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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


(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
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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

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

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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

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

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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

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
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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

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,
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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

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;

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

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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.

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
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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

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
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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

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

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.
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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

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