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Table 13. The relationships between other symptoms and patient’s profile (n=130)
Above high school
*: a significant difference by Chi-Square test
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
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.
Chapter 5. Discussion and conclusion
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
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
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
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.
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.,
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
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
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
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
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
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