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Table 13. The relationships between other symptoms and patient’s profile (n=130)

Table 13. The relationships between other symptoms and patient’s profile (n=130)

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Above high school



2 (40.00)



1 (20.00)



37



0 (0.00)



0 (0.00)



0

(40.00)



Marital

status



Smoking



Single



1 (20.00)



Married



40 (45.45)



Divorced

Widow/widowers



2 (50.00)

16 (48.48)



No



45 (45.92)



Yes



14 (43.75)



Alcohol

No

50 (50.00)

consumptio

n

Yes

9 (30.00)

Betal nut

No

59 (46.09)

consumptio

n

Yes

0 (0.00)

*: a significant difference by Chi-Square test



0.74



0.83

0.05

0.19



0 (0.00)

14

(15.91)

0 (0.00)

6 (18.18)

17

(17.35)

3 (9.38)

17

(17.00)

3 (13.00)

20

(15.63)

0 (0.00)



0 (0.00)

0.91



0.4

0.56

1



8 (9.09)

0 (0.00)

5 (15.15)

10

(10.20)

3 (9.38)

12

(12.00)

1 (3.33)

13

(10.16)

0 (0.00)



0 (0.00)

0.6

9



1



1 (1.14)



0 (0.00)

1



0 (0.00)

0 (0.00)

1 (1.02)



1



1 (1.00)



1



0 (0.00)



4 (4.08)



0.57



0 (0.00)

1



0 (0.00)

1 (0.78)



1



0 (0.00)

1 (3.03)



0 (0.00)

0.2

9



3 (3.41)



4 (4.00)



0.57



0 (0.00)

1



4 (3.13)



1



0 (0.00)



4.7. Summary

In this study female accounted for large portion of study population (61.54%) and most of patient aged from 60 to 89. There were

88.46% of patients were unemployed or did not work at all and half of patients (57.69%) had finished elementary of secondary school.

Regarding marital status, 67.69% patients had married and 25.38% were widows or widowers.

The duration of symptom before admission to the hospital ranged from 1 to 14 days. Most of patients (84.62%) were indicated to

operation of APP within 24 hours after admission. Regarding clinical symptoms, all of patients complained about abdominal pain, of

whom right iliac fossa is the most common position of abdominal pain (58.46%). There were 45.38% patients reported the pain shift.

Other common symptoms followed the abdominal pain were nausea or vomiting (15.38%) and diarrhoea (10%). Mild fever was found

in only 22.31% of total patients, while 92.31% had positive Macburney’s point and 63.08% had tenderness. The mean WBC count was

13.93 ± 4.97 and the proportion of leukocytosis was 63.08%. The means of CRP was 51.41 ± 54.92. The proportion of glycaemia was

38



46.15%. The means of creatinine, SGOT, SGPT were 87.05 ± 23.07, 30.00 ± 19.9, 27.91 ± 21.34, respectively. There were no

association had been found between clinical symptoms and background profile of patients.



39



Chapter 5. Discussion and conclusion

5.1. Introduction

There were five parts in this chapter. First part described the significance results of findings,

of which demographic characteristics of patients, results related to clinical presentation of

patients and the relationship between two groups of factors were depicted. Second part

summarised of what had gained from the study. Third and fourth parts were about the

contribution and implication of the study and the limitations of this study. Final part was a

recommendation for further research and a conclusion were ended this study.



5.2. Discussing the significance results of findings

5.2.1. Demographic characteristics of patients

The subjects of the study were the elderly, with their mean age ranged 71.01 ± 7.4. The

youngest was 60 year old and the oldest was 89 year old. For Vietnamese elderly, besides the

high risk of suffering organ impairments this age group could encounter lots of noncommunicable diseases, such as hypertension, diabetes mellitus, and heart diseases (Ly, 2008; D.

C. Nguyen, 2011; N. H. Tran, 2011; Trinh, 2011). There was no national or regional data about

the incidence rate of APP among older age population, but the incidence rate may

be similar to other countries.

Nguyen Tri Phuong Hospital (NTP hospital) is a district hospital responsible for providing

health care services for local people living in district 5, 10, 8 and other districts belong to Ho Chi

Minh city. The results showed that a large part of patients living in district 8 (23.85%) and Binh

Chanh province (13.08%). Patients living in Long An, a satellite province of Ho Chi Minh also

admitted to NTP hospital for treatment of APP with relative frequency (10%). Patients from other

province constituted a small portion of patients in the study.

Literature on APP in elderly showed that male population is more prone to acquire APP than

female cohort due to differences in sex hormones (Ben-Hur, et al., 1995; Jara, et al., 2006; Zen,

et al., 2010). However, several studies in Korea also indicated that the female APP patients were

lightly increasing (J. K. Lee, et al., 2000; Moon, et al., 2012). Moon et al (2012) argued that

40



Korean female patients often lived longer than male patients; therefore, the prevalence of female

APP patients was increasing in recent years. In our study female patients were predominant

(61.25%). The result may be come from the fact that the elderly female patients with APP

accounted for a large part of the elderly APP patients population treated at the hospital with the

ratio of male to female was 1:1.5 (Nguyen Tri Phuong Hospital, 2012).

Many patients in the present study were not working any more or retired due to their

reducing health (88.46%); there were, however, 11.54% still worked as manual labour or did

small business at home or open market for living. Since Kinh ethnic was the most common

ethnicity communities in the whole Vietnam, so 87.69% patients were belong to that ethnic. Hoa

ethnic and other minorities such as Cham, Khmer constituted the rest of study population. As the

residence data showed, 75.38% patients living in urban areas (several districts in Ho Chi Minh

city and other developing provinces such as Long An, Hue, and Dong Nai).

Regard to education level, more than half of patients had the level from elementary to

secondary school. This was appropriate with national consensus data in which most of older

people in Vietnam had an average education level due to most of their life time was in war time

when education dissemination was limited (Statistic Services-Ministry of Health, 2013). Among

130 subjects, 67.69% got married; while 25.38% were widow/widowers. Living without partner

in the rest of their life time may be a hard experience with these elderly and a contributable

factor that lead to late admission to the hospital. Indeed, there were 3.85% patients reported that

they lately presented to the hospital just because no relatives took them to the hospital.

Currently, many researchers more concerned on etiological realations between

epidemiological factors such as living environment and life style of patients and APP. A few

studies have revealed that smoking may have some impacts on the occurrence of APP. In 1999, a

study firstly mentioned about the possibility of an association between smoking and

appendicectomy. Although it could not prove that association since the authors did not have

insufficient data on the temporal relation of taking up smoking and APP, it indicated that a high

proportion of cohort members are likely to have started smoking before their appendicectomy

and there is no evidence to suggest that the relation between smoking and appendicectomy is due

to confounding (Montgomery, R.E., & Wakefield, 1999). Oldmeadow et al (2008) conducted a

case-control study and a cohort study to invetigate the causal relationship between smoking and

APP in 3808 Australian twin pairs. After adjustment for age and other confounders, there was an

41



increase in risk of appendectomy among current smokers relative to never-smokers, particularly

in females. However, a case-control study of Ergul et al (Ergul & Kusdemir, 2007 ) showed that

smoking over 15 years and being a former smoker decreased the risk of acute appendicitis and

that smoking less than 5 years increased the risk of having acute appendicitis not statistically but

clinically. In our study, the proportion of smoker patients was 24.62% and our data analysis

showed that there were no significant association between smoking and APP. Similarly to

smoking, only 23.08% patients were alcoholic or ever drunk alcohol and no assciation between

alcohol consumption and APP could be found. Reviewing literature also showed that there were

no studies investigated that association.

Smoking tobacco is the leading preventable cause of death globally, killing up to one half of

the people who consume it. The increasing use of tobacco with areca nut, commonly referred to

as betel nut throughout the Western Pacific, has played a significant role in the increased

incidence of adverse health effects in many countries of the Western Pacific Region such as

Cambodia, Guam, Papua New Guinea. It is now well-established that the habitual use of betel

nut alone can lead to serious adverse health effects (IARC, 2009). In Vietnam, although chewing

betel nut now is not popular among public, there were several subgroups consuming betel nut,

especially rural females. The result showed that there were no association between APP and

chewing betel nut.

5.2.2. Findings related to pre-operative interval time of patients with APP

At the time of admission, 80.62% patients were diagnosed as APP. Thus, there were 19.38%

of patients who were considered as misdiagnosis. The rate of misdiagnosis was similar to other

studies (Eldar, Nash, Sabo, Matter, & et al, 1997; Lunca, Bouras, Romedea, & Rom, 2004;

Storm-Dickerson & Horattas, 2003) since the diagnosis of APP in elderly could engage many

difficulties, especially in female patients (predominant part of this study population) due to the

fact that several genital diseases in female patients could cause symptoms just like APP.

The mean duration of symptoms prior to admission was 1.93 ± 1.66 days with the range

from 1 to 14 days. Compared to other studies (Abdelkarim, et al., 2014; Moon, et al., 2012), it

suggested that older patients with APP in the present study tended to seek health care lately, with

few of them visited NTP hospital after 10 to 14 days of onset of symptoms. Those may be

individuals suffered prolonged symptoms, but they bought antibiotic drugs and self-treated at

home. This bad health practice was so common in Vietnam and in case of APP it could lead to

42



higher risk of complications, especially perforation. According to Owens and Hamit (1978),

when the time elapsed from onset of symptoms to surgery was prolonged, the perforation rate of

the appendix increased. Lau et al. (1985) reported that when the time spent before hospital visit

exceeded 24 hours, the perforation rate of the appendix increased significantly. There were little

studies concerned the reasons why late admission occurred frequently in APP elderly population;

nevertheless, reasons for late presentation to the hospital had been documented in the present

study. Only 26 among 130 patients reported the reasons for late admission, of which late referral

from local hospital to NTP hospital, long distances from home to NTP hospital, and being

unwilling to visit hospital were main causes (46.15%, 23.08% and 15.38%, respectively).

After admission to the NTP hospital, most of patients were indicated appendectomy within

24 hours (84.62%). This figure was appropriate with the rate of correct diagnosis at the time of

admission. For the rest of patients, because of difficulties in diagnosis, indication of

appendectomy was delayed more than 24 hours. Compared to a study conducted in Vietnam, the

author reported a surprising high rate of appendectomy more than 24 hours (56.66%) (V. H. Tran,

2011). Thus, the ability of response to emergency abdominal pain in elderly patients among

health-care staff in NTP hospital was well established and that could reduce the rate of

complications to patients. Indeed, many studies showed that delay in performing of

appendectomy in elderly may resulted in a high risk of complications that need to be avoided

(Abdelkarim, et al., 2014; A. R. P. Walker, et al., 1989; Zoguéreh, et al., 2001). However,

whether that delay in operation or delay in admission plays an important role as the main cause

of complications of APP in elderly is still in question.

Before appendectomy, history of comorbidities, symptoms and signs of patients were well

documented. Half of patients in the study had suffered from hypertension and 11.54% lived with

diabetes for a long time. Moon’s study (2012) also indicated that hypertension was the most

common comorbid condition (53.6%), followed by diabetes (17.9%), heart disease (7.1%) and

pulmonary diseases (7.1%). Tran et al (2011) reported that among 90 older patient with APP, the

prevalence of heart disease was 41.11%, urinary tract diseases was 11.11%, and gastrointestinal

disease was 10%. The relationship between these health conditions and APP in elderly has not

been demonstrated yet. Omari et al (2014) investigated the perforation rate among 214 elderly

and found that hypertension and diabetes were two most common comorbid conditions (13% and

11%) in elderly, but the risk of perforation did not depend on the presence of these diseases.

43



Similarly, two other observational studies also showed that there was no association between

comorbidities and morbidity and mortality of APP as well (Ibis, Albayrak, Hatipoglu, & Turan,

2010; Storm-Dickerson & Horattas, 2003). However, it is clear that these may contribute in a

worse manner to the natural history of APP. In fact, hypertension may affect the rate of

circulation that results in reduction of blood provision to the appendix and that in turn boosts the

gangrene of the appendix. Diabetes, on the other hand, had impaired effect on immune system of

patients that cause late response to the inflammation of appendix. Both resulted in a higher risk

of complications in older patients with APP.

It could be said that symptoms, signs and laboratory findings are cornerstones in diagnosis

of APP in elderly and also the main objectives of description in this study. Abdominal pain, a

typical symptom of APP, was recorded in all of patients (100%). The result was comparable with

other studies in different countries around the world (Abdelkarim, et al., 2014; Moon, et al.,

2012).

Exploring the position of the pain showed that 58.46% had the pain at the site of right iliac

fossa. Other studied also showed the same proportion of patients with abdominal pain at right

iliac fossa (Abdelkarim, et al., 2014; Salahuddin, et al., 2012). Beside the classical site of

abdominal pain, they complained about the pain at the epigastric area (18.46%) and a diffused

pain (11.54%). This pattern of abdominal pain was in consistent with that reported in the

Vietnamese study of Tran (2011) in which 62.22% patients had right iliac fossa pain, followed by

24.55% epigastric area pain and 13.33% diffused pain. The natural process of the abdominal pain

also examined and the resulted revealed that 45.38% of patients reported there was a pain shift

from the central abdomen to the right iliac fossa. Many studies reported similar proportion and

the explanation for that is due to late response of immune system in older people (Abdelkarim, et

al., 2014). Along with the pain shift, the severity of the pain changed from mild to severe as the

pain shifted to the right iliac fossa. However, in this study we could not record the severity of

pain among study subjects due to the fact that most of patients had suffered the symptoms for a

long time prior to presentation to the hospital so that they could not remember how their pain

may be.

In association with abdominal pain, other symptoms were also reported by the patients.

Nausea or votmitting were the most common symptoms (15.38%), followed by diarrhoea (10%)

and dysuria (3.08%), while constipation was not found in any patients. Moon et al reported

44



similar results in which nausea found in 14.4% of patients, vomiting accounted for 6.1%,

diarrhoea was 5.3% and constipation was 10.7% (Moon, et al., 2012). Tran (2011) reported a

proportion of 24.44% patients had nausea or votmitting.

It is documented in literature that older patients with APP had mild fever or even no fever.

That was due to the fact that along with aging, elderly had a reduced immune function that could

causes unsatisfactory development of fever and an increase in the number of leukocytes (Lau, et

al., 1985; Owens & Hamit, 1978). In this study, the number of patients who had fever over 38.3 0

C was 29, yielding 22.31%. The mean temperature of these patients was 38.43 ± 0.51, meaning

that most of them had mild fever. This result was comparable with other studies. In a study

conducted in Jordan, there were only 41% of elderly patients with APP had mild fever

(Abdelkarim, et al., 2014). Tran et al (V. H. Tran, 2011) found that only 48.89% patients had

fever from 37-380C and 38.89% did not have fever.

MacBurney’s point, a typical sign of APP in younger patients, also occurred in elderly

population. In this study there were 92.31% patient had positive MacBurney’s point. A similar

result could be seen in Tran’s study (V. H. Tran, 2011) in which 88.88% of patients had that sign.

Tenderness was found in 82 patients (63.08%). Moon’s study showed that the proportion of

tenderness in APP patients was 100% (Moon, et al., 2012). Abdelkarim (2014) reported a

proportion of 84% older patients with APP had localized tenderness in Jordan. Tran et al (V. H.

Tran, 2011) also reported a high proportion of tenderness among older patients (91.11%). In

youth individuals, tenderness and rebound tenderness were two of the most frequent signs that

guide physicians to diagnose APP. However, due to many anatomical changes related to aging

such as abdominal muscular atrophy elderly may reduce the introduction of these signs. From

comparisons with the results from other studies, we suggested that our subjects may have more

severe abdominal muscular atrophy so that tenderness may reduce during their APP.

From the results of the innovative studies at the past time, WBC count was used as the only

useful laboratory findings in diagnosis of APP elderly (Lewis, Holcroft, Boey, & Dunphy, 1975).

In older patients with APP, WBC count may be less increase compared to younger ones and it

was believed that the impairment of immune system, weak systemic responses or inflammatory

responses, and poor blood circulation in elderly could pose to that mild increase in WBC count

(Lewis, et al., 1975). The mean WBC count of studied patients was 13.93 ± 4.97 K/μL, meaning

most of patients had an increase of WBC compared to normal level (4-10 K/μL). The proportion

45



of patients who diagnosed as leukocytosis was 63.08%. The result was totally comparable with

many studies both in Vietnam and other countries. Tran et al (2011) found that there were

71.11% patients had leukocytosis. Moon’s study (2012) reported the proportion of leukocytosis

in elderly 65-79 years of age was 68.9% and in elderly over 80 years of age was 57.1%.

Abdelkarim (2014) also reported the similar proportion of leukocytosis (63%).

By the time, advanced technologies have been utilized in diagnosis of APP both in elderly

and younger population. In spite of advantages such as prompt testing time and more accuracy of

testing, these modern tests may not help much in diagnosis of APP in elderly because of changes

found in these tests could be also seen in other diseases. To NTP hospital, the regulated

procedure for diagnosis and treatment of APP consists of history taking, physical examination,

and laboratory testing including WBC, CRP, Glycaemia, SGOT, SGPT, TQ, TCK, INR, ECG and

imaging findings.

Since symptoms of elderly patients are ambiguous, and differential diagnosis is usually

required, diagnostic images are frequently used (Moon, et al., 2012). Ultrasonography can often

diagnose an inflamed appendix and detects free fluid in the pelvis but this simple method is

influenced by the operator’s experience, the body built and co-operation of the patient (Eldar, et

al., 1997). The wider use of CT scan for patients with suspected appendicitis has been shown to

improve the accuracy of the diagnosis and decrease the negative laparotomy rates (Eldar, et al.,

1997; Franz, Norman, & Fabri, 1995; Storm-Dickerson & Horattas, 2003). However, in this

study only 43.85% cases of APP was identified by abdominal ultrasonography, while the rate

was lower with normal plain abdominal X-ray (35.38%). Similarly, abdominal MSCT only

identified 38.57% of total cases. Those results were similar to those in Moon’s study (Moon, et

al., 2012) in which 36.9% patients were diagnosed APP with abdominal ultrasonography and

48.1% were done using MSCT. Abdelkarim (2014) reported that the rate of positive diagnosis of

APP with ultrasonography was only 40% and low down to 29% using MSCT.

5.2.3. Findings related to appendectomy procedure of patients with APP

Histological finding is considered as the most accurate technology used to identify whether

a person had appendicitis or not. APP may be histologically classified as localized inflammatory,

purulent, gangrenous and perforative based on stages in natural history of APP. In this study,

62.31% patients had purulent APP and 30.77% had gangrenous APP. The high number of

patients who had gangrenous, an advanced stage of APP, indicated that elderly patients had

46



suffered APP for a long time before they visit to the hospital. However, the proportion of patients

with perforative APP was only 3.85%, too low compared with other studies. Moon’s study

(2012) on Korean APP patients showed that although the time from onset to surgery of patients

was only 55.27 ± 45.78 minutes, the proportion of perforative APP was very high, up to 20.5%

among age group of 65-79 and 21.4% among age group over 80. Salahuddin (2012) in Pakistan

conducted a study on 75 older patients with APP and found that 9 (25%) had gangrenous

appendix, while 12 (33.3%) patients had perforated appendix with a few having both gangrenous

as well as perforated appendix, and 15 (41.6%) had acutely inflamed appendix. Other studies

also reported a relative high rate of perforative appendix (32-72%) in elderly populations

(Abdelkarim, et al., 2014; Lunca, et al., 2004). Thorbjarnason (1967) argued that reduced

periappendiceal lymphatic tissues of elderly patients resulting in a weakened defense

mechanism, reduced elasticity of the appendix, sluggish large intestine functions, and reduced

systemic resistance against inflammation; those made patients often ignore signs of perforative

stage of APP. Other reasons behind the high rate of perforation were the late and atypical

presentation, delay in diagnosis and surgical intervention, and presence of comorbid diseases

(Eldar, et al., 1997; Paajanen, et al., 1994). Back to our study, it may suggest that along with the

anatomical changes in resistance mechanism, there were some unknown reasons that lead to low

rate of perforative APP among study subjects although they had prolonged duration of symptoms

prior to admission.

Historically, Schreiber (1990) firstly applied laparoscopic appendectomy in pregnancy and

achieved a successful outcome with complication rate merely of 0.75%. Guller and his

colleagues (2004) showed strong evidence that laparoscopic appendectomy in the elderly

brought great advantages such as shorter mean length of stay, higher rate of routine discharge,

lower overall complication rate, and lower mortality rate compared with open appendectomy

patients. In Vietnam, laparoscopic appendectomy was practiced since the years of 1996 in many

large hospitals around the country such as Bach Mai, Viet Duc and Cho Ray Hospital (T. C.

Nguyen, 1999). Until now, laparoscopic appendectomy becomes the most common

appendectomy procedure in many health facilities in the country (C. T. Nguyen, 2005; Vo, Dinh,

& Nguyen, 2002). In the present study, laparoscopic appendectomy was indicated in 100/130

patients (76.92%). A current study on laparoscopic appendectomy in 90 subject with age from 60

to 87 years old showed a high indication of the procedure (94.54%) and lower rates of

47



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Table 13. The relationships between other symptoms and patient’s profile (n=130)

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