Can normal inflammatory markers rule out acute appendicitis in elderly patients presenting with abdominal pain to the Emergency Department (ED).
Date First Published:
November 22, 2013
Last Updated:
November 23, 2013
Report by:
Magdy Sakr, Consultant (University Hospital Coventry)
Search checked by:
Mehmood Chaudhry, University Hospital Coventry
Three-Part Question:
In [elderly patients presenting to an Emergency Department with suspected appendicitis] does [normal inflammatory markers] role out the [diagnosis]?
Clinical Scenario:
A 78 years old lady presents to the Emergency Department with right lower quadrant abdominal pain for 2 days. She is known hypertensive and take bisoprolol 5 mg every morning. Clinical examination showed very slight tenderness in the right lower quadrant and suprapubic area, there is no guarding, masses or organomegaly. Urine dip and bowel sounds were normal. General examination is otherwise normal with temp of 37 degree Celsius, pulse of 58 beat per minute.
You wonder if you can rely on normal blood tests to be able to exclude appendicitis.
You wonder if you can rely on normal blood tests to be able to exclude appendicitis.
Search Strategy:
Midline,CINAHL,EMBASE search using OVID interface (1950- September 2013)
Using inflammatory markers
AND Abdominal pain OR ?appendicitis
AND Elderly OR Old age OR Above 65 years
Limit search to humans.
Using inflammatory markers
AND Abdominal pain OR ?appendicitis
AND Elderly OR Old age OR Above 65 years
Limit search to humans.
Outcome:
8 papers were found of which 3 were relevant to the question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Role of Leukocyte Count, Neutrophil Percentage, and C-Reactive Protein in the Diagnosis of Acute Appendicitis in the Elderly Horng-Ren, Yang; Yu-Chun, Wang; Ping-Kuei, Chung; Wei-Kung, Chen; Long-Bin, Jeng; Ray-Jade, Chen 2005 Taiwan(country of publication USA) | 85 Elderly >60 years old patients underwent appendectomy for suspected appendicitis 77 were confirmed histologically | Retrospective observational study of 85 consecutive patients over 30 months period. | No significant difference in leukocyte count or CRP values between patients with acute appendicitis and those with normal appendix. | If leukocyte count, differential and CRP all simultaneously normal the diagnosis of acute appendicitis should be reconsidered | Retrospective study with all weaknesses associated with retrospective studies. Small sample size. Age definition of elderly was 60 or over in included patients. |
| Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy Sülberg D, Chromik AM, Kersting S, Meurer K, Tannapfel A, Uhl W, Mittelkötter U. 2009 Germany | Patients who underwent appendectomies, compared group above 60 years old to those 60 years old or below | Prospective observational study over 30 months period | Patients with appendicitis in the above 60 years old group had higher CRP values than those with appendicitis who are 60 years or younger | More complications and perforations in the above 60 years old. | Used the cut off age of 60 years old as elderly. Small sample size in the above 60 years old group. Abstract in English,,article in German translated. |
| Is there a role for leukocyte and CRP measurements in the diagnosis of acute appendicitis in the elderly? Grönroos JM 1999 Finland | Patients aged 60 years or older who underwent appendectomy for suspected appendicitis over 3 years period. 40 females and 43 males recruited. | Prospective observational study | None of patients with normal appendix had elevation of both CRP and Leukocytes. | Small sample size. |
Author Commentary:
There is insufficient evidence for the use of inflammatory markers in the early diagnosis of appendicitis in the elderly. The diagnosis of acute appendicitis is less likely if all the results of leukocyte count, neutrophil percentage and CRP were within normal limits. The inflammatory markers although sensitive they are not specific, the sensitivity increases when they are combined.
References:
- Horng-Ren, Yang; Yu-Chun, Wang; Ping-Kuei, Chung; Wei-Kung, Chen; Long-Bin, Jeng; Ray-Jade, Chen. Role of Leukocyte Count, Neutrophil Percentage, and C-Reactive Protein in the Diagnosis of Acute Appendicitis in the Elderly
- Sülberg D, Chromik AM, Kersting S, Meurer K, Tannapfel A, Uhl W, Mittelkötter U. . Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy
- Grönroos JM. Is there a role for leukocyte and CRP measurements in the diagnosis of acute appendicitis in the elderly?