Canadian Journal of Surgery 1996; 39: 142-146
*Supported by a Career Scientist Award from the Ontario Ministry of Health
§Former resident in general surgery, University of Ottawa
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Résumé
Objectif : Évaluer l'influence de l'âge sur l'évolution et la gravité de la péritonite.
Conception : Examen de dossiers.
Contexte : Hôpital universitaire pour adultes.
Patients : Cent vingt-deux patients présentant une appendicite aiguë et 100 patients présentant une diverticulite colique aiguë nécessitant une opération ou un drainage percutané.
Principales mesures de résultats : Âge et sexe du patient, présence de perforation ou de gangrène (appendicite), étendue de la péritonite (diverticulite); durée des symptômes avant l'admission; leucocytose à l'admission; durée de l'hospitalisation avant la chirurgie; durée du séjour à l'hôpital; taux de décès.
Résultats : Les patients de 65 ans ou plus qui présentaient une appendicite aiguë couraient trois fois plus de risques de développer un appendice gangreneux ou perforé que les jeunes patients (taux de probabilité 3,1, intervalle de confiance à 95 %, de 1,1 à 8,4, p < 0,05); les patients âgés présentant une diverticulite perforée couraient trois fois plus de risques que les jeunes patients de développer une péritonite généralisée qu'une péritonite localisée (péricolique ou pelvique) (taux de probabilité de 2,9 %, intervalle de confiance à 95 %, de 1,2 à 7,5, p < 0,05).
Conclusion : Ces conclusions confirment l'hypothèse que les caractéristiques biologiques de la péritonite sont différentes chez les personnes âgées, qui courent plus de risques de développer un état plus avancé ou plus grave que de jeunes patients.
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Introduction
The death rate accompanying all forms of surgical illness, including intra-abdominal infections, increases consistently with advancing age.[1-3] In part this is due to an increased prevalence of chronic illnesses in the elderly and a predictable decline in the ability to maintain physiologic homeostasis. Additionally, age-related changes in the host responses to surgical illness have been described[1] and other observations have been made, suggesting that the clinical manifestations of peritonitis, both local and systemic, may be altered in the elderly.[4,5] To evaluate potential age effects on the evolution and severity of peritonitis, we reviewed two series of patients of varying ages admitted to an adult university hospital with appendicitis or perforated diverticulitis.
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Patients and methods
The charts of 100 patients with pathologically proven acute appendicitis were selected by random number table from those of 695 patients with a primary diagnosis of appendicitis during a recent 5-year period. Only 4 of the 100 patients were aged 65 years or older. Therefore we added for review the charts of all other patients aged 65 years or older with the same diagnosis, admitted during the same 5-year period (22 patients). Patient age, sex, duration of symptoms before admission, duration of hospitalization before surgery, leukocyte count on admission to the emergency department, the presence of a gangrenous or perforated appendix according to pathological examination, length of hospital stay and death rate were obtained from the 122 charts.
We also reviewed the charts, covering a recent 12-year period, of 100 consecutive patients with a primary diagnosis of perforated colonic diverticulitis who required nonelective surgical intervention (98 patients) or percutaneous drainage of an abscess (2 patients). The extent of peritonitis was classified as either pericolic or confined to the pelvis or as generalized (purulent or fecal), according to findings at laparotomy (or from imaging studies in the two patients with well-defined abscesses).[6] Other data similar to that in patients with appendicitis were recorded. Data are expressed as means (and standard deviations) and were analysed by independent t-testing, c2 test with Yates' correction and multiple linear regression (SystatFPU 5.2.1, Systat Inc, Evanston, Ill.).
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Discussion
Death and other outcomes of acute surgical illness are uniformly worse in the elderly than in younger patients, and the adverse impact of age on outcome from abdominal sepsis in particular is well recognized.[2,3] The higher death rate among the elderly undoubtedly reflects an increased prevalence of pre-existing cardiovascular and other diseases as well as a predictable decline in many physiologic functions. Anecdotal evidence suggests that the clinical manifestations of the acute abdomen may be considerably different in the elderly from those of middle-aged and younger people.[1,7] To address the possibility that the evolution and local severity of peritonitis are influenced by aging, we chose to review the charts of patients with acute appendicitis and perforated diverticulitis, since they are common acute surgical conditions, occur in individuals of widely varying ages and are amenable to grading in terms of their anatomic or pathological severity. In both appendicitis and diverticulitis, older patients were much more likely to have advanced or severe disease than younger patients.
Other reports[8,9] have indicated that appendicitis tends to be more advanced in older patients. The reasons for this may be several. Anatomic changes in the appendix with aging include vascular sclerosis and diminished blood supply, narrowing of the lumen, fibrosis of the muscularis and fatty infiltration.[10] Thus, the progression from simple obstruction of the appendiceal lumen to gangrene and perforation may occur more rapidly and with only small increases in intraluminal pressure.[11] However, the present data indicate that the period between the onset of symptoms and operation is prolonged in older patients and not that the rate of evolution of appendicitis is altered. A delay in the presentation of elderly patients to hospital has also been observed by others and may result from difficulties in leaving home, fear of hospitalization, alterations in usual symptoms and diminished perception of them, or diminished ability to express them effectively.[12-16] Absence of the expected localization of pain to the right lower quadrant was noted in almost one-half of older patients with appendicitis in one series,[14] and variability in the manifestations of appendicitis in the elderly is well described.[14,16] The perception of pain after abdominal surgery is known to be diminished in the elderly.[17] In this retrospective review we could not determine reliably whether a decreased severity of symptoms or other factors contributed to the delayed presentation of older patients with appendicitis.
We observed that older patients with perforated diverticulitis requiring operation were much more likely to have generalized peritonitis than were younger patients. This finding is consistent with the hypothesis that the elderly are predisposed to more severe peritonitis. An alternative explanation is that older patients with localized peritonitis were more responsive to nonoperative treatment and that those who underwent surgery (and thus were identified for review) were thereby selected to have advanced disease. Unfortunately the number of patients with diverticulitis who do not require intervention is not reliably known since investigations such as water-soluble contrast enemas and computed tomography were used infrequently, and the data are hospital- rather than population-based. Biased selection of patients may also have arisen from the admission or transfer of the oldest and most ill patients to this tertiary hospital. The period of hospitalization before operation was significantly related to the extent of peritonitis and was not a function of age among the patients reviewed, as might have been expected if responses to nonoperative treatment differed in the elderly. We chose to study only patients in whom the diagnosis was proven, for simplicity and to avoid additional difficulties in interpretation.
A predisposition of older patients to free perforation rather than a contained abscess or phlegmon was noted in another study[18] of patients hospitalized with symptomatic diverticular disease. Interestingly, a higher proportion of young (under age 40 years) than older patients underwent surgical intervention, which, together with the suggestion that many young patients require surgery at the time of their first episode of diverticulitis, was interpreted as indicating that diverticulitis is more severe in the young patient. In contrast, in a recent prospective study,[19] more patients older than 50 years required emergency laparotomy (apparently on the basis of generalized peritonitis) or surgical treatment during their first hospitalization than did younger patients. Grading with computed tomography or water-soluble contrast enema, or both, suggested that diverticulitis was more severe in young patients, but the patients investigated in this way were a subset of the larger group and presumably tended to exclude those who had generalized peritonitis (i.e., the most severe disease).
The finding of more advanced disease in patients with diverticulitis in this study was associated with a shorter period of symptoms before admission to hospital, suggesting that the severity of the process is determined early on, and primarily by factors other than the passage of time (as in appendicitis). Whether peritoneal mechanisms for containing the initial inflammatory process and perforation are more frequently ineffective in older patients or whether perforation and widespread soiling occur more rapidly, without opportunity for confinement, are speculative. Observations that the localization of pain and peritoneal signs to the right lower quadrant may be delayed or absent in elderly patients with appendicitis tend to support the concept that peritoneal responses are altered in the elderly.[11,14] Moreover, the absence of typical mani- festations of peritonitis in the elderly, specifically abdominal pain and signs of peritoneal irritation, has been associated with a poor outcome.[5]
In summary, we observed that the likelihood of an advanced or severe process was substantially increased in older patients with appendicitis and diverticulitis, consistent with the hypothesis that the biologic features of peritonitis differ in the elderly. Impaired local peritoneal responses could, for example, result in less localized, severe abdominal pain and a delay in the presentation of older patients with appendicitis or a failure to contain contamination after perforation of a colonic diverticulum, leading to the development of generalized peritonitis. If these retrospective clinical observations reflect a generalizable, age-related change in the biologic features of peritonitis, then an understanding of the basis for such a change may allow improvements in the care of elderly surgical patients with abdominal infections.
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References