Research ArticleClinical Studies

A Diagnostic Score (DS) Is a Powerful Tool in Diagnosis of Acute Appendicitis in Elderly Patients With Acute Abdominal Pain

MAARET ESKELINEN, JANNICA MEKLIN, KARI SYRJÄNEN and MATTI ESKELINEN
Anticancer Research March 2021, 41 (3) 1459-1469; DOI: https://doi.org/10.21873/anticanres.14904

Abstract

Background/Aim: Although acute appendicitis (AA) in elderly patients is different from AA in younger patients, the accuracy of diagnostic scores (DSs) in detecting AA is rarely considered. Patients and Methods: A cohort of 470 AAP (acute abdominal pain) patients older than 50 years, including 224 women (53.7%) and 193 men (46.3%), were included in the study. The most significant diagnostic predictors were used to construct DS formulas for AA diagnosis with (Tax+) and without body temperature (Tax–). Meta-analytical techniques were used to calculate the summary Se and Sp estimates for each data sets (history-taking, findings, and DS formulas). Results: In SROC analysis, the AUC values for i) symptoms ii) signs and tests iii) DSTax– and iv) DSTax+ were as follows: i) AUC=0.658 (95%CI=0.601-0.709); ii) AUC=0.751 (95%CI=0.701-0.800), iii) AUC=0.977 (95%CI=0.942-1.000), and for iv) AUC=0.980 (95%CI=0.956-1.000). Using roccomp analysis for these AUC values, the differences were significant as follows: between i) and ii) p=0.0358; between i) and iii) p<0.0001; between i) and iv) p<0.0001; between ii) and iii) p<0.0001; between ii) and iv) p<0.0001; and between iii) and iv) p=0.682. Conclusion: Similar to younger AA patients, the DS formula was superior to both the clinical history-taking and findings, and therefore, the use of DS should be an important part of the diagnostic decision tree of AA also in the elderly patients presenting with AAP.

Key Words:

Acute appendicitis (AA) in elderly patients is in many respects different from AA in younger patients with acute abdominal pain (AAP). AA among elderly patients might have lower diagnostic accuracy, longer delay from onset of symptoms to admission, and therefore, higher AA perforation rate leading to higher complication and mortality rate. Ceresoli et al. (1) analysed an AA cohort of 16,544 patients and showed, that after adolescence, the incidence of AA decreases along with increasing age (1). In their study on AAP patients, Kraemer et al. (2) reported that 15% of the patients older than 50 years of age had a final diagnosis of AA, as compared to nearly 30% of AA among younger patients (2). However, along with the aging of the Western populations, AA among the elderly is likely to be more common in the future (1).

The lack of commonly accepted guidelines and diagnostic scoring (DS) specified for elderly patients with AA (3) encouraged us to evaluate the accuracy of the clinical diagnosis of AA among elderly patients. We designed the present study to assess the relative accuracy of i) a clinical history-taking, ii) clinical findings, as well as iii) the DS without body temperature (Tax–) and iv) the DS with body temperature (Tax+) in detecting clinically confirmed AA among the elderly patients with AAP.

Patients and Methods

Included in the present study were 470 elderly patients older than 50 years, of whom 224 were women (53.7%) and 193 were men (46.3%). The diagnosis of AA was confirmed by considering all clinical history-taking details, clinical findings and results of the laboratory tests together and following the diagnostic criteria of AA as previously described (4-8) (Tables I and II).

View this table:
Table I.

The clinical history of the elderly patients (≥50 years) with acute appendicitis versus other cause of abdominal pain.

View this table:
Table II.

The clinical signs and investigations of elderly patients (≥50 years) with acute appendicitis versus other cause of abdominal pain.

Identifying the DS models. In the computation of the diagnostic score (DS), a multivariate logistic (stepwise) regression analysis (SPSS Statistics 26.0.0.1; IBM, Armonk, NY, USA) was used to disclose the variables with an independent predictive value. All the variables presented in Tables I and II were included in the analysis as binary data, e.g. AA=1 and other diagnosis of AAP=0. Using the coefficients of the regression model, a DS was built and its predictive value for AA was studied. The coefficient of the multivariate analysis showed the relative risk (RR=en, n=β) of a patient with a given history-taking detail, clinical findings or test to have an AA.

The formula without body temperature count (Tax–). The formula without Tax in hierarchical summary receiving operating characteristic (HSROC) analysis is; DSTax–=2.40× location of pain at diagnosis (positive endpoint=1, negative endpoint=0) + 3.67× tenderness (positive endpoint=1, negative endpoint=0) + 2.93× rigidity (positive endpoint=1, negative endpoint=0) –6.54 (Table III).

View this table:
Table III.

Diagnostic score for acute appendicitis (AA) in elderly patients (≥50 years) without body temperature in the DS model shown at five different cut-off levels: DS I=–3.60, DS II=–1.21, DS III=–0.47, DS IV=DS values between –4.14 and –0.47 excluded, n=128 patients, DS V=DS values between –1.21 and –0.47 excluded, n=43 patients.

The formula with body temperature count (Tax+). The formula with Tax is; DSTax+=1.95× location of pain at diagnosis (positive endpoint=1, negative endpoint=0) + 1.25× previous abdominal surgery (positive endpoint=1, negative endpoint=0) + 4.07× tenderness (positive endpoint=1, negative endpoint=0) + 2.96× rigidity (positive endpoint=1, negative endpoint=0) + 1.31× body temperature (positive endpoint=1, negative endpoint=0) – 8.12 (Table IV).

View this table:
Table IV.

Diagnostic score for acute appendicitis (AA) in elderly patients (≥50 years) with body temperature in the DS model shown at five different cut-off levels: DS VII=–1.97, DS VIII=–1.09, DS IX=–0.66, DS X=DS values between –1.97 and –0.66 excluded, n=29 patients, DS XI=DS values between –1.97 and 0.46 excluded, n=43 patients.

Statistical analysis. The other statistical analyses were performed using STATA/SE version 16.1 (StataCorp, College Station, TX, USA). Statistical tests presented were two-sided, and p-value <0.05 was considered statistically significant. Using 2×2 tables, we calculated sensitivity (Se) and specificity (Sp) with 95% confidence intervals (95%CI) for each clinical history-taking detail, finding or test, and using meta-analytical technique (metaprop) separate forest plots for Se and Sp were created for each set of data, including each diagnostic variable (as equivalent to “study ID”). We calculated the summary estimates of Se and Sp, positive (LR+) and negative likelihood ratio (LR–) and diagnostic odds ratio (DOR), using a random effect bivariate model and fitted the HSROC curves, including all diagnostic variables in the DSTax– and DSTax+ models, using the AA endpoint.

Results

Diagnostic performance of the clinical history-taking. The overall Se of the clinical history-taking for detecting AA was 83% (95%CI=72-92%). Se was higher than 83% for 11 diagnostic symptoms. The five best clinical history-taking variables (relieving factors, vertigo, jaundice, drugs for abdominal pain and use of alcohol) showed 98-100% Se in diagnosis of AA (Figure 1). The overall Sp of the history-taking for detecting AA was 34% (95%CI=22-46%) (Figure 2). Altogether, 10 symptoms showed Sp higher than 34%. The five best symptoms of AA (location of initial pain, location of pain at diagnosis, type of pain, nausea, and vomiting) showed 53-90% Sp (Figure 2).

Figure 1.
Figure 1.

Sensitivities of the history-taking in acute appendicitis (random-effects model). ES: Estimated sensitivity; CI: confidence interval.

Figure 2.
Figure 2.

Specificities of the history-taking in acute appendicitis (random-effects model). ES: Estimated specificity; CI: confidence interval.

Diagnostic performance of the clinical findings and tests. The overall Se of the diagnostic findings for detecting AA was 84% (95%CI=72-93%) (Figure 3), and 10 findings had Se exceeding 84%. The five most accurate findings (colour, tenderness, mass, bowel sounds and urine) showed 94-100% Se (Figure 3). The overall Sp of the findings was 45% (95%CI=29-61%) (Figure 4), while 8 findings showed Sp higher than 45%. The five most accurate findings (abdominal movement, tenderness, rigidity, rectal digital tenderness, and body temperature) showed 73-91% Sp (Figure 4).

Figure 3.
Figure 3.

Sensitivities of the signs and tests in acute appendicitis (random-effects model). ES: Estimated sensitivity; CI: confidence interval.

Figure 4.
Figure 4.

Specificities of the clinical signs and tests in acute appendicitis (random-effects model). ES: Estimated specificity; CI: confidence interval.

Diagnostic performance of the DS without body temperature (DSTax–). The most important predictors of AA without Tax (n=417) were location of pain at diagnosis, tenderness and rigidity, and used to construct the DSTax– formula for AA diagnosis; DSTax–=a patient is admitted to the emergency room with abdominal pain; at diagnosis the pain was localized at the right lower quadrant of the abdomen (RLQ) (1 point × 2.40); clinical examination showed RLQ tenderness (1 point × 3.67), rigidity (1 point × 2.93) – constant value 6.54. The best diagnostic performance level for DSTax– formula (DS IV; Se=97%, Sp=98%) was reached when the patients with a DSTax– value between -4.14 and - 0.47 were considered as “undefined” patients for whom follow-up is required before the decision to operate (n=128) (Figure 5). The DS model was tested at five different cut-off levels to disclose the best diagnostic performance in elderly patients (Figure 5). The Se and Sp of these five DSTax– formulas were 90% (95%CI=80-97%) and 95% (95%CI=89-99%), respectively (Figures 5 and 6). Three of these formulas showed Se >90% and three formulas had Sp >95%. The best diagnostic DSTax– formula in these elderly patients (formula DS IV, Figures 5 and 6) showed Se of 97% (95%CI=86-100%) and Sp of 98% (95%CI=96-100%).

Figure 5.
Figure 5.

Sensitivities of diagnostic scores without body temperature (DSTax–) at five different cut-off levels (DS I-V). ES: Estimated sensitivity; CI: confidence interval.

Figure 6.
Figure 6.

Specificities of diagnostic scores without body temperature (DSTax–) at five different cut-off levels (DS I-V). ES: Estimated specificity; CI: confidence interval.

Diagnostic performance of the DS with body temperature (DSTax+). The significant independent predictors were used to build up the five different DSTax+ models. The Se and Sp of these five DSTax+ models were 90% (95%CI=84-95%) and 96% (95%CI=92-98%), respectively (Figures 7 and 8). Four formulas showed Se >90% and three formulas Sp over 96%. The DSTax+ (formula DS IX, Figures 7 and 8) showed Se of 93% (95%CI=81-99%) and Sp of 97% (95%CI=94-99%) (Figures 7 and 8).

Figure 7.
Figure 7.

Sensitivities of diagnostic scores with body temperature (DSTax+) at five different cut-off levels (DS VI-X). ES: Estimated sensitivity; CI: confidence interval.

Figure 8.
Figure 8.

Specificities of diagnostic scores with body temperature (DSTax+) at five different cut-off levels (DS VI-X). ES: Estimated specificity; CI: confidence interval.

HSROC and comparison of the AUC values. STATA (metandiplot) was used to draw the HSROC curves to visualise the pooled overall diagnostic performance of the different DS formulas in detecting AA in elderly patients (Figures 9 and 10). In SROC analysis, the AUC values for i) clinical history-taking ii) diagnostic findings and tests iii) DSTax– (Figure 11) and iv) DSTax+ (Figure 12) were as follows: i) AUC=0.658 (95%CI=0.601-0.709); ii) AUC=0.751 (95%CI=0.701-0.800), iii) AUC=0.977 (95%CI=0.942-1.000), and for iv) AUC=0.980 (95%CI=0.956-1.000). In roccomp analysis for the AUC values, the differences were significant as follows: between i) and ii) p=0.0358; between i) and iii) p<0.0001; between i) and iv) p<0.0001; between ii) and iii) p<0.0001; between ii) and iv) p<0.0001; and between iii) and iv) p=0.682.

Figure 9.
Figure 9.

Hierarchical summary receiver operating characteristic (HSROC) curve of the history-taking in acute appendicitis.

Figure 10.
Figure 10.

Hierarchical summary receiver operating characteristic (HSROC) curve of the clinical signs and tests in acute appendicitis.

Figure 11.
Figure 11.

Hierarchical summary receiver operating characteristic (HSROC) curve of the five DSTax–.

Figure 12.
Figure 12.

Hierarchical summary receiver operating characteristic (HSROC) curve of the five DSTax+.

Discussion

The clinical history-taking and findings in elderly versus younger AA patients. Our interest was to compare the performance of the clinical history-taking variables, findings and laboratory tests between the elderly AA patients and younger adult AA patients reported in our recent study (9), to examine whether the common clinical variables differ in elderly and younger adults. The Se of the history-taking in detecting AA in elderly 83% (95%CI=72-92%) was slightly higher than that detecting AA in younger female and male patients; 80% (95%CI=67-90%) and 81% (95%CI=66-92%), respectively. In addition, the overall Sp of the clinical history-taking in diagnosis of AA in elderly (34%; 95%CI=22-46%) was slightly higher than that in younger adult female and male patients; 30% (95%CI=19-42%) and 31% (95%CI=20-43%), respectively. Instead, the overall Se of the findings and tests in detecting AA in the elderly was 84% (95%CI=72-93%), which was slightly lower than that among the younger adult female and male patients; 86% (95%CI=79-92%) and 88% (95%CI=82-94%), respectively. However, the Sp of the clinical history-taking in diagnosis of AA in the elderly (45%; 95%CI=29-61%) was significantly higher than that of the younger female and male patients; 34% (95%CI=20-50%) and 34% (95%CI=20-51%), respectively.

When the performance of the DS models was compared between elderly and younger adult AA patients, the trend was similar. The pooled Se of the DS models in diagnosis of AA in the elderly (90%; 95%CI=80-97%) and in the younger female and male patients was very similar; 90% (95%CI=85-95%) and 93% (95%CI=88-96%), respectively. Although, Se and Sp usually behave reciprocally, it was a surprise to find that the Sp of the DS in the elderly (95%; 95%CI=89-99%) was significantly higher than that in the younger adult female and male patients; 85% (95%CI=74-94%) and 84% (95%CI=74-92%), respectively. In spite of that, the AUC values based on HSROC analysis of the DSTax– and DSTax+ in the elderly [AUC=0.977 (95%CI=0.942-1.000) and AUC=0.980 (95%CI=0.956-1.000), respectively], and those in younger female [0.953 (95%CI=0.923-0.969)] and male patients [0.956 (95%CI=0.930-0.969)] (9) were very similar, with no significant difference in the roccomp analysis.

Elderly patients DSTax– and DSTax+. AUC values based on HSROC comparison test showed that the diagnostic performance of the clinical findings was slightly better than that of the clinical history-taking details only (p=0.0358). However, as measured by the AUC values, the DS model is superior to both i) the clinical history-taking and ii) findings and tests. Previous studies with a design similar to ours are scanty and only two retrospective studies have evaluated the applicability of the DS models in elderly AA population. Shchatsko et al. (9) used Alvarado score in 96 patients and suggested that elderly patients with Alvarado score between 5 and 10 had high risk of AA. Another retrospective study of 41 elderly patients (10) used Alvarado score with 0.969 AUC value. However, both these studies were retrospective (9, 10), and the lack of convincing evidence in elderly AA patients prompted the expert panel (3) not to recommend Alvarado score for diagnosis of AA in elderly patients.

The present study specifically focused on HSROC analysis and AUC value as the most important DS test characteristics. The main objective of the DS is to separate those elderly AA patients who do need urgent attention from those who don’t need. Some previous studies (2, 9) have emphasized the value of Tax analysis in AA diagnosis, but Tax analysis has certain limitations, including i) variation in the definition of Tax cut-off, as well as ii) variations in the duration of abdominal pain in the time of Tax testing (2, 9). In earlier studies, the frequency of fever in the elderly patients with AA diagnosis has varied between 30-80% (2, 9). There is still controversy, whether the elderly AA patients with presentation of fever differ significantly from those without fever. The present study favours the lack of any such difference, because no statistically significant difference was established in the HSROC analysis between DSTax– and DSTax+ formulas in diagnosis of AA in these elderly patients.

Conclusion

Although, some previous studies (11, 12) have reported that the diagnostic accuracy of AA is lower in the elderly patients as compared to younger AA patients, the results of our study do not support this statement. In contrast, the AUC value of DS for AA in the elderly patients is slightly higher than that in younger AA patients. Similar to the younger patients (6), the DS formula is superior to both the clinical history-taking and findings, and therefore the use of DS (with or without body temperature) should be an important part of the diagnostic decision tree of AA also in the elderly patients presenting with AAP.

Acknowledgements

The study was funded by the Päivikki and Sakari Sohlberg Foundation.

Footnotes

  • This article is freely accessible online.

  • ↵* These Authors contributed equally to this study.

  • Authors’ Contributions

    All Authors contributed to the collection and analysis of data, drafting, revising the manuscript, and read and approved the final manuscript.

  • Conflicts of Interest

    The Authors report no conflicts of interest or financial ties in relation to this study.

  • Received January 6, 2021.
  • Revision received January 29, 2021.
  • Accepted February 1, 2021.

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A Diagnostic Score (DS) Is a Powerful Tool in Diagnosis of Acute Appendicitis in Elderly Patients With Acute Abdominal Pain
MAARET ESKELINEN, JANNICA MEKLIN, KARI SYRJÄNEN, MATTI ESKELINEN
Anticancer Research Mar 2021, 41 (3) 1459-1469; DOI: 10.21873/anticanres.14904
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