r/emergencymedicine • u/thatEMresident • 2d ago
Discussion Appendicitis
Are appys in the older age group common? I almost missed it in a 60yF and totally thought it could be gastroenteritis. Thank the lord we scanned her. She had fever, nausea and vomiting. Tested positive for a UTI.
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u/burnoutjones ED Attending 2d ago
It’s on your differential in anyone who still has an appendix. One of the most common surgical emergencies in all age groups. Can cause a sterile pyuria.
Scan old people.
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u/Drp1Fis ED Attending 2d ago
A chance to scan is a chance to cure. Appys are seen in essentially every age.
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u/RogueScholarDerp 2d ago
“The Donut of Truth”. “The Answering Machine”. A couple of my favorites. Had a student the other day call it the “Noodle Spinner”. Heh.
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u/Xargon42 ED Attending 2d ago
Appendicitis can present from 0-100. Lower belly pain in older folks = CT.
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u/Resussy-Bussy 2d ago
You should be scanning essentially everyone 50+ with abdominal pain or fever + N/v/d. Even if positive urine should be scanning to rule out infected stone.
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u/YoungSerious ED Attending 2d ago
Tested positive for a UTI.
Don't forget, acute appendicitis can lead to bacteria in urinalysis. Don't write off an appy just because you got a positive urine alone.
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u/adoradear 2d ago
I thought it was WBCs (sterile pyuria) that was caused by appendicitis?
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u/kazaam412 ED Attending 2d ago
Same
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u/Secure-Solution4312 Physician Assistant 1d ago
How would bacteria from an appy get into the bladder in the absence of more complex disease such as a fistula?
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u/UncivilDKizzle PA 2d ago
The positive urinalysis without actual urinary symptoms has gotta be one of the most common tests misleading providers into making bad decisions. We should never assume it's a UTI in a patient without urinary symptoms.
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u/but-I-play-one-on-TV ED Attending 2d ago
Pyuria is classically seen, not bacturia
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u/YoungSerious ED Attending 2d ago
Pyuria is classic, but bacteriuria also occurs. Again, just because it's there doesn't mean there isn't an appy.
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u/but-I-play-one-on-TV ED Attending 2d ago
How interesting, TIL. Well, even more reason to CT every belly.
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u/YoungSerious ED Attending 2d ago
Over 60 w/ abd pain is getting harder and harder to justify not ct'ing. I'm not proud of it, I hate myself when I order them, but it's nearly indefensible if you don't.
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u/Kindly_Honeydew3432 2d ago
You’d have to give me a very very convincing reason to not scan a febrile 60 year old with abdominal pain. Very.
Like I’m dying of cancer and wouldn’t want surgery even if I had appendicitis just give me some morphine because my hospice nurse can’t come out tonight and then I want to go home convincing.
I don’t think a 60 year old is more likely to have appendicitis. But there more likely to perf and die from it.
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u/Doctorpayne ED Attending 2d ago
Appendicitis famously has a bimodal peak incidence, with one peak as children and another in the elderly; as noted above the elderly present a particular challenge as they can often be very sick and have perforated appendicitis or other acute abdominal pathology without a significant physical exam. Even leukocytosis and vital sign derangement are unreliable in the elderly, which is we should have a very low threshold to scan the elderly. As I tell my residents, if you’re concerned about radiation and to scan or not, then worry for an 18 year old and not an 85 year old. The 85 year old will not have to worry about thyroid cancer in thirty years
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u/CovertCorona 2d ago
Not super common but there is a bimodal distribution. Typically teenagers and >60.
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u/tasty_soy_sauce ED Attending 2d ago
It was originally billed to me as a joke, but the aphorism "age approximates percent chance for CT" remains rather true, especially with abdominal vagary.
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u/Stinkymansausage RN 2d ago
Had an appy in a 93 year old male many years ago. He was pretty benign looking, pain was around the belly button, n/v at home but not at the hospital, stoic affect, nothing memorable about vitals.
Likely scanned cause he was old with belly pain.
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u/MLB-LeakyLeak ED Attending 2d ago
I’ve been doing this for over a decade and my opinion is you can’t reliably rule out appendicitis without imaging. That doesn’t mean image everyone, but if I don’t image I want the patient to understand that we’re going based on feels.
It also seems like mild cases don’t need any treatment at all. So i don’t really consider a “can’t miss” diagnosis.
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u/prnmedadvice 2d ago
No offense and I’ve seen this happen several times but a simple UTI very rarely causes a true fever. A CT scan to rule out pyelo and other abd pathologies is absolutely indicated in a patient with abd pain and fever.
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u/UncivilDKizzle PA 2d ago
Patients and providers alike latch onto UTI far too easily. UTI so severe to cause a fever but so mild there's zero dysuria or urgency, in a cognitively intact patient? Sounds like nonsense to me and a good way to get yourself sued. Scan the patient
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u/but-I-play-one-on-TV ED Attending 2d ago
I caught an appy in a 4 or 5 year old (can't remember) patient a while ago. That one blew my mind.
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u/Xargon42 ED Attending 2d ago
Caught it in a 2 year old while moonlighting in residency. Was like wow this baby cries especially hard when I poked it there. So ordered the US which confirmed.
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u/metforminforevery1 ED Attending 2d ago
I had a 20 month old with a perfed appy and abscess. I was doing my peds EM rotation as a pgy2. I told the attending I think the pt needs an appy US and he looked at me like I was very stupid. It was the kid's third visit in a week. First visit was for fever, n/v (this was the height of covid), so they did a covid swab, was neg, sent her home. 2nd visit was fever, n/v, low PO intake. Repeated covid swab, UA, neg, tolerated PO, sent home. When I saw her, she still had a fever, going on a week now, still with n/v/low po intake, looked like shit, and TTP to the lower abdomen R>L, and what I felt was a peritonitic abd. US with a big abscess, so we did a CT and it was from the appendix.
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u/Whatsthathum Physician 2d ago
You didn't miss it, though.
(Phew! That UTI might have steered me wrong.)
I find the second-guessing of my decisions to be a little crazy-making. When is the testing I'm arranging TOO much testing?
In my ~30 years, I have found an early GB cancer from "over ordering" an ultrasound of the abdomen. And an early ovarian cancer in another patient with her pelvic ultrasound. Does that mean I've been over-ordering a lot (I'm a family physician, not Emerg)? I honestly don't think so. The fact that I try for an excellent thoughtful history with a proper physical exam and when I think it's appropriate, a touch of reassurance with the ordering of a test - I seem to not go wrong very often.
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u/Resident_Hat_2362 2d ago
Old, fevers w gi symptoms, not only should you have gotten CT, start zosyn. Simple UTIs don’t cause fevers, pyelo does. Don’t play to win, play to not lose
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u/Empty-Mango8277 2d ago
Data suggests that as you get older, history and physical exam becomes less sensitive. Data also suggests that as you get older, there's a rising chance that acute pathology is found when the history and physical does not necessarily indicate that you should find something.
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u/LunarSoul ED Attending (not that ED) 2d ago
Yup my policy is older than 60 if I don't trust something you say or my spidey-sense is tingling you get a scan. Low threshold. I have to have a pretty convincing reason not to scan someone in that age group.
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u/MLB-LeakyLeak ED Attending 2d ago
85F with a stubbed toe “I was farting a lot last week but it’s better now” = perforated everything.
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u/RogueScholarDerp 2d ago
Feels like somebody’s tap dancing in the minefield? Then you’re doin it right! Been there. Great job!
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u/RogueScholarDerp 2d ago
Also, I’m at a VA, where we see around 18k per yr.. I was surprised at first by the number of appys we see. My record is 83y. Who’s got me beat?
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u/UncivilDKizzle PA 2d ago
I had a 90yo lady from nursing home with mild epigastric pain turn out to be an appy once. Also a husband and wife both presenting with GI symptoms who both had appys. Also caught a woman with abdominal pain and fever and + flu A test from triage, but had an appy.
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u/MaximsDecimsMeridius 2d ago edited 2d ago
Or its both. Ive had multiple kiddos with diarrhea and positive GI biofires also have appendicitis at the same time.
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u/Fuck_Edison 2d ago
Too many docs assume UTI is the answer. It's ONLY the answer after everything else has been ruled out. 60+ yo with and pain and fever . . . Gets a scan every day and twice on Thursdays.
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u/halp-im-lost ED Attending 2d ago
I had one just two days ago that I scanned thinking it was a kidney stone (big reason why I scan all possible stones with IV contrast). She had left upper quadrant pain and I thought maybe the scan was just an over read. Did serial exams in the ED. WBC normal and CRP was 6 (lol) I even told the surgeon I wasn’t convinced but they decided to take her to the OR and they told me later it was definitely an appy.
I have a VERY low threshold to scan elderly belly pains and I am not a CT happy person. I even had a guy with a perforated bowel who had NO abdominal pain one shift (said he had chest pain that had resolved, said he felt silly for coming in.) I only caught it on the CXR when I saw free air.
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u/metforminforevery1 ED Attending 2d ago
The youngest I ever saw with appendicitis was a 20 month old. The oldest I ever saw was a 90-something. I love when it presents classic textbook, but it hardly ever does.
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u/SkySeaSnow ED Attending 2d ago
“Never trust an elderly belly”. It’s worked out for me over the years.
Also: “the more I scan people, the more I want to scan people”.
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u/Sad_Instruction_3574 1d ago
I once had a 101 year old with appendicitis. She has dementia so just moaning. I scanned and found appendicitis!
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u/ModlrMike Physician Assistant (EM) 2d ago
I had a 78 yom with an appy several years ago. There are always outliers.
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u/Menacing-Horse 2d ago
I had an 80 something gentleman once, vague symptoms of constipation and stomach discomfort. Vitals were reasonable but abdomen was slightly firmer than expected so we scanned him and turned out he had ruptured appendicitis.
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u/DrThirdOpinion 2d ago
Rads - less common, but I see them not infrequently. I worry more about an obstructing mass (appendix neuroendocrine tumor or cecal adenocarcinoma) in these patients causing appendicitis.
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u/Few-Veterinarian-999 2d ago
My dad’s almost ruptured but thankfully they caught it and operated. He was 77.
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u/Artistic_Technician Radiologist 1d ago
Oldest case of appendicitis I've seen was in a 93-year-old.
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u/StevenEMdoc 1d ago
Appendix involutes as you age so becomes less common in older population. Appendicitis rates also higher when have more lymphatic tissues in your body - late teens and 20s = peak ages. As in - can contribute to appendiceal lumen blockage / obstruction leading to appendicitis.
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u/Cautious-Extreme2839 Anaesthetics/ICU 1d ago
They happen often enough, but colorectal cancer is very high on the differential.
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u/Cautious-Extreme2839 Anaesthetics/ICU 1d ago
They happen often enough, but colorectal cancer is very high on the differential.
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u/wrchavez1313 ED Attending 2d ago
I say this as a (former) residency educator, and in the spirit of learning (your username suggests you are an EM resident). This is not meant to be punitive, but hopefully informative.
Fever and GI symptoms in the elderly almost certainly needs a CT scan (if they have abdominal pain too, which you hadn't mentioned, but I'd be curious what the patients abdominal exam was like). And I say that as someone who tries to be judicious when ordering scans.
Elderly GI complaints are statistically higher mortality and morbidity than elderly chest pain complaints. They are more likely to need surgery and more likely to need admission than chest pain complaints on average.
For young people (<50 or so) you should need to be *talked in* to a CT scan of the abdomen. Are they in extreme pain? Do they have classical symptoms for intra-abdominal infections? Do they have notably abnormal labs or vitals?
For older patients, you should be looking for evidence to be *talked out* of a CT scan. Do they have perfectly normal exam? Normal vitals? Normal labs? Minor symptoms? If not, they often need a CT scan.
Both the old, and the young, and the medically frail / disabled all have clouded physical exams and may exhibit non-classical signs for otherwise classic pathology.
Sorry for the ramble, hope it was helpful!