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IJCRR - 4(7), April, 2012

Pages: 39-44

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APPENDICITIS IN THE ELDERLY - A MICROANATOMICAL PERSPECTIVE

Author: A. Anand, D. Ravichandran

Category: Healthcare

Abstract:Background of the study: The appendix lies in the junction between small and large intestine. It is highly vascular and rich in lymphoid follicles and forms a part of Gut Associated Lymphoid Tissue (GALT). With advancing age, the diameter of the lumen and lymphoid follicles supposedly get reduced. Therefore appendicitis is less common in the elderly population and more common in the young and adolescents. Aim and Objective: To study the micro anatomical features of appendix in terms of presence of luminal diameter and lymphoid tissue in the walls of human vermiform appendix.Methodology: 54 post appendectomy specimens belonging to the age group of 40 \? 80 years were utilized for the present study. The specimens were subject to routine histological study Results and Conclusion: The entire specimen (100%) showed histological evidence of presence of lumen and lymphoid tissue contrary to the conventional teaching.

Keywords: appendix, lymphoid tissue, appendicitis

Full Text:

INTRODUCTION
The inflammation of the Human vermiform appendix always poses a challenge to the surgeon in spite of numerous technological and surgical advancements in the field of gastrointestinal surgery. The Human vermiform appendix is regarded as a specialized structure rather than as a vestigial organ 1 . Many factors contribute to the causative aspect of acute appendicitis; however the obstruction to the lumen by a facecloth is cited to be the commonest cause2 . In later decades of life the lumen is partially of wholly obliterated whereas it is widely patent in early childhood 3 . More so as age advances the lymphoid follicles in the walls of the vermiform appendix also undergo degeneration and is replaced by scar tissue. Since in the elderly the lumen of the appendix is either partially or fully obliterated and there is a reduction in the distribution of lymphoid tissue in the appendicular walls, logically there should be no inflammation of the organ in the older age group. The life expectancy has increased when compared to the previous century. Therefore the incidence of appendicitis in the elderly age group is on the rise4 . Undiagnosed appendicitis can lead to rupture of appendix which in turn will give rise to perforation and peritonitis. To our knowledge review of literature showed a dearth of histological studies proving the luminal obliteration and decrease of lymphoid follicles in the older age group. Therefore the present study is undertaken to introspect the state of lumen and lymphoid tissue in the elderly population from a micro anatomical point of view and its possible role in the pathogenesis of acute appendicitis.

MATERIALS AND METHODS
Specimen tissues of vermiform appendix was collected from patients undergone appendicectomy between the age group ranging from 44 years to 79 years over a period of three years after due clearance from the Institutional ethical committee and informed consent from the patient. The patients were elaborated about the reason for surgery and the procedure of surgery. They were explained about the significance of appendix and its functions. The process of histological sectioning was explained in common language. The significance of the study was also explained to them. They were assured of confidentiality and non-disclosure of identity. The total number of cases of elderly persons in the series was 54. Out of this 2 specimens belonged to female patients and 52 belonged to male patients. Persons undergoing negative appendicectomy and cases of gangrenous appendicitis were excluded from the purpose of study. The obtained specimen tissues were processed and stained with hematoxylin and eosin and were observed under microscope for the presence of appendicular lumen and aggregations of lymphoid follicles.

DISCUSSION
The incidence of acute appendicitis in adolescents is 20%5 . Few other authors have reported that the life time risk of acute appendicitis is 7%2 . Acute appendicitis is more common in adolescents and young adults5 The pathogenesis of appendicitis is associated with obstruction (due to a faecolith) in majority of cases (50 to 80%)2 . Other causes include impaction due to a gall stone, tumor or ball of worms. This is usually the outcome of increased intraluminal pressure and retention of contents which allows acute suppuration to occur3 . However less commonly, in some number of cases the inflammation is not associated with luminal obstruction and the pathogenesis of the inflammation is not known. When inflammation of the appendix exceeds its confines there is a significant increase in the rate of mortality5 This has been attributed to the atypical presentation of appendicitis due to physiological changes and disease manifestation in the elderly population1 According to conventional teaching and prescribed standard texts, the lumen of the human vermiform appendix is either partially or fully obliterated in old age. In a study on Bangladeshi people, Rahman MM (2008)6 reported a progressive decrease in the weight of the appendix with age. The maximum luminal diameter was observed in the age group of 21-35 years and the minimum luminal diameter was noted in the elderly age group (56-70 years)6,7. The presence of lymphoid follicles in the walls undergo a significant reduction in the elderly which invariably leads to a delayed or decreased immune response2,8 All these factors, reduced luminal diameter, decreased lymphatic follicle and its replacement by fibrous tissue have been attributed to a reduction in the incidence of acute appendicitis in the elderly. Therefore the diagnosis of appendicitis in the elderly age group is difficult to make and it carries a significantly increased risk of mortality and complications9 In the present study the samples were collected from patients aged above 40 years. All the specimens (n= 54) showed presence of appendicular lumen and aggregation of lymphoid follicles in the walls irrespective of the age distribution (44yrs – 79 years, the mean age being 64 yrs). The presence of the lumen and aggregation of lymphoid follicles in all the cases (100%) is contrary to the conventional and established teaching.

CONCLUSION
In summary, in the present series the authors did not observe any case with obliteration of appendicular lumen, reduction or absence of lymphoid aggregations in the walls of the appendix in elderly age group. These findings in the present study indicate that the human vermiform appendix still is an enigma and cannot be taken lightly by surgeons with regards to its age. In elderly persons with pain abdomen the appendicitis should be also included as a probable cause since, the morbidity and mortality associated with this condition at this age is significantly higher. However the authors recommend future studies with a larger sample size to establish our findings.

ACKNOWLEDGEMENTS
The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

References:

1. Peter L Williams and Warwick. Gray‘s Anatomy In: Splanchnology. 36th ed; Churchill Livingstone, Edinburgh; 1986: 1353 - 1354

2. Chen Liu. Robbins and Cotran Pathologic Basis of Disease in: The Gastrointestinal Tract. 7th ed; Elsevier, Philadelphia; 2007: 870 - 872

3. Neil R Borley. Gray‘s Anatomy, The Anatomical Basis of Clinical Practice In: Abdomen and Pelvis. 40th edn; Churchill Livingstone, Spain; 2008: 1142 – 1144

4. Sanda RB, Seliem SI, Omar E, Ashraf S. Perforated appendicitis in a septuagenarian. Ann Afr Med 2011;10:249-51

5. Charles V. Mann. Bailey and Love‘s Short Practice of Surgery In: The Vermiform Appendix. 22nd ed; ELBS, London; 1995: 828- 841

6. Rahman MM, Khalil M, Khalil M, Jahan KM, Shafiquazzaman M, Parvin B. Mass of the Vermiform Appendix in Bangladeshi People. J Banglades Soc Physiol. 2008 Dec; (3): 8-12

7. Bhide SA, Waderkar KV, Koushik SA. Peyer‘s patches are precocious to the appendix in human development. Dev. Immunol. 2001; 8(2):159 – 66.

8. Datta AK. Essentials of Human Anatomy. Part – I. 6th ed. Calcutta: Current Books International. 2007. P.228-30

9. Gurleyik G, Gurleyik E. Age-related clinical features in older patients with acute appendicitis. Eur J Emerg Med 2003;10:200-3

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