Urgent message: Consider the possibility of appendicitis in the elderly even in the absence of typical/classic symptoms. Acute appendicitis in this population is associated with high morbidity and mortality rates.

Author: Alona Dalusung-Angosta, PhD, APN, NP-C and Bryan Holmes, NREMTP

Introduction
Acute appendicitis is one of the most common causes of abdominal pain, affecting 7% of the general population. The majority of cases occur in patients ages 10 to 30, and the risk of mortality from perforated appendicitis is low in this population.1 In the elderly, however, the risk of morbidity and mortality is high.2,3 Acute appendicitis is uncommon in older patients and the presentation of symptoms is atypical. That may pose a challenge to urgent care clinicians.

Case Presentation
R. M. is a 72-year-old white male who presented to the urgent care clinic with 2 days of abdominal cramping/fullness, intermittent vomiting, and urgency to defecate. He reported taking Pepto-Bismol with no relief and went to a local urgent care clinic seeking a prescription for an antiemetic and medication for his abdominal cramping. R.M. claimed he had food poisoning from eating leftover dinner 2 days before and stated that about 1 hour after eating, he did not feel well. He also said he had these similar symptoms about a year ago and was told he had “mild food poisoning.”

Review of systems was positive for anorexia, intermittent vomiting, a feeling of wanting to defecate, and abdominal fullness. R.M. reported no fever, chills, muscle aches, chest pains, shortness of breath, or urinary problems. His last bowel movement was 2 days ago with soft, brown stools. R.M. described his abdominal complaints as “off and on cramping and fullness” and the cramps as colicky and without radiation. Nothing relieves the cramps or provokes them. The patient rated his abdominal cramps/fullness as 9/10. His previous medical history was negative, except for right knee osteoarthritis and being overweight; he reported no surgical history. R.M is married, lives with his wife, has three grown children, is retired and a non-smoker ho does not drink alcohol.

Observations/Findings

  • Temp: 99.0° F
  • P: 108
  • R:22
  • BP: 138/90
  • O2 Sat: 97%

On physical examination, R.M. appeared to be in no acute distress. He was an overweight male and appeared mildly anxious. His head was normocephalic, sclera were not icteric, conjunctiva were not pale. RM.’s lungs were clear to auscultation bilaterally. His heart rate and rhythm were normal, with audible S1S2, without any murmurs. R.M. had decreased bowel sounds and his abdomen was mildly distended without palpable masses. He had tenderness throughout his abdomen, more prominent over the right lower quadrant, without rigidity, guarding, or rebound. Rovsing’s sign was positive, however, and obturator and psoas signs were negative.

Labs/Imaging
R.M. was sent to a nearby emergency department via ambulance. His urinalysis was normal. His white blood count was elevated. Other labs, including liver function tests, were normal. Rectal exam was negative for occult blood. Abdominal x-ray revealed dilated loops of small bowel. Computed tomography of the abdomen showed small bowel dilatation and an enlarged appendix with thickened walls consistent with appendicitis.

Discussion
Acute appendicitis is an uncommon gastrointestinal disease in the elderly. When it strikes an older patient, the presentation usually is atypical. The rate of perforation and mortality in appendicitis in the elderly is increased when compared with the younger population (Lyon & Clark, 2006). The urgent care clinician could have easily excluded the diagnosis of acute appendicitis in this case, and have given R.M. an antiemetic and/or an antispasmodic agent, which would have resulted in tragedy.

Conclusion
Prudent history-taking and physical examination by an urgent care clinician can be lifesaving for elderly patients with appendicitis who need early aggressive treatment. When caring for older patients who present with abdominal complaints, acute appendicitis should be included in the differential diagnosis.

References

  1. Lee JF, Leow CK, Lau WY. Appendicitis in the elderly. Aust N Z J Surg. 2000;70(8):593-596.
  2. Harbrecht BG, Franklin GA, Miller FB, et al. Acute appendicitis—Not just for the young. Am J Surg. 2011;202(3):286-290.
  3. 3. Su YJ, Lai YC, Chen CC. Atypical appendicitis in the elderly. International Journal of Gerontology. 2011;5(2):117-119.

Alona Dalusung-Angosta is a Board Certified Nurse Practitioner at Advanced Urgent Care in Las Vegas, Nevada. She is also an Assistant Professor at the University of Nevada, Las Vegas School of Nursing. Bryan Holmes is a Nationally Registered Paramedic who serves as the Medical Services Supervisor at Advanced Urgent Care. He is also an American Heart Association instructor and serves as an Assistant Instructor at Pima Medical Institute, Las Vegas.

Atypical Appendicitis in the Older Patient
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