What should be considered in the evaluation and management of acute appendicitis in a 70‑year‑old patient?

Management of Acute Appendicitis in a 70-Year-Old Patient

In a 70-year-old patient with suspected appendicitis, obtain a CT scan with IV contrast immediately if the Alvarado score is ≥5, proceed directly to laparoscopic appendectomy once diagnosed, and never rely on clinical symptoms or laboratory values alone for diagnosis. 1

Diagnostic Approach: Imaging is Mandatory

Do Not Trust Clinical Presentation Alone

• Never base the diagnosis on clinical signs and symptoms alone in elderly patients – atypical presentations are the rule, not the exception 1
• Never base the diagnosis solely on elevated WBC or CRP values – while these should prompt further workup, they lack sufficient diagnostic accuracy in the elderly 1
• Elderly patients present later (mean 7.88 days vs 3.56 days in younger adults) and frequently have delayed or atypical symptoms 2

CT Scan is the Gold Standard

• Obtain CT scan with IV contrast in all elderly patients with Alvarado score ≥5 to confirm or exclude appendicitis and distinguish perforated from non-perforated disease 1
• CT has 100% sensitivity, 99.1% specificity, 95.7% positive predictive value, and 100% negative predictive value in patients over 65 years 1
• If Alvarado score <5, observe clinically and obtain CT with IV contrast if the patient fails to improve 1
• CT use increased from 28% to 67% in elderly patients between study periods, reflecting recognition of diagnostic challenges 3

Alternative Imaging When CT Contraindicated

• Use ultrasound only in patients who cannot receive CT with IV contrast (acute/chronic kidney disease) to confirm appendicitis, but not to exclude it 1
• Do not use ultrasound to distinguish perforated from non-perforated appendicitis 1
• If available, use MRI when CT contraindicated; if MRI unavailable, use non-contrast CT 1

Critical Recognition: Higher Complication Rates

Expect Complicated Disease

• Elderly patients have significantly higher perforation rates (46.7% vs 20.7% in younger adults) 2
• The perforation rate in elderly patients is 12.9% of all perforated cases versus only 2.9% of non-perforated cases 4
• Negative appendectomy carries a 25% complication rate in elderly patients versus only 3% in younger patients, making accurate preoperative diagnosis critical 1

Recognize Mortality Risk Factors

• Overall mortality is 2.3-5.5% in elderly patients versus 0% in those under 50 years 5, 4
• Mortality reaches 11.9% in perforated appendicitis versus 1.5% in non-perforated cases 4
• Pre-existing severe comorbid conditions are the major contributor to mortality 5

Surgical Management: Laparoscopic Approach Preferred

Proceed to Surgery Promptly

• Perform appendectomy as soon as possible once the diagnosis is confirmed – delays increase mortality in elderly patients 1, 6
• 85.0% of elderly patients should be operated within 24 hours versus 88.7% in younger adults 2
• Laparoscopic appendectomy is preferred due to reduced length of stay, morbidity, and costs 1
• Expect longer operative times (71.1 vs 60.3 minutes in younger adults) 2

Surgical Technique Considerations

• Use the stump closure method (stapler, endoloops, clips) based on local expertise – no evidence favors one method over another 1
• Place abdominal drainage in complicated appendicitis (perforation/abscess/peritonitis) 1
• Avoid midline or paramedian incisions – these are associated with higher wound infection rates and longer hospital stays 5

Non-Operative Management: Limited Role

When to Consider Non-Operative Management

• Consider non-operative management only in highly selected elderly patients with uncomplicated appendicitis on CT who wish to avoid surgery and accept recurrence risk 1
• Use non-operative management with percutaneous drainage for appendicular abscess if accessible 1

When Surgery is Mandatory

• Never use non-operative management in complicated appendicitis with diffuse peritonitis or suspected free perforation – immediate surgical exploration is required 1, 6
• Delaying surgery for complete hemodynamic optimization increases mortality 6

Antibiotic Management

Preoperative Antibiotics

• Administer preoperative broad-spectrum antibiotics to all elderly patients undergoing appendectomy within 1 hour of presentation 1, 6
• Options include piperacillin-tazobactam, ampicillin-sulbactam, ceftriaxone plus metronidazole, or ampicillin plus clindamycin/metronidazole plus gentamicin 7

Postoperative Antibiotics

• Do not administer postoperative antibiotics for uncomplicated appendicitis 1
• Give postoperative broad-spectrum antibiotics for 3-5 days in complicated appendicitis, with discontinuation based on clinical and laboratory improvement 1, 6
• Extend to 7 days in immunocompromised or critically ill patients 6

Postoperative Expectations and Follow-Up

Anticipate Higher Morbidity

• Overall postoperative complications occur in 27.9-35.8% of elderly patients versus 12.9% in younger adults 4, 2
• Severe complications occur in 6.9% versus 2.4% in younger patients 2
• Expect prolonged hospital stays (7.9 days vs 3.6 days in younger adults) 2
• In perforated cases, morbidity reaches 73.8% versus 11.9% in non-perforated cases 4

Mandatory Cancer Screening

• Recommend elective colonic screening in all elderly patients with appendicitis (both operatively and non-operatively treated, especially if laparoscopic) due to increased risk of appendiceal and colonic tumors 1

Critical Pitfalls to Avoid

• Never delay surgery attempting complete hemodynamic stabilization – initiate aggressive fluid resuscitation but do not delay source control 6
• Never rely on scoring systems alone – use them to exclude appendicitis with low scores, but not to confirm diagnosis 1
• Never assume normal labs exclude appendicitis – elderly patients may not mount typical inflammatory responses 1, 8
• Never use inadequate antimicrobial coverage perioperatively – this is associated with treatment failure 6
• Recognize that septic progression from perforated appendicitis is the main cause of mortality in this age group 4