Clinical Presentation Of Acute Appendicitis Research Articles

"Assessment the Incidence, Pattern and Clinical Presentation of Acute Appendicitis at ATAT Hospital"

"Assessment the Incidence, Pattern and Clinical Presentation of Acute Appendicitis at ATAT Hospital"

Appendicitis predictive score for children younger than 4 years

The clinical presentation of acute appendicitis in infants and young children is nonspecific. The diagnosis is often delayed and is accompanied by high rates of appendiceal perforation. The aim of the present study was to develop an early diagnostic scale for acute appendicitis in children less than 4 years of age. Results: The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). Conclusions: In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis. 100 children less than 4 years of age with a presumptive diagnosis of acute appendicitis were retrospectively evaluated in 4 hospitals. The case group comprised 90 patients with histopathological diagnosis of positive appendicitis (with inflammation in the appendiceal wall) while the control group comprised 10 patients with a histopathological diagnosis of negative appendicitis (without inflammation). Epidemiological, clinical, laboratory, and ultrasound variables were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression to construct a predictive risk score. Accuracy of the score was measured by the area under the receiver operating characteristic curve. Final model comprised 4 variables (Blumberg's sign, C-reactive protein, neutrophil-lymphocyte index and positive ultrasound). The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis.

The Clinical, Laboratory and Imaging Tests in Diagnosing Acute Appendicitis in Children: A Retrospective Study in a Tertiary University Hospital in Tehran, Iran

Background: Acute Appendicitis (AA) is a common cause of emergency room visits among children. Non-specific symptoms of appendicitis may pose a major challenge. Due to the lack of access to imaging modalities in all facilities and its high cost, the evaluation of clinical symptoms and examination results is important in diagnosing acute appendicitis. 
 Methods: This study is a retrospective cross-sectional study. Patients admitted to our emergency department and were suspected of having acute appendicitis by pediatric residents, and underwent an appendectomy during 2013-2018 were included. A checklist of the patients’ clinical signs and symptoms, and laboratory results and imaging findings completed from the records of these patients.
 Results: We reviewed the files of 300 patients with a clinical diagnosis of acute appendicitis and having an appendectomy. Leukocytosis was found in 248 (82.7%), neutrophilia in 240 (80%) and CRP level equal or above 12 mg/L was observed in 107 (35.7%) patients. Ultrasound was performed in 283 patients (94.33%); of which 228 (80.56%) were reported as acute appendicitis. Abdominal CT scan was performed in 19 patients (6.33%); of which acute appendicitis was reported in 17 patients (89.47%).
 Conclusion: The results of this research showed that RLQ tenderness, and nausea/vomiting are the most common signs and symptoms, and leukocytosis is the most common laboratory finding in children with acute appendicitis. It can be suggested that relying just on the clinical presentation of AA (RLQ tenderness, fever, nausea/vomiting, anorexia and leukocytosis), can lead to the correct diagnosis of 78% of the suspected patients.

Assessment the Incidence, Pattern and Clinical Presentation of Acute Appendicitis at ATAT Hospital

Background: Acute appendicitis is one of the commonest surgical Emergency encountered in both children and adults. The life time risk of developing appendicitis in the USA is 8.6% for males and 6.7% for females with the highest incidence in the second and third decades. The incidence in the United Kingdom is about 52per 100,000 population (Mike, 2015; John, 2008 and Addis, 1990). It is relatively a rare disease in Africa. The incidence is estimated to be less than 9 per 100,000population in South Africa (Richard, 2014). The incidence of the disease is now thought to have increased in African populations which are probably due to the adoption of more western patterns of life. However few studies were done in Ethiopia A retrospective analysis was undertaken on 200 cases of acute appendicitis surgically managed at Yirgalem Hospital from January 1997 to December 1999. During this period the disease accounted for 27.9% of the operations for acute abdominal emergencies and for 1.1% of total hospital admissions. The overall mortality rate of 0.2-0.8% is attributed to the complications of the disease other than surgical interventions .the mortality rate rise above 20% in patients older than 70 years, primarily because of diagnostic and therapeutic delay. Objective: The study aims to assess the incidence, pattern and clinical presentation of acute appendicitis at ATAT Hospital, from december30-january12. Methodology: A retrospective cross sectional study will be conducted at ATAT hospital GURAGE zone surgical patients who were admitted to the surgical ward with the diagnosis of acute appendicitis from meskerem 2009- Pagume 2011E.C. The data will be conducted by reviewing records and data will be analyzed manually. Result: The result will be compared with other studies and will be presented using tables. During the two years of study a total of 342 emergency abdominal emergencies. There were 128 patients presenting at Atat Hospital with acute appendicitis. Out of these, the records of 114 (89.06%) patients were retrieved for analysis remaining cards couldn’t be traced. 8 (7.01%) Of patients had appendicular masses and were managed conservatively, While 106 (92.6%) had emergency surgery for acute appendicitis. Conclusion and Recommendation: Acute appendicitis is the most common cause among all emergency acute abdominal operations performed in Atat hospital. Efficient information, Education and communication strategy needs to be designed to increase the knowledge of the community about appendicitis. Further studies should be made concerning appendicitis during pregnancy.

Microbiota Assessment of Pediatric Simple and Complex Acute Appendicitis.

Background and Objectives. The aim of this study is to determine the prevailing microbiota in samples from pediatric patients with acute appendicitis, as well as evaluate the antibacterial sensitivity of the isolated microorganisms, comparing the data obtained with the clinic’s antibacterial therapy guidelines. Materials and Methods. The study group consisted of 93 patients between the ages of 7 and 18. All patients underwent a laparoscopic or conventional appendectomy. The children were hospitalized with signs and symptoms suggestive of acute appendicitis. Microbiological cultures from the appendix and abdominal cavity were collected intraoperatively. Results. E. coli was identified in most cases irrespective of the clinical presentation of acute appendicitis. Most strains were susceptible to ampicillin and amoxicillin/clavulanic acid. Five strains of E. coli produced extended spectrum beta-lactamase (ESBL). Pseudomonas aeruginosa (P. aeruginosa) was the second most commonly isolated causative agent. Furthermore, it was common in cases of acute complex appendicitis. Most strains of P. aeruginosa were resistant to amoxicillin/clavulanic acid, ertapenem, ampicillin and cefotaxime, yet were susceptible to ceftazidime. Regardless of the clinical presentation, the samples yielded mixed isolates. Conclusion. E. coli is the main causative agent of acute appendicitis in the pediatric population displaying susceptibility to various antibiotics. P. aeruginosa was more prevalent in cases of acute complex appendicitis. P. aeruginosa isolates were susceptible to ceftazidime; however, they were resistant to cefotaxime, which should, therefore, be removed from guidelines for empirical antibacterial treatment of acute appendicitis due to phenotypic resistance of P. aeruginosa. We recommend antibiotics with distinct implementation to avoid antibiotic resistance.

Keep it Simple, Laboratory Parameters to Predict Complicated Acute Appendicitis in Children Younger Than Five Years.

The clinical presentation of acute appendicitis in the youngest age lacks specific signs and symptoms, and it is difficult to obtain an accurate clinical diagnosis. Once the diagnosis is made, it is necessary to determine if the appendicitis is simple and able to be managed non-surgically, or complicated, therefore requiring surgery. Together with the clinical picture and imaging, routine laboratory values play a vital role in this decision. The aim of this study is to evaluate routine blood in their ability to differentiate between complicated and uncomplicated acute appendicitis. A retrospective analysis was conducted from a single pediatric surgery department of all children 5years of age or younger who underwent surgery for acute appendicitis between the years 2010-2020. 728 children were diagnosed with acute appendicitis, and 42 children were under the age of 5years. There was a significant difference in the C-reactive protein, white blood cell count, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio in the complicated group versus the uncomplicated group. The value of these together for prediction complicated appendicitis were 84.8% sensitivity, 80.9% specificity, 82.8% positive predictive value, and 72.8% negative predictive value. These values were all higher than both the Alvarado score and the PAS (P < .05). C-reactive protein, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio are simple laboratory parameters that can help identify complicated versus uncomplicated appendicitis in children 5years old or younger. These universal parameters may help guide the treatment and decision to operate on a difficult to diagnose population.

Bilateral Thrombophlebitis Revealing an Agenesis of the Inferior Vena Cava as Part of Polysplenum Syndrome

Polysplenum syndrome is a rare malformation characterized by the association of multiple spleen with other abnormalities dominated by cardiovascular and visceral malformations. We report the observation of a young patient admitted to the emergency room for a clinical presentation of acute appendicitis. The abdominal ultrasound scan had invalidated the diagnosis and pushed to perform an abdominopelvian computed tomography detecting a bilateral iliac acute thrombophlebitis with agenesis of the inferior vena cava supplemented by a large azygos vein, short pancreas and multiple splenic lobules.

Clinical presentation of appendicitis in the paediatric age group

Misdiagnosis and complications result from the unusual clinical presentation of acute appendicitis in school children. The aim of this study was to see how age affected clinical presentation, intraoperative findings and post-operational complications in children suffering from acute appendicitis. From November 2016 until December 2018, 112 children under the age of 16 years who underwent both emergency and elective appendectomy in Basaveshwar teaching and general hospital, Kalburgi, were enlisted in this retrospective research study. Out of 112 cases, the majority of the cases, i.e., 60 (54%) were males, followed by 52 females (46%), and the ratio of male to female was 1.5:1. An acute inflamed appendix was the commonest intra-operative observation in this study, i.e., in 92 cases (82%), followed by a perforated appendix in 9 cases, gangrenous mass in 6 cases, appendicular mass in 3 cases and Meckel's diverticulitis in 2 cases respectively. Wound gaping was seen in 4 (4%) cases and postoperative ileus in 3 (3%) cases, respectively. There was no mortality. Appendicitis is a common surgical emergency in the paediatric age group. Early diagnosis & surgery are the key factors in the management of paediatric appendicitis. The younger ones having a more altered general state & a higher tachycardia degree, indicating that the disease has had more systemic repercussions. Hence, when treating a young child suffering from acute abdominal pain and systematically addressing the question of whether it may be acute appendicitis, extreme caution is needed.

Acute Appendicitis With Appendiceal Intususseption

Intussusception of the appendix is the introduction of the appendix into the lumen of the cecum may be accompanied by the development of acute appendicitis, or proceed without it. The combination of intussusception and acute inflammation of the appendix makes the diagnosis of appendicitis difficult due to the absence of classic clinical symptoms. The article presents the case of successful treatment of a patient with an untypical clinical presentation of acute appendicitis that developed in an invaginated vermiform appendix.

Neurogenic appendicopathy: an underestimated disease-systematic review of the literature.

Appendectomy is one of the most frequently performed surgeries worldwide, but neurogenic appendicopathy (NA) remains a poorly understood disease with controversial clinical management. The aim of this review was to obtain a clear definition of the disease and summarize its management. We performed a systematic review of the literature on NA in PubMed, EMBASE, Web of Science, and Cochrane databases from inception to 19/01/2021 according to PRISMA statement standards. Eligibility criteria were original articles examining histopathology, clinical management, and/or follow-up of patients with NA. The literature review is complemented by a clinical case. In 40 articles, the estimated incidence of NA among appendectomies performed in patients with a suspicion of acute appendicitis (AA) was 10.4% (N = 740, range 1.8-32%). NA more frequently causes recurrent and longer lasting pain compared to AA; however, these diseases are usually not clinically or radiologically distinguishable. Based on our analysis, NA is defined as the presence of three criteria: (1) clinical presentation of AA, (2) absence of acute inflammation on histopathology, and (3) presence of S-100-positive spindle cells or proliferation of Schwann cells. Laparoscopic appendectomy has been shown to be a safe and successful treatment. NA is a poorly known disease, which may clinically appear as AA but is often related to recurrent and longer lasting abdominal pain. Patients with NA may suffer for years before diagnosis. In cases of typical symptoms, appendectomy should be performed even in cases of macroscopically and radiologically normal-appearing appendices with normal laboratory results.

Influence of age on clinical presentation, diagnosis delay and outcome in pre-school children with acute appendicitis

BackgroundUnusual clinical presentation of acute appendicitis in preschool children leads to misdiagnosis and complications.We aimed to analyze the influence of age on clinical presentation, laboratory findings and complications in preschool children with acute appendicitis.MethodsFrom January 2012 until December 2017, 29 children younger than 6 years of age (median 50 months) with acute appendicitis were enrolled in this retrospective study. Patients were grouped according to their age: group 1: < 48 months (n = 13); group 2: > 48 months (n = 16), their clinical data, laboratory results and complications were compared.ResultsIn group 1, duration of nausea and vomiting was longer, alteration of general state was more frequent and pain in the right fossa iliaca less frequent than in group 2 (p = 0.026, p = 0.000 and p = 0.029, respectively). Heart rate was higher in group 1 than in group 2 (p = 0.012). Leucocyte and polynuclear neutrophil counts were lower in group 1 than in group 2 (p = 0.028 and = 0.004, respectively) but C-reactive protein levels were not different between groups. In the whole cohort however, C-reactive protein at admission value correlated negatively with age (p = 0.025).Abdominal ultrasound allowed diagnosis in 19/29 patients (65.5%), without any difference between groups. Appendicular perforation was more frequent in group 1 than in group 2 (p = 0.003). Perforation was also related to longer hospital stay (p = 0.018). Peritonitis occurred in 21/29 (72%), post-operative ileus in 5/29 (17%) and sepsis in 4/29 (14%) patients without any difference between groups. In the whole cohort, hospital stay correlated negatively with age (p = 0.000). There was no mortality.ConclusionsAmong preschool children, those younger than 48 months present with longer duration of pre-admission symptoms indicating longer infection course than in older children. Altered general state and higher degree of tachycardia in the younger reflect higher systemic repercussions of the illness. Less specific abdominal pain and dissociation of the inflammatory markers with lower leucocyte- and neutrophil counts and higher C-reactive protein levels in the younger may contribute to further diagnosis delay and higher rate of perforation in these patients.

Perforated retroperitoneal appendicitis presented with right thigh abscess: case report and literature review

The typical clinical presentation of acute appendicitis is initial diffuse abdominal pain that shifts to right iliac fossa, nausea, vomiting supported with elevated white blood cell count [3]. It is reported that there are atypical presentation of acute appendicitis approximately 20%-30%. Retroperitoneal perforated appendix can cause retroperitoneal and psoas abscess. After abscess formation, inflammation and pus may extend to pelvis and extra-abdominal compartments through certain routes and tissue plains. Reported routes in literature such as deep to inguinal ligament (through psoas sheath, femoral sheath and femoral canal), fibro-osseus canals (through sacrosciatic notch and Obturator foramen). We report a 67 years old patient with initial presentation of right thigh abscess and psoas abscess caused by perforated retroperitoneal appendicitis. He was managed with vertical drainage of the thigh abscess and laparoscopic appendectomy with psoas abscess drainage. There are several reports that diagnostic modalities such as CT of the abdomen and pelvis or MRI could direct the management to surgical or non-surgical plans. The early surgical intervention to the intra-abdomen pathology with sufficient drainage of the psoas and thigh abscess is the definite treatment. It is suggested that in unexplained thigh or groin pain/soft tissue infection with fever and leukocytosis a gastrointestinal pathology should not be overlooked.

Role of ultrasound in the diagnosis of acute appendicitis: A prospective study

Background and Aim: Although the clinical presentation of acute appendicitis is typical in 70% of the cases, about 30%of the patients have an uncertain pre-operative diagnosis. Consequently the rate of unnecessary laparotomy is as high as 20-25%. The aim of the study was, to evaluate the role of ultrasound in the diagnosis of acute appendicitis in clinically equivocal cases. Materials and Methods: 100 patients clinically suspected to be acute appendicitis were referred for ultrasound examination. Presence of appendicoliths, loculated collections, complex masses in the right iliac fossa were also considered in the diagnosis of acute appendicitis. The sonological findings were correlated with surgical findings. In patients, who had negative graded compression US examination, abdomen and pelvis were assessed with curvilinear transducer of 3.5-7.0MHz Results: Of the 100 patients who formed the study population, 76 patients had acute appendicitis. Ultrasound was sensitive in detecting acute appendicitis in 66 patients. 10 patients were falsely diagnosed as acute appendicitis on ultrasound. One patient was false positively diagnosed as having acute appendicitis. US could detect normal appendix in 8 cases. Ultrasound provided alternate diagnosis in 6 patients, thus influencing the management. The overall accuracy of ultrasound in the diagnosis of acute appendicitis was 86.36%. The sensitivity, specificity, predictive value of a positive test and predictive value of a negative test were 86.64%, 83.33%, 97.05% and 50% respectively. Conclusion: Ultrasound being non-invasive, non-traumatic, readily available modality is a result-oriented examination in clinically equivocal cases of acute appendicitis.

A Case of Collision Tumor of MALT Lymphoma and Poorly Differentiated Adenocarcinoma Diagnosed Incidentally After Appendectomy for a Clinical Presentation of Acute Appendicitis.

This report presents a case of collision tumors of low-grade B-cell lymphoma and poorly differentiated adenocarcinoma in the caceum of a 63-year-old woman. Lymphoma was diagnosed incidentally after appendectomy for a clinical presentation of acute appendicitis. Imaging follow-up demonstrated mesenteric lymphadenopathy and liver lesions, and all surgically resected regional mesenteric lymph nodes and liver biopsy were found to be infiltrated by both mucosa-associated lymphoid tissue (MALT) lymphoma and adenocarcinoma. Systemic chemotherapy was administered for advanced colonic adenocarcinoma with liver metastases. The occurrence of synchronous lymphoma and adenocarcinoma of the colorectal region is rare, and this is a previously unreported case of a patient that was diagnosed during management of acute appendicitis.

Clinical presentation of acute appendicitis in Babol; northern of Iran.

Clinical presentation of acute appendicitis in Babol; northern of Iran.

Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital.

BackgroundAcute appendicitis is the most common surgical abdominal emergency. Delayed treatment increases the incidence of complications. The aim of this study was to investigate the presentation, incidence, and predictors of complications, and histological findings in adult patients with clinical diagnosis of acute appendicitis.MethodsThe study was a prospective observational study and included patients aged 12 years and older diagnosed with acute appendicitis. Data collected included demographic data, clinical presentation, duration of symptoms and reasons for presentation delay, diagnostic investigations, operative and histology findings, length of hospital stay, and mortality.ResultsA total of 146 patients were admitted with a mean age of 26 years (SD = 12 years). The male to female ratio was 1.6:1. Predominant presenting symptoms were right iliac fossa pain (95%), nausea (80%), and vomiting (73%), with 63% of patients presenting 2 days after onset of symptoms. Fever was present in 15% and only 31% of patients gave a typical history of acute appendicitis of vague peri-umbilical pain. The negative predictive values of white cell count and C-reactive protein for acute appendicitis were 28% and 50%, respectively. Sensitivity of the ultrasound to detect acute appendicitis was 60% with a negative predictive value of 31%; 30% of patients had complicated appendicitis. Histology results showed a normal appendix in 11% of patients. The 30-day mortality rate was 1.4%.ConclusionsPatients with acute appendicitis rarely present with a typical history of vague peri-umbilical pain. The negative predictive values of both white cell count and ultrasound proved that neither of these measurements was accurate in the diagnosis of acute appendicitis. Most of our patients with complicated disease present late, with the most common reasons for this delay being lack of access to a medical clinics and prior treatment by general practitioners. Complications were higher in males and in those aged 45 years and above.

Computed tomography in adults with atypical clinical presentation of acute appendicitis: comparison of findings with inflammatory serum markers

Introduction Acute appendicitis (AA) is the most common cause of acute abdominal pain in adults [1,2]. 70% of patients have classical clinical features such as pain near the umbilicus that grows more intense over time and shifts to the right lower quadrant (RLQ), fever, and guarding at McBurney´s point [3]. Those

Tumor carcinoide bronquial y apendicular

Carcinoid tumor (CT) is an unusual neoplasm observed in several locations and associated with the production of vasoactive substances and occasionally with carcinoid syndrome (flushing, diarrhea, wheezing). A retrospective review of the medial records of all children with a diagnosis of CT treated in our service between 1966 and 2003 was performed. Ten patients (5 boys and 5 girls with a mean age of 8 years) were diagnosed with CT. Eight had CT of the appendix, of which 4 showed the typical clinical presentation of acute appendicitis. Seven of these tumors were localized at the tip of the appendix and measured 2 cm or less. In one patient, the tumor was located at the cecum and measured 3.5 cm. In this patient, reoperation with ileocecal resection was performed. Two patients (4 and 6 years old) had bronchial CT associated with chronic respiratory manifestations. An accurate diagnosis was made after a 1-year follow-up. Pneumonectomy and tracheobronchial sleeve resection were carried out. None of the patients showed symptoms of carcinoid syndrome. All the patients underwent biochemical and radiological studies and fiberoptic bronchoscopy during follow-up. All the patients are currently disease-free. Typical symptoms of acute appendicitis were not observed in half of patients with CT of the appendix. CT associated with carcinoid syndrome is exceptional in pediatric patients. In most CT of the appendix, simple appendicectomy was associated with an excellent prognosis. Diagnosis of bronchial TC tends to be delayed and consequently CT should be considered in the differential diagnosis of children with respiratory symptoms unresponsive to standard medical treatment.

An atypical clinical presentation of acute appendicitis in a young man with midgut malrotation

Midgut malrotation occurs as a result of failure in normal intestinal rotation and fixation during early pregnancy. Pathological conditions reported in the literature involving midgut malrotation predominantly relate to infants and children. In adults malrotation is often revealed as an incidental finding on computed tomography (CT), or the associated altered anatomy can be the cause of atypical clinical symptoms of relatively common intestinal disorders. An unusual presentation of acute appendicitis, with fever and recurrent pain in left iliac fossa is reported. Underlying intestinal malrotation delayed the correct clinical diagnosis of acute appendicitis. It was not until a CT scan was performed that a malrotation was identified. The predominant appearances of malrotation are the siting of the ascending colon, caecum (and appendix) in the left side of the abdomen and the right-sided placement of the duodenojejunal junction.

Acute appendicitis in late adulthood: incidence, presentation, and outcome. Results of a prospective multicenter acute abdominal pain study and a review of the literature.

Acute appendicitis is the second most common cause of surgical abdominal disease in late adulthood. It is a serious condition: major errors in management are made frequently and the condition is associated with significant morbidity and mortality. Data collected within a multicenter prospective trial and a literature review were used to analyze diagnostic and therapeutic difficulties in detail. In a multicenter intervention study (MEDWIS A 70) data from 2,280 patients with acute abdominal pain were collected prospectively. Patients with histologically proven acute appendicitis, aged 50 years and older (n=102), were compared with younger patients (n=417) to determine differences in presentation, clinical course, and outcome. The basis for the literature review was a Medline search for appendicitis in late adulthood and in the elderly, covering the years 1980-1998. In addition, studies on clinical presentation of acute appendicitis in all age groups were also reviewed and appropriate data were extracted. Patients aged 50 years and older with acute abdominal pain had a significantly higher incidence of surgery. Fourteen percent had acute appendicitis (27% in younger patients), with an increased complication rate (20% vs. 8%) and mortality (3% vs. 0.2%). Significantly more signs and symptoms suggestive of acute abdominal disease and peritonitis were recorded among older patients, reflecting the higher perforation rate (35% vs. 13%). Clinical presentation of appendicitis in younger patients was far more ambiguous. There were no significant differences in outcome between older and younger patients as regards perforations. Perforations are directly associated with treatment delay. Overall delay is a result of late presentation of older patients to hospital and postadmission delay. Appendicitis in late adulthood is characterized by a delay in treatment, high perforation rates, and unfavorable outcome parameters, all mutually correlating. Older patients with acute abdominal pain are high-risk patients, unlike their younger counterparts. They have to be clinically evaluated by experienced surgeons within a narrow time margin. The problem of late presentation and/or referral should be addressed, perhaps by education of primary care physicians and the public.