Clinical Geriatrics

Digestive Disease Week 2009

Chicago, IL

May 30-June 4, 2009

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American Academy of Neurology 61st Annual Meeting

Seattle, WA

April 25-May 2, 2009

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Elderly Patients Present with More Advanced Appendicitis

Chicago, IL—It is common for elderly patients with acute appendicitis to be suffering from more advanced disease when they seek medical attention, but the factors responsible for their delayed presentation have not been thoroughly investigated. As a result of their delayed presentation, these patients experience higher incidences of perforation and sepsis. Investigators led by Rebecca J. Rose, MD, of the Department of Surgery, State University of New York at Buffalo, recently conducted a retrospective study to ascertain what factors may account for the delayed presentation and more advanced disease states of elderly patients with acute appendicitis and presented their results at the DDW meeting.

They conducted a 5-year retrospective chart review from 1999 to 2004 at a tertiary referral center in which 375 consecutive medical records were identified for patients who underwent appendectomy. After excluding incidental, interval, or pathologically negative appendectomies, 276 patients were identified and stratified into two groups. The first group included patients ≤ 60 years old (243 patients) and the second group included patients ≥ 70 years old (33 patients).

Clinical parameters studied included the Alvarado criteria (right lower quadrant [RLQ] pain, pain migration, anorexia, nausea/vomiting, rebound pain, fever, leukocytosis, left shift), interval from symptom onset to Emergency Department (ED) presentation, interval from ED presentation to surgery, length of hospital stay (LOS), laboratory profile, CT findings, operative procedure and findings, pathology, and postoperative complications. T-test and chi square were used for statistical comparisons.

Time from symptom onset to ED presentation was significantly longer in the elderly (66.1 hrs vs 41.8 hrs, P < 0.045) but time from triage to surgery was not (13.3 hrs vs 13.6 hrs, P = 0.94). The elderly had significantly decreased pain migration to the RLQ (27% vs 60%), decreased nausea/vomiting (64% vs 81%), and anorexia (45% vs 65%); however, rates of localized tenderness were the same (100% vs 94%).

Overall complication rates were higher in the older group (36% vs 20%). There was no difference in white blood cell elevation (79% vs 78%, P = 0.45) between the two groups, but the elderly more commonly had a left shift (96% vs 80%). Older patients had a significantly higher rate of suppurative (72% vs 49%, P < 0.023) and perforated appendicitis (73% vs 25%, P < 0.001) and a significantly longer length of stay (7.3 hrs vs 3.6 days, P < 0.001). They were also more likely to have open rather than laparoscopic appendectomy (82% vs 60%, P < 0.02).

The investigators said that delays in coming into the ED as well as more subtle and atypical pain presentation are factors that appear to be associated with the advanced disease state of appendicitis when diagnosed in the elderly. Reasons for delayed ED presentation are unclear, they said, but may be related to blunting of abdominal pain in the elderly, the diffuse nature of their pain, a poor family support system, and/or poor body awareness. Shortening the pre-ED admission interval appears to be the most important factor in lowering the higher perforation and complication rate in elderly appendicitis.

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Magnesium Citrate and Senna Effective for Colonoscopy Bowel Prep

Chicago, IL—A multicenter study that compared the efficacy of different bowel preparation regimens used for elderly patients undergoing colonoscopy found that magnesium citrate combined with senna provides more effective bowel preparation than high-volume polyethylene glycol. Kinesh P.