Appendicitis

Characteristically, the initial symptom of appendicitis is periumbilical pain, followed by nausea and then by localized pain and tenderness in the right lower quadrant. Low-grade fever and leukocytosis also occur typically. However, in elderly patients, pain more often begins in the right lower quadrant and may not be severe until perforation occurs. Because the blood supply to the appendix is generally decreased in elderly patients, the course of the disease can be fulminant. In some cases, symptoms and signs may be minimal, leading to chronic infection with marked low-grade fever and poorly defined localization of abdominal signs.

In the elderly, appendicitis occasionally occurs in association with colon cancer. Low-grade obstruction can lead to appendiceal distention that mimics true appendicitis.

The treatment is appendectomy. Antibiotics should be given before surgery and continued for at least 48 hours afterward. If perforation has already occurred and peritonitis is spreading, the value of drainage is controversial. Simple drainage is recommended for a localized abscess, and appendectomy should follow in a few weeks. In nearly all other cases, however, the appendix is removed during the initial operation.

If the patient who has had a simple appendectomy fails to recover promptly, the colon should be examined by endoscopy or barium enema.