1. Morbidity and mortality of appendicitis in elderly
Appendicitis is one of the more common surgical emergencies, and it is one of the most
common causes of abdominal pain. The morbidity in elderly remain significant at 28-60% (J. K.
Lee, Leow, & Lau, 2000). The incidence of APP in the elderly population (>60 years) is between
5-10%. It is also estimated that 7% of elderly patients with acute abdominal pain have APP
(Doria, et al., 2006; Vissers & Lennarz, 2010). Several studies in Korea showed that elderly APP
patients composed 8.3 to 16.4% of the total APP patients (An, Soh, Cho, Back, & Lee, 2002;
Sim, Lee, & Hwang, 1998).
In 1944 the mortality of APP was 2.4% and some reports from 1995-1999 showed that the
mortality rate of APP is less than 1% in the general population (Hardin, 1999; Temple,
4


Hunchcroft, & Temple, 1995; Yamini, Vargas, Bongard, Klein, & Stamos, 1998). However,
recent studies have demonstrated a considerable increase in mortality of APP due to perforation
(Blomqvist, 2001). The mortality rate in elderly patients with APP is between 4% and 10%
(Blomqvist, 2001; J. K. Lee, et al., 2000). Older patients with APP have a risk of mortality 16
times higher than that in the young adult with APP (Hui, 2002; Semm, 1983).
The rate of perforation is reported to increase by 5% per 12 h to 36 h after the onset of
symptoms, therefore, prompt diagnosis and treatment are required (Bickell, 2006). It was
estimated that the perforation rate is about 30% at 60 years of age (Koepsell, et al., 1981).
The rate of misdiagnosis of APP in elderly is also high. Several studies reported that
approximately 20% of all cases having incorrect diagnosis as APP and negative appendectomy as
consequence (McCallion, et al., 1987). Delayed or incorrect diagnosis therefore has both clinical
and economic consequences (Flum & Koepsell, 2002) and this has resulted in considerable
researches to identify clinical, laboratory and radiological findings that are diagnostic of
appendicitis and the development of clinical scoring systems (some computer aided) to guide the

clinician in making the correct diagnosis.
2.2.2. Age distribution of appendicitis
Appendicitis is largely a disease of childhood and young adults. Many studies have
demonstrated approximately 90% of cases occurring in children and young adults (peak 10-30
years) and only 10% being in the elderly over 60 years (Hale, Molloy, & Pearl, 1997; J. H. Lee,
Park, & Choi, 2010; Smink, Fishman, & Kleinman, 2005; Temple, et al., 1995; Uba, Lohfa, &
Ayuba, 2006). There are two hypotheses that have been developed to explain that age distribution
of appendicitis. The first one may come from physiological features of appendix. The appendix
tissue possesses the features of a lymphoid organ and there is a larger amount of lymphoid tissue
in young subjects. Lymphoid hyperplasia can be caused by any obstruction occurring in the
lumen of the appendix and this can develop into appendicitis if the condition continues.
Appendicitis is therefore seen more frequently in young people. However, the lumen of the
appendix enlarges after lymphoid tissue atrophies and probability of obstruction decrease over
aged people. For that reason, incidence of APP decreases with age.
The second explanation may result from the efficiency of the immune system in young
population due to the fact that remote agents like air-pollution and sandstorms are associated
with significant variations in the incidence of appendicitis (Kaplan, Dixon, & Panaccione, 2009).
5


On the other hand the immaturity of the immune system before the age of five years and
immunosenescence as well as the atrophy of the wall and obliteration of the lumen of the
appendix in elderly may explain why appendicitis is less common in these age groups.
2.2.3. Sex distribution of appendicitis
A consistent observation seen in many epidemiological studies is a slight preponderance of
appendicitis in male population. There are several theories suggested but the consistent evidence
could not be demonstrated. Since the 17-ketosteroids estrogen and progesterone have been
implicated in the modulation of the immunosuppressive state of pregnancy, it may be that
different levels of estrogens and androgens between male and female may be responsible for this
observed difference in incidence (Ben-Hur, Mor, & Insler, 1995; Jara, Navarro, & Medina, 2006;

Zen, Ghirardello, & Iaccarino, 2010). Furthermore, antigen-presenting cells which play key roles
in innate and adaptive immunity as well as tolerance have been found to express estrogen
receptors on their surface implying that their functions may be modulated by sex hormones and
would explain the purported immunological dimorphism between genders (Bouman, Heineman,
& Faas, 2005; Kovats & Carreras, 2008). One study suggests that the better prognosis in females
following infectious challenge may be due to gender-specific differences in LPS-induced TNF-α
and IL-1β but not IL-6 and suggests that the underlying mechanism may be due to alterations in
mitogen-activated protein kinase phosphorylation (Imahara, Jelacic, & Junker, 2005).
2.2.4. Genetic factors
Several studies during last decades showed that appendicitis is likely to be heritable among
family members (N. Andersson, Griffiths, & Murphy, 1979; Basta, Morton, & Mulvihill, 1990;
Ergul, 2007). A prospective study noted a significant familial relationship when comparing three
groups of children aged 2-19 years admitted to a single large center whose family histories were
taken at admission over a 52-month period (Gauderer, Crane, & Green, 2001). The authors
concluded that children with appendicitis are three times more likely to have a positive family
history of appendicitis in first degree relatives than controls. In a survey of 282 patients, it was
discovered that 21% of patients undergoing appendectomies had first-degree relatives (siblings,
parents, and children), 12% had second-degree relatives (grandparents, grandchildren, uncles,
aunts, nieces, and nephews), and 7% had third-degree relatives with a history of appendicitis
(Basta, et al., 1990). Similar observations had been made in smaller studies earlier (N.
Andersson, et al., 1979; Brender, Marcuse, & Weiss, 1985). These familial associations,
6


however, do not prove a genetic component since members of families often share similar
environments.
Twin studies have attributed both genetic and environmental factors in the predisposition to
appendicitis. The evidence suggests that environmental and genetic factors may account for
about 70% and 30% of the predisposition to appendicitis, respectively. The ratio attributable to
genetic factors appears to be consistent (Basta, et al., 1990; Duffy, Martin, & Mathews, 1990;

Oldmeadow, Wood, Mengersen, & et al, 2008). An interesting observation linked the incidence
of appendicitis to cigarette smoking in 3808 pairs of Australian twins after controlling for sex,
age and year of birth. This was not affected by socioeconomic status or the father’s occupation
and the effect was stronger in females (Oldmeadow, et al., 2008).
2.2.5. Geographic distribution of appendicitis
The different incidences found across geographic regions are possibly explained by
economic and public health factors rather than by environmental factors. The incidence of
appendicitis increases with the level of sophistication of the health system across nations (Barker,
Morris, & Simmonds, 1988; Barker, Osmond, & Golding, 1988). For example, the rate of
appendicitis in Europe during the 1980s was 116 per 100,000 while this rate was 96-120 in the
USA, 75 in Ontario, 200 in Hong Kong, and 32-37 in Thailand for the same years (Al-Omran,
Mamdani, & McLeod, 2003; Chatbanchai, Hedley, Ebrahim, Areemit, Hoskyns, & de-Dombal,
1989; Luckmann & Davis, 1991; Zoguéreh, Lemaître, Ikoli, Delmont, Chamlian, Mandaba, &
Nali, 2001). In developing regions such as Africa and Asia, the incidences of appendicitis are not
quite high (Ajao, 1979; Arnbjörnsson, 1983; Oguntola, Adeoti, & Oyemolade, 2010; A. R.
Walker & Segal, 1995). This may be because people living in these regions are less influenced by
the western-type diet (fast-food diet) with the majority of foods consumed being high in
carbohydrates and low in fiber. The height of males as a factor in the development of the disease
is not clear (Addiss, Shaffer, Fowler, & Tauxe, 1990). However, the effect of sex hormones in
females alongside the predisposition of males to consume 'fast-food' are considered to be
important (A. R. Walker & Segal, 1979).
2.2.6. Racial/ethnical variation
Epidemiological studies report that the incidence of APP within a single country tends to
increase or decrease at different times of the year. Walker et al. reported the prevalence of
appendicitis as 0.5% in rural blacks, 1.2% in urban blacks, and 14% in urban whites (A. R.
7


Walker & Segal, 1979). Walker et al. also evaluated the relationship between ethnicity and
appendicitis in a study of 56 high school age (16-18 years) young people in South Africa and

found that the rate of appendectomies was 0.6% in rural Blacks, 0.7% in urban Blacks, 2.9% in
Indians, 1.7% in Coloureds (Eur-African-Malay), and 10.5% in Caucasians (A. R. Walker,
Walker, Duvenhage, Jones, Ncongwane, & Segal, 1982) This situation is similar within different
ethnic communities in western societies, where the gap between gender and ethnic origins has
shown similar distributions. In California, the incidence of appendicitis was 137.5 per 100.000
for Caucasian males while this incidence was 162.7 for Hispanics, 98.0 for Asian/others, and
70.7 for blacks. The same was true in female patients (R. E. Andersson, 2008) with rates per
100,000 of 98.8, 97.5, 64.6, and 49.6 for the above groups respectively. The authors reported that
the difference observed between whites and blacks was associated with their consumption of
different amounts of fiber. One study from the USA comparing the incidence of appendicitis in
various ethnic groups concluded that the rate was lower in Negroes and Asians in comparison to
Caucasians and Hispanics (Luckmann & Davis, 1991). A case-control study from Brazil
comparing the people of that country on the basis of skin colour claimed that race was a factor in
the incidence of appendicitis. After excluding native Indians the study found a significantly
lower incidence of appendicitis in Negroes in comparison to Caucasians (Petroianu, OliveiraNeto, & Alberti, 2004). This finding has to be interpreted in the context of social differences and
genetic variables between black and white Brazilians. A study on phenotypes as an indicator of
genotypes in the same country concluded at an individual level, color, as determined by physical
evaluation, is a poor predictor of genomic African ancestry, estimated by molecular markers”
(Parra, Amado, & Lambertucci, 2003). From the Republic of South Africa, another multiracial
society, some publications suggest that appendicitis has racial associations. The incidence of
appendicitis in Black children was estimated at 8.2 per 100,000 which is 10-20 times less than
the incidence in their White compatriots (A. R. Walker, Shipton, & Walker, 1989; A. R. P.
Walker, Walker, & Manetsi, 1989). It should be remembered that the Apartheid political system
in the country at the time left the native Africans economically and social disenfranchised with a
standard of living that was not comparable to their White counterparts. What these studies share
is the inability to separate race from poverty.
2.2.7. Environmental factors

8

Seasonal variations in appendicitis are reported in several studies across many regions.
Most studies report a summer peak and a decrease during winter months (Al-Omran, et al., 2003;
Luckmann & Davis, 1991). Several studies in Saudi Arabia showed a winter low but a spring
peak which coincides with the sandstorm season characterized by rise in infections and allergic
conditions of the upper respiratory tract (Kwaasi, Parhar, & Al-Mohanna, 1998; Sahm, Pross, &
Lippert, 2011). Seasonal variation of appendicitis with its peak associated with a season
characterized by high ambient pollen and other phyto-allergens or sandstorm is an observation
that can neither be explained by diet nor fecaliths but may have a bearing on immune modulation
playing a role.
However, other studies have shown that the seasonal variation also depend on the latitude of
the regions where APP occurs. In a study conducted in two Turkish cities with different climatic
characteristics and altitudes, the number of patients with acute appendicitis increases at low
altitude in Istanbul during spring and summer (p<0.05). At high altitude in Kars, this increase is
seen during winter (p>0.05). A further study reported that AA was seen more frequently in the
winter months in Kerman, an Iranian city with an altitude similar to that of Kars (Nabipour &
Mohammad, 2005; Sulu, Gunerhan, Ozturk, & Arslan, 2010). In other words, an increase in
altitude resulted in more appendicitis cases being seen during the winter months. The reason for
this trend is unclear, but it has been reported that several factors may play a part: 1) the varying
effects of bacterial or viral pathogens that cause infections at different temperatures, 2) the effect
of allergens occurring in summer and warmer months, 3) changes in the form of nutrition, and 4)
the effect of migration for touristic purposes during the summer.
Another controversial environmental factor is daytime humidity. In a study by Brummer, a
significant relationship was observed between humidity and AA, and it was reported, in their
study on the physiology of hunger, that a decrease in body fluid loss, fecal stasis, and fecal
dehydration prepared the ground for inflammation (Brumer, 1970). In contrast, van
Nieuwenhoven et al. reported that changes in intestinal system functions such as intestinal
permeability and orocaecal transit time were not the reason for dehydration occurring (van
Nieuwenhoven, Vriens, Brummer, & Brouns, 2000).
2.2.8. Other epidemiological factors of appendicitis

Other factors said to influence APP development include vascular disorders, non-specific
viral infections, depression and emotional problems due to a stressful lifestyle, being the child of
9


a mother who smoked while pregnant, air pollution, and anemic diseases these have not,
however, been widely accepted (Ahmed, Shahid, & Russo, 2005; Butland & Strachan, 1999;
Ewald, Mortensen, & Mors, 2001; Kaplan, et al., 2009; A. R. Walker & Segal, 1995).

2.3. Clinical presentations of acute appendicitis in the elderly
2.3.1. Clinical symptoms of acute appendicitis in the elderly
In 1886, Fitz in his study firstly identified appendicitis was a disease of young males (1524) and the rate of APP in elderly (older than 60 years of age) was only 1%. However, he also
documented the variability in presentation of appendicitis in elderly. with fewer symptoms, a less
reliable duration of disease, a lower WBC count, and a lower temperature.
Other studies after the work of Fitz investigated deeper the variability of clinical
manifestations of APP in elderly. A study of Goldenberg in 1955 showed that the natural history
of appendicitis in the elderly is closely similar to that in younger patients. However, Hubbell et al
(1960), Thorbjarnarson and Loehr (1967), and Lewis et al (1975) reported that the incidence of
rupture of appendix, the number and severity of complications in the elderly group were higher
than those in younger group. Bernard (1977) conducted a study with the aim of identification of
the differences and similarities in presentation between elderly and younger patients. His
conclusions were that elderly patients presented an increasing portion of the patients with
appendicitis and presented in a manner generally similar to the younger patients. Minor variation
in the prodrome should be expected, but abdominal pain, especially with right lower quadrant
tenderness, was hard to be found. The older patients could be expected to have fevers and WBC
counts similar to the younger patients. In a nutshell, all of these and others lastly just described
clinical presentations of APP in elderly in general and suggested that diagnosis of APP in older
patients should mainly base on history and clinical examinations. Recent years, with the support
of modern technologies such as ultrasonography and computed tomography the study of APP in
the elderly become more clearly and comprehensively.

Basically, the features of appendicitis in the elderly are similar to what is obtainable in the
young adults though its presentation is more varied and subtle. One of the classical symptoms of
appendicitis is right lower abdominal pain. In classical cases the pain of appendicitis follows a
known classical course. The pain usually starts with sudden periumbilical pain, which becomes
localised in the right iliac fossa. Typically the pain is initially diffused, central and minimally
10


severe presenting as visceral pain. In a period of about six to eight hours after the onset of the
pain, the pain migrates to the right lower quadrant of the abdomen. This time around the pain is
somatic, more severe and usually localized. This is described as visceral-somatic sequence of
presentation of pain of appendicitis. This visceral-somatic sequence occur less in the elderly
appendicitis as compared to other categories of patients. In the elderly patient with the pain of
appendicitis, the pain may be localised in the right lower quadrant from the beginning. This pain
also in some patients may be diffused and may never become localized (Paajanen, Kettunen, &
Kostiainen, 1994).
The next common symptoms after lower abdominal pain are anorexia and nausea. They are
present in all cases of appendicitis. Vomiting is present in some cases but not as constant as pain
and nausea. Vomiting comes only after the onset of pain and usually once or twice in most cases.
If vomiting is persistent, the diagnosis of simple appendicitis should be questioned (Carr, 2000).
Table 1. The differences between classical history and history of appendicitis in elderly
Classical history of appendicitis
History of appendicitis in Elderly
1. Abdominal pain
a. The sequence of abdominal pain
Central abdominal pain followed by vomiting Periumbilical pain which migrates to the right
lower quadrant
b. History of pain
24 h of periumbilical pain followed by

May be localized in the right lower quadrant
from the beginning
intensity of pain was more severe

migration of the pain to the right iliac fossa

progression to a more constant severe pain
2. Associated symptoms
anorexia
anorexia
nausea
nausea
low grade fever
No or low or high-grade fever
vomiting (represent the development
vomiting
of diffuse peritonitis following perforation)
loss of appetite
bowel habit disturbances (the onset of pain)

change in bowel habits

(one or two episodes of loose stools)

2.3.2. Signs of acute appendicitis in elderly
11


On physical examination, the patient may have low-to high-grade fevers. The most
important finding is right lower abdominal tenderness on palpation; however, the tenderness is

less localized to the right lower quadrant in the elderly. Peritoneal signs (including abdominal
distension, reduced abdominal wall movement, severe tenderness and guarding) are significantly
increased, and bowel sounds are more often reduced on auscultation. Several physical
examination manoeuvres can help in cases where the location of the appendix is atypical. With a
retroperitoneal retrocaecal appendix, the patient may display right flank tenderness as well as the
psoas sign, which is pain elicited by stretching the iliopsoas muscle by the extension of the right
thigh. The obturator sign is pain on internal rotation of the right thigh and corresponds to the
inflammation of a pelvic appendix. Lastly, Rovsing's sign refers to pain in the right lower
quadrant with palpation of the left lower quadrant and indicates an inflamed appendix in the right
iliac fossa.
The physical examination can be complicated, and for the unwary clinician even misleading
at times, by the fact that many elderly patients have a weak abdominal musculature. This would
mean that the expected signs of rigidity and guarding in a patient with peritonitis may not be
present. It should also be noted that the rates of perforation are much higher in the elderly
population and so many of the patients can also present with diffuse abdominal tenderness and
peritonism (Hiu, Major, & Avital, 2002; Körner, Söndenaa, & Söreide, 1997).
Table 2. The difference between classical signs and signs of appendicitis in the elderly
Clasical signs of appendicitis
Most common signs
Localized peritonism
May be absent

Elderly

- maximum tenderness at McBurney’s point
- muscle guarding
Tachycardia
Skin flushing
Oral fetor
Rovsing’s sign

Obturator sign
Psoas sign

Additional signs
Tachycardia
Skin flushing
May be absent
Rovsing's sign
Obturator sign
Psoas sign

2.3.3. Laboratory investigations of acute appendicitis in elderly
Laboratory studies frequently reveal an elevated WBC count with neutrophilia in patients
with acute appendicitis. Ninety-five percent of the geriatric patients with acute appendicitis have
12


leukocytosis. In the elderly, an elevated band count greater than 6% has been shown to have a
high predictive value for appendicitis.
If the diagnosis of appendicitis is questionable, imaging modalities such as ultrasonography
and computed tomography can be helpful, especially in the elderly population in which there is a
broader differential of abdominal pain. Helical abdominal computed tomography has higher
sensitivity and specificity than trans-abdominal ultrasonography for identifying appendicitis.
Interestingly, ultrasonography has proven to be more useful in older patients than younger
patients in confirming a suspected case of appendicitis (70% vs. 51%). This phenomenon in
older patients is likely explained by their more advanced stage of appendiceal inflammation,
which facilitates sonographic detection.
Table 3. The differences between classical and specified lab findings in the elderly
Classical laboratory investigations
Elevated WBC count with neutrophilia

Increase of C-reactive protein level
Ultrasonography
Computed Tomography

Laboratory investigations in elderly
Blood test
Leukocytosis (95% elderly)
Increase of C-reactive protein level
Imaging
Ultrasonography
Helical abdominal computed tomography

2.4. Factors affecting clinical presentations of acute appendicitis in elderly
2.4.1. Anatomical changes in elderly
As aging, the serosa and the submucosa of appendix becomes relatively less elastic. As a
result their response to intraluminal pressure is less effective and that in turn leads to ischaemia
and early gangrene of the wall of appendix. These pathological changes of appendix make the
first step of early perforation of appendicitis in the elderly.
Another anatomical change in elderly is that the blood supply to the appendix is limited by
atherosclerosis accumulating in the lumen of arteries and veins of appendix. The wall of the
appendix is weakened by fibrosis and fatty infiltration. In addition, there is progressive atrophy
of lymphoid tissue along the wall of the appendix. This causes partial or total obliteration of the
lumen that narrows appendix.
The elderly has weakened peristalsis encouraging food residue to form in the appendix. The
food residue forms bezoar allowing secretions to accumulate in the appendix lumen (Maxwell &
Ragland, 1991). At old age the openings of appendix will atrophy which aids regurgitation of
13


stool, undigested food, parasites, making it easy to enter the appendix lumen causing obstruction,

local tissue ischaemia and necrosis of the appendix (P. Peltokallio & Jauhianinen, 1970). The
weakened wall of appendix also encourages the accumulations of these materials. Appendix in
the elderly therefore has tendency for secretions to accumulate and prone to ischaemia on the
platform of anatomic changes enumerated above.
2.4.2. Physiological changes in elderly
Physiologically, the elderly patients with deteriorating organs have lower physiological
reserve than the young adults. They also have higher pain threshold response. They have poor
reflexes in general and poor localisation of pain. The initial symptoms in the elderly patients with
appendicitis are usually attributed to indigestion or constipation, thus ignoring the initial
symptoms until they worsened. These declining physiologic functions exacerbate morbidity and
mortality in the elderly.
Another important factor contributing to increased pathological changes in the appendix is
reduced local immunity in the appendix. There is poor inflammatory response from
inflammatory cells. All these will also cause decrease ability to eliminate bacteria invasion hence
faster bacterial multiplication without much interference. The T-cell function is decreased,
autoantibodies levels are raised, bone marrow capacity is reduced and the inflammatory response
is dampened. Frequently, the bacteremic elderly patient does not develop fever and may have
hypothermia instead (Khalili, Hiatt, Savar, Lau, Phillips, & Margulies, 1999). Local tissue factor
in bacterial control is poor. The overall effects of these changes in the anatomy and the
physiology of appendix is narrowing of the appendix lumen, decreased local tissue defence
capability, and loss of mucosal integrity paving way for bacterial invasion of appendix (Horattas
& Haught, 1992). Bacterial invasion leads to rapid pus formation and gangrene with perforation
and generalised inflammation of the peritoneum.
2.4.3. Comorbidities
The diagnosis of APP in the elderly population is particularly difficult as the clinical picture
is often complicated by comorbidities. These include conditions which can mask or suppress the
normal inflammatory reaction, such as diabetes or immunosuppression (Binderow & Shaked,
1991; Tsai, Hsu, & Chen, 2008).
Comorbidities frequently imply that symptomatology for acute appendicitis may be
confused with already existing symptoms making the clinical diagnosis more difficult. In

14


addition, concurrent medication may further complicate this issue and further compromise the
elderly physiology increasing susceptibility to other conditions. The elderly patient frequently
refuses medical care and this can impede appropriate management.
2.4.4. Implications of anatomical and physiological changes
The anatomical and physiological changes that are noted in the elderly also contribute to a
more aggressive inflammatory change in the elderly appendicitis. The outcome of treatments in
them is critical because of this delay in presenting to the hospital and also on the account of a
more aggressive inflammatory response (Lau WY, et al, 1985). There are serious implications for
changes in the anatomy and physiology of the appendix of the elderly patients. The consequences
of these changes are a different inflammatory response in appendicitis. This different response
causes delay and misdiagnosis of this entity in the elderly patient presenting with appendicitis.
These changes are the causes of high incidence of atypical presentation in the adult. It can lead to
a faster progression of the disease with early perforation of appendix (Smithy WB, 1986). In
essence the hardened blood vessels, degradations of appendix, reduced local lymph nodes, poor
ability to eliminate inflammation; all encourage aggressive inflammatory response in the elderly
appendicitis.
Appendix easily perforates and cause localised or diffused peritonitis. Awareness of
possibility of appendicitis in the elderly is the master key to successful management of this
pathology in the aged people. This group of patients have poor response, their symptoms and
pathological changes are often inconsistent with the chief complaint of abdominal pain. The
chief symptom in appendicitis is lower abdominal pain and this is most often less severe.
Sometimes abdominal pain is not typical, only abdominal distension, nausea and other symptoms
are noted. These inconsistent symptoms resulting from differences in the anatomic and
physiologic changes are responsible for a high rate of non classical presentation of appendicitis
in the elderly. One must bear in mind that many other pathologies mimic appendicitis of this age
group. The differential diagnoses therefore are wide and difficult due to their atypical
presentations and their aging state. One must consider appendicitis in every elderly patient with

lower abdominal pain. This is important because appendicitis takes a more rapid and virulent
course in the elderly with weaning organs if treatment is delayed (Horattas MC, et la 1990). On
the basis of the pathologic process the following types of appendicitis can be noted: simple,
complicated, acute, recurrent and chronic appendicitis.
15


The results of this study show that delayed onset of symptoms at presentation and delayed
surgical treatment is the most significant factor associated with advanced stage appendicitis and
postoperative complications (Ghnnam, 2012). Delay in treatment is regarded as the main cause
of perforation and complications, but there are controversies as to whether pre-admission or postadmission delay is more important.
Elderly people often present to hospitals in an advanced stage of the disease. The reasons
for delay in presentation may include problems of access to medical care, communication, or fear
of hospitalization. Some believe that the physiology differs in the elderly and that the progression
to perforation is more rapid owing to decreased lymphoid tissue or blood supply (Koepsell, et al.,
1981).
2.4.5. Delay onset of symptoms
Many authors believe that the delayed onset of symptoms at presentation is affected by
many factors. Some of elderly patients live alone and have difficulty in accessing medical care
early (Carr, 2000). In addition, older patients who have a higher pain threshold compared to
young ones often neglect their symptoms, so they will seek medical treatment later (Jess,
Bjerregaard, & Brynitz, 1981). However, controversies on whether pre-admission (delay in
presentation) or post-admission delay (delay in treatment) is more important still exist (P.
Peltokallio & Tykka, 1981).

2.5. The diagnosis of acute appendicitis in elderly in Nguyen Tri Phuong
hospital
Each year there are about 851 cases who are admitted to Nguyen Tri Phuong Hospital for
treatment of APP and older patients, who are over 60 years of age, account for 30% of total
cases. For years, the procedure of diagnosis of APP was developed and applied for patients of all

age, including the elderly. Followed the procedure, patients who have abdominal pain are asked
about their background profile such as age, residence, education etc and their history of
comorbidities at first. After that, they should report their symptoms such as abdominal pain,
nausea, or vomiting. The clinical examination is also made to collect all possible signs of APP in
patients. The key signs that could let physicians suspect APP are fever, abdominal pain migrating
to the right lower quadrant of the abdomen and localized tenderness over McBurney’s point.
16


Patients with these signs and symptoms are supposed to take laboratory works (blood test, urine
test) and imaging tests (ultrasonography, computed tomography, plain radiography and even
cytopathology) for confirmed diagnosis of APP. With this procedure, the possibility of correct
diagnosis of APP in elderly rises up to 82%. However, there are still older patients who have
misdiagnosis of APP due to atypical presentation of APP. To improve the accuracy of diagnosis
of APP in the elderly, the most important thing is to describe the most common clinical features
of APP in the older patient population at Nguyen Tri Phuong Hospital and then based on those to
revise the procedure so that it is appropriate for the elderly only. Nevertheless, to date there are
not any surveys or studies concerning APP in the elderly in Nguyen Tri Phuong Hospital.

2.6. Review of relevant research
A retrospective study on 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 (20032013) were conducted in Jordan. Patients were grouped into those with perforated and those with
nonperforated appendicitis. The results showed that APP 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 (Abdelkarim,
Muhammad, Ghazi, Ahmad, Mohammad, & Sahel, 2014).
A study was conducted to examination clinical presentations of APP in elderly. Patients who
underwent appendectomy for acute appendicitis between 2007- 2012 were included in the study.

Individuals with other reasons of acute abdomen not defined as acute appendicitis were
excluded. With these criteria, 1382 patients were included in the study. Patients were divided into
three age groups: group I; younger than 29, group II; 29 to 65, and group III; 65 and older.
Variables selected for analysis included age, sex, duration of symptoms, duration of
hospitalization (total and preoperative), operative approach, operative findings, operative time,
morbidity and mortality rates, and pathological confirmation. Results showed that the duration of
symptoms and hospitalizations (total and preoperative) were higher in the group III.
Postoperative outcomes were worse in the group III compared to the other groups. However,
miss diagnosis rate was lower in that age group. In general, acute appendicitis in the elderly
17