Certain groups are at high risk for appendicitis. Collectively, these patients present atypically and more often have delayed diagnoses as a result, with a concomitant increase in complications, such as appendiceal perforation. Emergency physicians must adopt an aggressive approach to evaluating these patients to reduce morbidity and mortality rates associated with unrecognized appendicitis.
Very young patients present insiduously and have a higher perforation rate. The rate of misdiagnosis is as high as 57 percent in children under age 6 years, with perforation rates approaching 90 percent in some studies. 2 22 Diagnosis in the pediatric population can be confounded by difficulty with communication and atypical symptoms, including concurrent respiratory symptoms. It is important to stress that peritonitis in children can present with such varied signs as lethargy, inactivity, and hypothermia. Appendicitis is a common condition requiring emergency operation in children, and early surgical consultation is recommended in suspicious cases.
The very old may have subtle signs and symptoms even late in the course of appendicitis. Members of this population tend to present late to physicians, often after a period of self-medication. Misdiagnosis rates can surpass 50 percent, with a high incidence of perforation, ranging from 40 to 70 percent. 2324 and 25 Mortality rates for patients over 70 with acute appendicitis approach 30 percent.26 In addition to late presentation with an advanced course, anatomic changes in the appendix involving the vascular bed and reduced mural thickness are thought to contribute to the fulminant course of appendicitis seen in the elderly. 27 One study found that the most significant predictors of acute appendicitis in the aged were tenderness, rigidity, pain at diagnosis, fever, and previous abdominal surgery. 28 Since extensive laboratory studies may obscure the diagnosis in patients with other concurrent medical problems, a high index of clinical suspicion is needed in the management of these patients.29
Pregnant patients can be difficult to diagnose with appendicitis because of variation in presentation resulting from appendix displacement by the gravid uterus as well as the fact that physiologically typical symptoms of appendicitis, such as nausea and vomiting, can be mistakenly attributed to pregnancy. Nonetheless, appendicitis remains the most common extrauterine surgical emergency in pregnancy, and fetal mortality rates can be four times higher if the appendicitis is complicated by perforation and peritonitis.30 Consequently, the diagnosis of appendicitis must be entertained in any gravid patient presenting with abdominal pain and gastrointestinal symptoms. As an adjunct, ultrasound can be used to aid in diagnosis, particularly in differentiating obstetric causes from appendicitis.
Patients with AIDS are particularly susceptible to complications from appendicitis. Although symptoms are no different for appendicitis in this population, 31 diagnosis can be delayed because of patients' high tolerance for discomfort, the baseline frequency of gastrointestinal symptoms unrelated to appendicitis, and the occurrence of nonsurgical opportunistic pathologic conditions with similar presentations. One study noted a higher incidence of perforation in this population, possibly related to the delay in presentation or to the immunocompromised state.31 One clear difference in management relates to the WBC, which is generally not elevated even in acute appendicitis. CT remains a good choice for differentiating surgical from nonsurgical pathologic conditions in unclear cases, but the overall management still focuses on basic assessment with aggressive surgical intervention.
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