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Can normal inflammatory markers rule out acute appendicitis in elderly patients presenting with abdominal pain to the Emergency Department (ED).

Three Part Question

In [elderly patients presenting to an Emergency Department with suspected appendicitis] does [normal inflammatory markers] role out the [diagnosis]?

Clinical Scenario

A 78 years old lady presents to the Emergency Department with right lower quadrant abdominal pain for 2 days. She is known hypertensive and take bisoprolol 5 mg every morning. Clinical examination showed very slight tenderness in the right lower quadrant and suprapubic area, there is no guarding, masses or organomegaly. Urine dip and bowel sounds were normal. General examination is otherwise normal with temp of 37 degree Celsius, pulse of 58 beat per minute.
You wonder if you can rely on normal blood tests to be able to exclude appendicitis.

Search Strategy

Midline,CINAHL,EMBASE search using OVID interface (1950- September 2013)
Using inflammatory markers
AND Abdominal pain OR ?appendicitis
AND Elderly OR Old age OR Above 65 years
Limit search to humans.

Search Outcome

8 papers were found of which 3 were relevant to the question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Yang et al,,
Taiwan(country of publication USA)
85 Elderly >60 years old patients underwent appendectomy for suspected appendicitis 77 were confirmed histologicallyRetrospective observational study of 85 consecutive patients over 30 months period.No significant difference in leukocyte count or CRP values between patients with acute appendicitis and those with normal appendix.If leukocyte count, differential and CRP all simultaneously normal the diagnosis of acute appendicitis should be reconsideredRetrospective study with all weaknesses associated with retrospective studies. Small sample size. Age definition of elderly was 60 or over in included patients.
Sülberg D et al
Patients who underwent appendectomies, compared group above 60 years old to those 60 years old or belowProspective observational study over 30 months periodPatients with appendicitis in the above 60 years old group had higher CRP values than those with appendicitis who are 60 years or youngerMore complications and perforations in the above 60 years old.Used the cut off age of 60 years old as elderly. Small sample size in the above 60 years old group. Abstract in English,,article in German translated.
Grönroos JM
Patients aged 60 years or older who underwent appendectomy for suspected appendicitis over 3 years period. 40 females and 43 males recruited.Prospective observational studyNone of patients with normal appendix had elevation of both CRP and Leukocytes.Small sample size.


There is insufficient evidence for the use of inflammatory markers in the early diagnosis of appendicitis in the elderly. The diagnosis of acute appendicitis is less likely if all the results of leukocyte count, neutrophil percentage and CRP were within normal limits. The inflammatory markers although sensitive they are not specific, the sensitivity increases when they are combined.


  1. Horng-Ren, Yang; Yu-Chun, Wang; Ping-Kuei, Chung; Wei-Kung, Chen; Long-Bin, Jeng; Ray-Jade, Chen Role of Leukocyte Count, Neutrophil Percentage, and C-Reactive Protein in the Diagnosis of Acute Appendicitis in the Elderly The American Surgeon 2005; 71(4):344-7.
  2. Sülberg D, Chromik AM, Kersting S, Meurer K, Tannapfel A, Uhl W, Mittelkötter U. Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen 2009;80(7):608-14.
  3. Grönroos JM Is there a role for leukocyte and CRP measurements in the diagnosis of acute appendicitis in the elderly? Maturitas . 1999 Mar 15;31(3):255-8