Diagnostic problems surrounding appendicitis in the elderly are well known in emergency medicine (see Ch§p.: Z„4) In one series, only 51 percent of patients over the age of 60 with proven appendicitis had that diagnosis made during the ED phase of their care. 13 Delayed presentation is common and contributes to the higher perforation and complication rate. One must be careful to not exclude appendicitis because of prolonged symptoms, as a small but significant percentage of the elderly will wait more than a week to seek care for this condition.

The abdominal pain is generally reported to be in the right lower quadrant; however, the description may be vague or the pain poorly localized. 913 In one study, migration was recorded in only 35 percent of elderly patients with appendicitis. 8 Anorexia, an expected finding in younger patients, may be lacking, while nausea and vomiting are reported in roughly half of elderly patients with appendicitis. 8913 Diarrhea and urinary tract symptoms do not exclude the disease.

Fever may be absent in one-third or more. Tenderness in the right lower quadrant is a frequent finding occurring in 80 to 90 percent of these patients. The presence of peritoneal signs such as rigidity and rebound tenderness have been reported to range from 20 percent to more than 80 percent. 8 Laboratory assessment is potentially misleading, as 20 percent will have a white blood cell count below 10,000. 913 Abdominal radiographs rarely add to the diagnostic process and can lead one astray by suggesting small bowel obstruction.89

It is prudent to include appendicitis in the differential diagnosis of any elderly patient with abdominal pain who has not undergone an appendectomy. The clinician must not expect a neat diagnostic package. In one series, only 20 percent of older patients with appendicitis had all of fever, nausea or vomiting, tenderness in the right lower quadrant, and an elevated white blood count.13

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