In general, the diagnosis of acute appendicitis in adults is rarely challenging, and outcomes with early treatment are very favorable. However, in cases involving infants, the elderly, or pregnant women, both diagnosis and treatment can be more difficult, requiring particular attention.
Neonatal Acute Appendicitis
The appendix in neonates has a funnel-like shape, making obstruction caused by lymphoid hyperplasia or fecalith rare. Consequently, neonatal acute appendicitis is extremely uncommon. Additionally, neonates are unable to describe their symptoms, and their early clinical manifestations lack specificity, usually presenting with anorexia, nausea, vomiting, diarrhea, and dehydration. Fever and elevated white blood cell counts are also generally not pronounced, making early preoperative diagnosis difficult. Perforation rates can reach as high as 80%, and mortality rates are similarly high. Diagnostic assessments should focus on tenderness and abdominal distension in the right lower quadrant. Early surgical intervention is typically required.
Pediatric Acute Appendicitis
In children, the omentum is underdeveloped and cannot provide adequate protection, and children are often unable to clearly describe their symptoms. Clinical characteristics include:
- Rapid and severe disease progression, often with early onset of high fever and vomiting.
- Right lower abdominal signs may be minimal and atypical, but localized tenderness and muscle stiffness are important signs of pediatric appendicitis.
- A higher risk of perforation, with an increased incidence of complications and mortality.
Diagnosing pediatric acute appendicitis requires thorough, patient examination while gaining the child’s trust and cooperation. Opposite lower quadrant comparison during examination and careful observation of the child’s responses can help in making a proper judgment. Treatment revolves around early surgery combined with fluid therapy to correct dehydration and the use of broad-spectrum antibiotics.
Acute Appendicitis During Pregnancy
This is relatively common, especially in the second trimester when rapid uterine enlargement causes the cecum and appendix to be displaced upward and to the right upper abdomen. The site of tenderness also shifts upward. The abdominal wall is elevated, and the inflamed appendix does not stimulate the parietal peritoneum, resulting in less pronounced signs such as tenderness, muscle rigidity, and rebound pain. Furthermore, insufficient coverage of the inflamed appendix by the omentum increases the risk of intraperitoneal spread of peritonitis. These factors make diagnosis in the second trimester particularly challenging, with inflammation more likely to lead to miscarriage or preterm labor, posing a threat to both maternal and fetal safety.
Treatment primarily involves early appendectomy. Late-term intra-abdominal infections are more difficult to control, emphasizing the importance of early surgical intervention. During the perioperative period, progesterone should be administered. The surgical incision should be placed higher, and procedures should be performed gently to minimize uterine stimulation. Postoperatively, broad-spectrum antibiotics are indicated, and postoperative care should be enhanced. For acute appendicitis near term complicated by perforation or severe systemic infection, cesarean section and simultaneous appendectomy may be considered.
Acute Appendicitis in the Elderly
As the population ages, the incidence of acute appendicitis in older adults has also risen. Due to decreased pain sensitivity, weaker abdominal muscles, and diminished defensive mechanisms, elderly patients often present with mild complaints and atypical signs, with clinical presentations appearing less severe despite significant pathological changes. Fever and elevated white blood cell counts are also typically not pronounced, making delays in diagnosis and treatment more likely. Additionally, arterial sclerosis in older adults may affect appendiceal blood flow, increasing the risk of ischemia and necrosis. Complications such as cardiovascular disease, diabetes, and renal insufficiency are common in the elderly, further complicating their condition. Upon diagnosis, timely surgery is essential, with concurrent management of comorbidities.
Appendicitis in AIDS/HIV-Infected Patients
The clinical symptoms and signs of appendicitis in individuals with AIDS or HIV infection are generally similar to those with normal immune function but may be atypical. These patients often do not exhibit markedly elevated white blood cell counts, leading to delays in diagnosis and treatment. Ultrasound or CT imaging can aid in diagnosis. Appendectomy remains the primary treatment method, with emphasis on early diagnosis and surgical intervention to achieve better short-term survival outcomes. Without early intervention, perforation rates are high (approximately 40%). Therefore, AIDS and HIV infection should not be considered contraindications for appendectomy.