The incidence of acute appendicitis in the elderly is showing an increasing trend with the progression of population aging in our country. According to estimates from a comprehensive hospital in Tianjin, patients over 60 years old account for approximately 3-4% of all cases of acute appendicitis. The mortality rate also increases with age, ranging from 5-20%.

bubble_chart Pathogenesis

Anatomically, the ileum enters the cecum from the posteromedial side in 90% of cases, and from the posterior side in 8%. The ileocecal valve is composed of upper and lower lips, with the valve lips near the valvular orifice formed by ileal muscle and mucosa. The valve lips are not symmetrical, with the upper lip being more prominent. Hunter reported that the lower lip of the valve is sometimes absent.

bubble_chart Clinical Manifestations

Acute appendicitis in the elderly has the following characteristics:

1. Elderly individuals experience degenerative changes in blood vessels and lymphatic vessels, thinning of the appendiceal membrane, fatty infiltration, and fibrosis of the appendiceal tissue, along with vascular sclerosis, leading to relatively reduced blood supply to the tissues. Therefore, appendicitis is prone to necrosis and perforation after inflammation.

2. The atrophy and reduced responsiveness of the abdominal muscles in the elderly result in a discrepancy between symptoms and pathological changes. Symptoms are often milder than the pathological changes. Abdominal pain is not very severe or typical. Due to a dulled response to pain, the manifestations may only include abdominal distension and fullness, nausea, making differential diagnosis sometimes difficult and prone to misdiagnosis. Elderly patients with acute appendicitis often seek medical attention late, and by the time they do, most have already developed gangrenous perforation or abscess formation.

Clinical manifestations

In elderly patients, the onset of acute appendicitis is sometimes not prominent, and abdominal pain may develop gradually and be mild. Therefore, there may sometimes be a lack of typical history such as nausea, vomiting, and migratory right lower abdominal pain, and even fever may not be obvious, leading to late medical consultation and frequent misdiagnosis. If the perforated appendix can be localized to form a mass, the prognosis is generally better. However, if peritonitis develops after perforation, or even intestinal paralysis or toxic symptoms appear, it indicates severe inflammation and a dangerous condition, often with a poor prognosis.

bubble_chart Auxiliary Examination

The filling defect revealed by barium contrast depends on the anatomy of the valve membrane and the condition of the ileum entering the cecum. The anteroposterior view shows a Rose Flower valve shape, the lateral view presents an "ε shape," and the tangential view normally shows a symmetrical filling defect at the ileocecal junction. In cases of prolapse, a complete circular filling defect is observed. Air contrast radiography should not be performed until it is confirmed that the barium has fully filled the ileocecal valve area.

bubble_chart Diagnosis

The diagnosis is generally not difficult, but misdiagnosis can occur in cases where patients seek medical attention late and present with atypical symptoms. Therefore, it is essential to first conduct a detailed medical history inquiry, focusing on the history related to the disease characteristics, paying attention to the exact onset time, location, nature, and transfer time of abdominal pain, as well as accompanying symptoms. Before diagnosing appendicitis, it is also necessary to rule out diseases that are easily confused with it, such as ulcer disease, cholecystitis, and strangulated intestinal obstruction. Secondly, a comprehensive physical examination should be conducted meticulously, noting that elderly patients may have milder sign responses, relaxed abdominal walls, and that abdominal wall surgery may be required, with a good prognosis.

In terms of treatment, exploratory laparotomy is performed when malignancy cannot be ruled out. Generally, exploratory laparotomy is performed when there is a severe malignancy in the membrane. Except in cases of severe anatomical abnormalities or massive intestinal bleeding, resection surgery is not typically performed. The prolapsed ileum membrane can be repositioned through a cecal incision. This syndrome is a benign sexually transmitted disease with a good prognosis.