Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis

A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process

BACKGROUND

The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history.

METHODS

Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses.

RESULTS

124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4.

CONCLUSIONS

There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration.

TRIAL REGISTRATION

Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021).

CLINICAL TRIALS REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021).

Diagnostic value of monocyte-lymphocyte ratio and red cell distribution width- lymphocyte ratio against other biomarkers in children with acute appendicitis, cross-sectional study

Our study aims to ascertain the diagnostic value of the Monocyte-lymphocyte ratio (MLR) and red cell distribution width (RDW)-lymphocyte ratio (RLR) by comparing them with other biomarkers in distinguishing patients with and without acute appendicitis (AA). A total of 223 children were recruited in the study conducted according to the Cross-Sectional Study design. Patients under 18 years were assigned to 3 groups; AA, nonspecific abdominal pain (NAP), and a control group. According to the outcome of our research, while C-reactive protein (CRP), white blood cell (WBC), neutrophil count (NEU), neutrophil to lymphocyte ratio (NLR), and MLR had excellent diagnostic power, RLR had acceptable diagnostic power, and platelet to lymphocyte ratio (PLR) had only fair diagnostic power. MLR and NLR, which are simple, inexpensive, and easily accessible parameters, can be recommended to be used together with other biomarkers in diagnosing AA in children.

Negative Appendicectomy Rates in Females of Childbearing Age: A Retrospective Analysis and Literature Review

Introduction

A negative appendicectomy rate (NAR) is defined as the portion of pathologically normal appendices removed surgically in patients suspected of having acute appendicitis. The lifetime risk of acute appendicitis is 8.6% for males and 6.7% for females; contrarily, the lifetime risk of appendicectomy is 12% for males and 23.1% for females. This study aims primarily to evaluate the true NAR in females of childbearing age to offer insight into potential strategies to reduce the number of unnecessary operative procedures carried out, along with their associated morbidity and mortality.

Methods

All emergency appendicectomies over a one-year period were retrospectively identified and collected from a single tertiary care centre. Preoperative clinical, laboratory and postoperative histopathological data were collected. The negative appendicectomy rate in subgroups divided by biomarkers and radiological imaging findings were analysed. The diagnostic value of these modalities in the context of acute appendicitis was found by calculating the sensitivity, specificity, positive predictive values, and negative predictive values.

Results

A total of 417 patients were included (median age 26; M:F, 0.7:1.0). The overall negative appendicectomy rate was 35.0% (146/417). Two-hundred sixty-one patients underwent an appendicectomy in the child-bearing age group. The NAR was significantly higher in those females with raised WBC and C-reactive protein (CRP) compared to their male counterparts (p-value -<0.001).

Conclusion

Women of childbearing age have a higher NAR of 43% when compared to the general population of 35%. Preoperative tests, including ultrasound scans, computed tomography and inflammatory markers in blood tests, help direct those who would benefit from surgery to the operating theatre, however, no test alone is suitably sensitive or specific. To reduce the NAR, management options include a return to observation and serial examination, increased use of low-dose CT or a commitment to improving the performance of ultrasonography.

Hyperbilirubinemia as a Possible Predictor of Appendiceal Perforation in Acute Appendicitis: A Prospective Study

Introduction: Acute appendicitis, a common abdominal surgical emergency, can mostly be diagnosed clinically by assessing the symptoms and physical findings but confirmation of the diagnosis solely depends upon the histopathological study of the resected appendix specimen, being supplemented by a few laboratory tests and ultrasonography (USG). In spite of all these available investigations, the diagnosis of acute appendicitis, because of its nebulous presentation and the variability of signs, remains a Herculean task for the surgeon.

Methods: This is a prospective study conducted on 125 patients diagnosed with acute appendicitis and posted for appendicectomy. Total serum bilirubin (TSB), and total leucocyte count (TLC) were done in all cases. USG of the abdomen was done in all the cases to confirm the diagnosis and to rule out other causes of acute abdomen. TLC more than 11 x 10³ cells/µL and TSB more than 1.1 mg/dL were considered positive. They were operated on and their diagnoses were confirmed post-operatively by histopathological examination. Patients were subdivided according to histopathological findings into: normal appendix (n = 11), uncomplicated acute appendicitis (n = 86), gangrenous appendicitis (n = 10) and perforated appendix (n = 18). Laboratory results, operative findings, and histopathological findings were compiled, analyzed, and compared with reference values.

Results: Out of 125 patients, 114 (91.2%) were histologically positive for acute appendicitis, while 11 (8.8%) had normal histology. TLC was elevated in 95 (76 %) patients and it was normal in 30 (24%) cases. Among the patients with leucocytosis, only 90 (94.74%) had positive histology for acute appendicitis, while the remaining five (5.26%) had normal histology. Among the 30 patients who had normal TLC, 24 had positive histology for acute appendicitis, while the remaining six had normal histology. The specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were 78.95%, 54.55%, 94.74%, and 20%respectively. Similarly, 67 patients (53.6%) had elevated TSB, while it was within normal limits in 58 (46.4%) patients. From the patients with hyperbilirubinemia, 65 (97.01%) had positive histology for acute appendicitis, while the remaining two (2.99%) had normal histology. Among 58 patients who had normal TSB, 49 had positive histology for acute appendicitis, while the rest nine had normal histology. The specificity, sensitivity, PPV, and NPV are 57.02%, 81.82%, 97.01%, and 15.52% respectively. However, when both TLC and TSB were compared as markers of appendicular perforation, the sensitivity, specificity, PPV, and NPV of total serum bilirubin were found to be 89.29% against 21.43%; 53.49% vs. 2.33%; 38.46% vs. 6.67% and 93.88% vs. 8.33% of total leukocyte counts respectively.

Conclusion: Elevated total serum bilirubin could be used as a better predictor of appendiceal perforation in acute appendicitis.

Clinical, Laboratory and Radiographic Features Associated With Prolonged Hospitalization in Children With Complicated Appendicitis

OBJECTIVE

In children with appendicitis, rupture of the appendix is associated with a significant increase in morbidity. We sought to characterize the spectrum of illness in children with complicated appendicitis and to define those factors associated with a longer hospital stay.

STUDY DESIGN

We conducted a retrospective review of 132 children, 18 years of age or younger at a large urban teaching hospital in the Bronx, NY between October 2015 and April 2018 with an intraoperative diagnosis of perforated appendix. Clinical, laboratory and radiologic findings were reviewed, and the primary study outcome was length of stay (LOS) dichotomized at the median, which was 7 days. Statistical analyses were done to characterize morbidity and define variables predictive of longer stay.

RESULTS

Children in the longer LOS group experienced significantly more morbidity, including ICU stay, ileus, and need for multiple drainage procedures. A longer duration of symptoms prior to presentation was associated with a longer stay. Multivariable logistic regression analysis indicated that the presence of abscess and presence of free fluid in the right upper quadrant (RUQ FF) on initial imaging and C-reactive protein (CRP) level >12 at admission, were independently associated with a longer stay.

CONCLUSION

There is considerable variation in the morbidity of complicated appendicitis. The association between longer stay and the findings of abscess and RUQ FF on initial imaging along with an elevated CRP may provide a useful tool in identifying those children at risk for worse outcomes.

Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis

BACKGROUND

Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children.

OBJECTIVES

The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective.

SELECTION CRITERIA

We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies.

DATA COLLECTION AND ANALYSIS

We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity.

MAIN RESULTS

We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains.

AUTHORS' CONCLUSIONS

MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.

sTREM-1 as a diagnostic biomarker for acute appendicitis in children

BACKGROUND

The typical history of acute appendicitis is observed in less than 60% of cases. Therefore, searching for a surrogate marker is mandatory. Our goal was to determine whether the soluble triggering receptor expressed on myeloid cells (sTREM-1) is an efficient biomarker for acute appendicitis.

METHODS

sTREM-1 serum levels were measured in addition to carrying out routine diagnostic tests (urine dipstick, complete blood count and CRP) in children admitted to the Emergency Department with suspected appendicitis. Statistical analysis was performed in order to examine whether sTREM-1 was a significant predictor of appendicitis.

RESULTS

Fifty three of 134 children enrolled in the study were diagnosed with appendicitis. There was no significant difference in serum sTREM-1 levels (p = 0.111) between children with or without appendicitis (n = 81). Leukocytes, neutrophils and CRP were significantly elevated in the appendicitis group (p < 0.001). The appendix diameter was significantly larger and the Alvarado score significantly higher in the appendicitis group (p < 0.001).

CONCLUSION

serum sTREM-1 is not a good marker for acute appendicitis. Customary tests in addition to a proper patient history and physical examination are still the most effective methods to diagnose acute appendicitis.

Leucocyte count and C-reactive protein cannot be relied upon in the diagnosis of acute appendicitis in HIV-infected patients

BACKGROUND

South Africa has the highest prevalence of human immunodeficiency virus (HIV) infection in the world, and is commonly found in association with appendicitis. Atypical presentation of appendicitis in the presence of HIV infection makes clinical diagnosis of appendicitis unreliable, and inflammatory markers are commonly used as adjuncts. The aim of this study was ascertain the value of inflammatory markers in the diagnosis of appendicitis in patients with and without HIV infection.

METHODS

Patients with acute appendicitis were studied and divided into HIV-infected and HIV-uninfected groups. Symptoms, and systemic and local signs were recorded. Appendiceal pathology was classified as simple or as complicated by abscess, phlegmon or perforation. Total white cell count (WCC) and C-reactive protein (CRP) were chosen as inflammatory markers. Findings were compared between the two groups.

RESULTS

The study population consisted of 125 patients, of whom 26 (20.8 per cent) had HIV infection. Clinical manifestations did not differ statistically, and there was no difference in the incidence of simple or complicated appendicitis between the two groups. The mean CRP level was significantly higher in HIV-infected patients (194.9 mg/l versus 138.9 mg/l in HIV-uninfected patients; P = 0.049), and mean WCC (x109/L) was significantly lower (11.07 versus 14.17×109/l respectively; P = 0.010).

CONCLUSION

Clinical manifestations and pathology did not differ between HIV-infected and HIV-uninfected patients with appendicitis, except that the WCC response was significantly attenuated and CRP levels were generally higher in the presence of HIV infection.

A combined medical/surgical appendicitis pathway decreases pediatric CT utilization, perforation, and negative appendectomy rates

Background

We sought to improve the care of pediatric patients with possible appendicitis by decreasing unnecessary CT scanning. In an early QI initiative, we systematically emphasized the superiority of Ultrasonography (US) over CT, but did not find a decrease in CT utilization in practice. We therefore redoubled our initiative using a multimodal approach. We hypothesized a combined diagnostic and treatment pathway that allowed residual diagnostic uncertainty and used both surgery and antibiotic therapy for appendicitis that would decrease the need for diagnostic CT scanning.

Results

Prior to implementation of the protocol, 33% of ER patients with appendicitis typical abdominal pain were treated for appendicitis (with surgery); after implementation, the total number treated remained unchanged 32.5% (p = NS), but the appendectomy rate dropped from 33 (204/619) to 23% after implementation of the pathway (96/419, p < 0.0005) with 50 patients treated with antibiotics. There was a reduction in CT scanning (pre 39% vs. 11%, p < 0.0001) while the use of US increased (pre 30% vs. 53%, p < 0.0001). The perforation rate decreased from 12 to 5% (p < 0.002) and negative appendectomy decreased from 13 to 4% (p < 0.0001). Of the 50 patients treated with antibiotics, 10 eventually crossed over to surgery.

Conclusion

The use of a diagnostic and therapeutic pathway that offers antibiotic therapy for early probable appendicitis decreases the need for diagnostic CT scanning without increasing morbidity in pediatric appendicitis. Adherence to a medical/surgical treatment protocol that reserves surgery for clinically advanced appendicitis results in a reduction in CT scanning, perforation rates, negative appendectomy rates, and overall surgery for appendicitis.

A study of C-reactive protein and D-dimer in patients of appendicitis

Background:

Acute appendicitis is the most common abdominal surgical emergencies across the world.

Objective:

The aim of this study was to determine the value of C-reactive protein (CRP) and D-dimer as diagnostic markers of acute appendicitis.

Study Design:

It was a Prospective observational clinical study.

Method:

The present study was carried out in General Surgical Unit of University Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi from September 2015 to July 2017. All data including patient's demography, clinical examination, laboratory test results, and appendix histology were summarized. Receiver operating characteristic (ROC) curve of TLC, CRP, and D-dimer was analyzed.

Results:

Total 65 patients who presented with periumbilical pain or pain in right iliac fossa (RIF) were included in the study. The mean age of the patients was 31.18 ± 14.59 years (range: 15 to 65 years) with male : female ratio was 2.21:1. The most common symptom was pain in right iliac fossa (100%) followed by nausea/vomiting (69.2%). The mean leucocyte count, CRP, and D-dimer levels were significantly raised in appendicitis group as compared to negative appendicectomy group (P = 0.025, P = 0.036, and P = 0.025, respectively). The receiver operating characteristic (ROC) curve for TLC was not helpful for differentiating between appendicitis and negative appendicitis (P = 0.073). In addition, D-dimer was helpful for differentiating between appendicitis and negative appendicitis (P = 0.002). However, CRP was also found to be helpful for differentiating between appendicitis and negative appendicitis (P = 0.030).

Conclusion:

The diagnosis of appendicitis remains multifactorial and biochemical markers like CRP and D-dimer may help to guide the surgeon in the decision making.

Diagnostic accuracy of combined WBC, ANC and CRP in adult emergency department patients suspected of acute appendicitis

OBJECTIVES

To assess the sensitivity, specificity, and negative predictive value (NPV) of normal total white blood cell count (WBC) and normal absolute neutrophil count (ANC) combined with a normal proprietary C-reactive protein (pCRP) level in adult emergency department (ED) patients with abdominal pain suspected of possible acute appendicitis.

METHODS

We prospectively enrolled patients ≥18 years of age at seven U.S. emergency departments with ≤72 h of abdominal pain and other signs and symptoms suggesting possible acute appendicitis. Sensitivity, specificity, and NPV for normal WBC and ANC combined with normal pCRP were correlated with the final diagnosis of acute appendicitis.

RESULTS

We enrolled 422 patients with a prevalence of acute appendicitis of 19.1%. The combination of normal WBC and pCRP exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), an NPV of 98.8% (95% CI, 95.9-99.7%) and a specificity of 50.0% (95% CI, 44.7-55.3%) for acute appendicitis. Normal ANC and pCRP resulted in a sensitivity of 100% (95% CI, 95.4-100%), a negative predictive value of 100% (95% CI, 97.5-100%) and a specificity of 44.4% (95% CI, 39.2-49.7%) for acute appendicitis. Normal WBC and pCRP correctly identified 171 of 342 (50.0%) patients who did not have appendicitis with 2 (2.5%) false negatives, while normal ANC and pCRP identified 150 of 338 (44.3%) of patients without appendicitis with no false negatives.

CONCLUSION

The combination of normal WBC and ANC with normal pCRP levels exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult patient cohort. Confirmation and validation of these findings with further study using commercially available CRP assays is needed.

Time course response of inflammatory markers in pediatric appendicitis

PURPOSE

We aim to evaluate the diagnostic value and time course response of the triple inflammatory markers: white blood cell count (WBC), neutrophil percentage (Neu), and C-reactive protein (CRP) in pediatric acute appendicitis.

METHODS

A retrospective review of clinical data pertaining to 1391 patients admitted with suspicion for pediatric appendicitis from 2012 to 2017 was conducted. Triple inflammatory markers were acquired upon admission. Appendicitis was confirmed histologically post-appendectomy. The diagnostic value and time course response of these markers was trended in relation to the duration of abdominal pain on admission.

RESULTS

718 patients had histologically confirmed appendicitis. WBC and Neu demonstrate high sensitivity for early appendicitis at 94.6% and 80.0% at Day 1, while CRP demonstrates highest sensitivity of 97.9% at Day 4. The triple markers had poor overall diagnostic value when interpreted individually, however, had a high combined sensitivity of 99.7% and negative predictive value of 98.7% regardless of duration of disease. Overall negative appendectomy rate was 6.7% (n = 52). Among 19 patients with triple markers negative who underwent appendectomy, 17 (89.5%) were histologically normal.

CONCLUSIONS

The triple inflammatory markers have limited diagnostic value when interpreted individually, but are strong discriminators of pediatric appendicitis when combined. Their high sensitivity and negative predictive value could potentially help patients avoid unnecessary admissions or costly imaging studies, and reduce negative appendectomy rates. In addition, their objective nature confers an advantage over existing clinical scoring systems which comprise subjective elements.

Accuracy of Mean Platelet Volume (MPV) and Red Cell Distribution Width (RDW) for the Diagnosis of Acute Appendicitis: Evaluation of Possible New Biomarkers

Introduction:

Acute appendicitis is the most common cause of the abdominal pain in surgery. Despite its significant prevalence, the diagnosis is associated with many problems in some cases, which leads to false appendectomy.

Objective:

The aim of this study was to determine the validity of diagnostic tests of mean platelet volume (MPV) and red cell distribution width (RDW), as a new possible tool in the diagnosis of acute appendicitis. Methods: In this study, all patients who referred to the emergency department of Besat Hospital, Hamadan, Iran, in 2015, with abdominal pain and first impression of acute appendicitis, undergone appendectomy, were evaluated. The diagnostic markers of pre-operative and post-operative pathology and the validity of MPV and RDW were determined in diagnosis of acute appendicitis.

Results:

Laboratory and clinical data from 438 patients, presenting the signs and symptoms of acute appendicitis with the mean age of 26.51±13.9 years, were examined (55.6% men). The sensitivity, specificity, positive and negative predictive value of MPV in the diagnosis of acute appendicitis were 59.77, 98.66, 99.5 and 34.26 percent, and for the RDW were 57.79, 56.00, 86.07 and 21.98 percent, respectively. The area under the receiver operating characteristic (ROC) curve for RDW and MPV was 0.61and 0.90, respectively. The mean of MPV in patients with normal pathologic outcome was 9.52±1.60 and in patients with acute appendicitis was 7.51±1.22. There was a significant difference between the mean MPV in both groups (p<0.001). The mean of RDW in patients with normal pathology were 13.42±1.97 and 13.05±1.09, in patients with acute appendicitis. There was a significant difference between the mean RDW of the two groups (p=0.009).

Conclusion:

MPV and RDW indexes have the potential to be used by the surgeons in diagnosis of acute and perforated appendicitis, especially in adults, in order to reduce unnecessary appendectomy, but MPV is more valid in screening acute appendicitis, compared to the RDW.

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Can Outcomes of a Prospective Study Be Reproduced in Real Life?

BACKGROUND

The feasibility of day case surgery (DCS) appendectomy for uncomplicated acute appendicitis (UCAA) was evaluated by the prospective AppendAmbu (Feasibility of Outpatient Appendectomy for Acute Appendicitis) study (ClinicalTrials.gov ID NCT01839435). The aim of this study was to evaluate the real-life feasibility of DCS for UCAA.

STUDY DESIGN

This single-center, retrospective, non-interventional study was conducted after the AppendAmbu study and included UCAA only. The primary end point was DCS success rate (ie length of stay <12 hours) in the intention-to-treat population (all patients with UCAA) and in the per-protocol population (population with UCAA and no preoperative and intraoperative exclusion criteria). The secondary end points were to determine the DCS quality criteria to evaluate and compare the morbidity and mortality of DCS and conventional hospitalization for UCAA (Clavien, Comprehensive Complication Index) and to externally validate the St Antoine criteria for the selection of patients for DCS.

RESULTS

From January 2016 to September 2017, two hundred and ninety-six patients underwent operations for acute appendicitis. The proportion of patients with successful DCS management was 27% in the intention-to-treat population and 95% in the per-protocol population. The unplanned consultation rate was 15%, the unplanned hospitalization rate was 4%, and the unplanned reoperation rate was 0%. The postoperative morbidity of patients managed by DCS was not different from that of patients managed in conventional hospitalization. The DCS success rate was 0%, with a St Antoine score of 0, and 80% of patients had a St Antoine score of 5 (p < 0.0001).

CONCLUSIONS

Day case surgery constitutes progress in surgery as a result of enhanced recovery programs. It avoids unnecessary prolonged hospitalization.

Can Platelet Indices Reduce Negative Appendectomy Rates?

Introduction

The role of whole blood count parameters in the diagnosis of diseases in which inflammatory processes play a role is one of the more frequently mentioned topics in the literature in recent years. Studies of acute appendicitis have also been carried out in this regard, but studies focused on platelet parameters are few and contradictory. We aimed to investigate the role of mean platelet volume (MPV) and platelet distribution width (PDW) in the diagnosis of acute appendicitis.

Materials and methods

We retrospectively screened the medical records of patients older than 15 years who had an appendectomy from January 2012 to January 2015 at a training hospital in Kocaeli, Turkey. Patients were divided into three groups according to their pathology results: non-appendicitis (Group 1), uncomplicated appendicitis (Group 2), and complicated appendicitis (Group 3). We calculated the sensitivity, specificity, positive and negative predictive values, the likelihood ratios in the diagnosis of appendicitis for white blood cell (WBC), neutrophil count, c-reactive protein (CRP), MPV, and PDW values were calculated.

Results

There were no significant differences in the MPV between Group 1 (n = 39; 7.89 ± 1.32 fL), Group 2 (n = 119; 7.80 ± 1.19 fL), and Group 3 (n = 89; 7.70 ± 0.80 fL; p = 0.141). Also, we found no significant differences in PDW between Group 1 (117.38% ± 1.17), Group 2 (17.17% ± 1.04), and Group 3 (17.12% ± 0.64; p = 0.228).

Conclusions

Only nine of the 208 patients whose pathology reports confirmed appendicitis had healthy values for both CRP and WBC. Many factors affect MPV and PDW. Therefore, platelet indices are not useful markers in diagnosing acute appendicitis.

Complicated appendicitis and considerations for interval appendectomy

Acute appendicitis is one of the most common surgical emergencies. Of the 300,000 appendectomies performed each year, 25% are due to complicated appendicitis. This article reviews the incidence and pathophysiology of acute appendicitis, the nonoperative management of complicated appendicitis, and the rationales for and against interval appendectomy.

Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.

A pre-operative clinical scoring system to distinguish perforation risk with pediatric appendicitis

IMPORTANCE

Appendicitis is a common, potentially serious pediatric disease. An important factor in determining management strategy [whether/when to perform appendectomy, duration of antibiotic therapy/hospitalization, etc.] and predicting outcome is distinguishing whether perforation is present.

OBJECTIVE

The objective was to determine efficacy of commonly assessed pre-operative variables in stratifying perforation risk in children with appendicitis.

DESIGN

A retrospective analysis of consecutive cases was performed.

SETTING

The setting was a large urban hospital pediatric emergency department.

PARTICIPANTS

Four hundred forty-eight consecutive cases of CT [computerized tomography]-confirmed pediatric appendicitis during a 6-year period in an urban pediatric ED [emergency department]: 162 with perforation and 286 non-perforated.

MAIN OUTCOME(S) AND MEASURE(S)

To determine efficacy of clinical and laboratory variables with distinguishing perforation outcome in children with appendicitis.

RESULTS

Regression analysis identified 3 independently significant variables associated with perforation outcome - and determined their ideal threshold values: duration of symptoms>1day; ED-measured fever [body temperature >38.0 °C]; CBC WBC absolute neutrophil count >13,000/mm³. The resulting multivariate ROC [receiver operating characteristic] curve after applying these threshold values gave an AUC [area under curve] of 89% for perforation outcome [p<0.001]. Risk for perforation was additive with each additional predictive variable exceeding its threshold value, linearly increasing from 7% with no variable present to 85% when all 3 variables are present.

CONCLUSIONS

A pre-operative scoring system comprised of 3 commonly assessed clinical/laboratory variables is useful in stratifying perforation risk in children with appendicitis. Physicians can utilize these factors to gauge pre-operative risk for perforation in children with appendicitis, which can potentially aid in planning subsequent management strategy.

LEVEL OF EVIDENCE

III.

Evaluation of the diagnostic value of serum level of total bilirubin in patients with suspected acute appendicitis

Introduction

Clinical diagnosis of acute appendicitis still remains a problem. Delays in diagnosis of acute appendicitis may cause perforation and septic peritonitis which result in increasing morbidity and mortality. The aim of this study was to determine the sensitivity, specificity and the diagnostic value of total serum bilirubin levels as a predictor of acute appendicitis.

Methods

In this cross-sectional study, patients who underwent appendectomy with the diagnosis of acute appendicitis from April 2012 to March 2013 at Emam Reza Hospital in Mashhad (Iran) were enrolled. Serum bilirubin-Total and Direct-, were measured. Then based on the final pathologic reports, patients were categorized into five groups of normal appendix, chronic inflammatory changes, acute appendicitis, gangrenous and/or necrotic changes, and perforated appendicitis. Independent sample t-test, ANOVA, and Chi-square test were used for data analysis by SPSS version 16.

Results

There were 174 patients studied, (117 male, 57 female) with a mean age of 27.15±0.7 years. All of the patients had rebound tenderness; 75.3% had nausea, 58.6% had anorexia and 21.3% had fever. The histological reports of all patients showed 76.4% acute appendicitis. Analyzing p-values for SGPT, SGOT, WBC was (p=0.903) and differential count was (p=0.959). The study showed no significant difference between the pathological groups. However, there were no significant differences in serum total bilirubin levels between the pathological groups. Total bilirubin showed sensitivity of 48% and specificity of 61% in the diagnosis of acute appendicitis. Total serum bilirubin more than 0.85 mg/dl was the cut-off value with the best performance for diagnosis of appendicitis.

Conclusion

Bilirubin levels are reliable, sensitive and specific to diagnosis and a prediction of complicated appendicitis.

The Influence of Age on the Diagnostic Performance of White Blood Cell Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis

OBJECTIVE

White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted.

METHODS

This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups: <5, 5-11, and 12-18 years of age. Diagnostic performance of WBC count and ANC was then assessed at specific cut-points.

RESULTS

A total of 2,133 patients with a median age of 10.9 years (interquartile range = 8.0-13.9 years) were studied. Forty-one percent had appendicitis. The area under the curve (AUC) for WBC count was 0.69 (95% confidence interval [CI] = 0.61 to 0.77) for patients < 5 years of age, 0.76 (95% CI = 0.73 to 0.79) for 5-11 years of age, and 0.83 (95% CI = 0.81 to 0.86) for 12-18 years of age. The AUCs for ANC across age groups mirrored WBC performance. At a commonly utilized WBC cut-point of 10,000/mm³ , the sensitivity decreased with increasing age: 95% (<5 years), 91% (5-11 years), and 89% (12-18 years) whereas specificity increased by age: 36% (<5 years), 49% (5-12 years), and 64% (12-18 years).

CONCLUSION

WBC count and ANC had better diagnostic performance with increasing age. Age-adjusted values of WBC count or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis.

Clinical and laboratory findings in the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial

BACKGROUND

The current research on acute appendicitis aims to improve the diagnostics and to clarify to whom antibiotic treatment might be the treatment of choice.

METHODS

The present study is a retrospective analysis of a prospectively collected data in our randomized multicenter trial comparing surgery and antibiotic treatment for acute uncomplicated appendicitis (APPAC trial, NCTO1022567). We evaluated 1321 patients with a clinical suspicion of acute appendicitis, who underwent computed tomography (CT). Age, gender, body temperature, pain scores, the duration of symptoms, white blood cell count (WBC) and C-reactive protein (CRP) were recorded on admission.

RESULTS

CT confirmed the diagnosis of acute appendicitis in 73% (n=970) and in 27% (n=351) it revealed no or other diagnosis. Acute appendicitis patients had significantly higher WBC levels than patients without appendicitis (median 12.2 and 10.0, respectively, p<0.0001), whereas CRP levels did not differ between the two groups. Ideal cut-off points were assessed with receiver operating characteristic (ROC) curves, but neither these markers or neither their combination nor any clinical characteristic could accurately differentiate between patients with acute appendicitis and those without. The proportion of patients with normal WBC count and CRP was significantly (p=0.0007) lower in patients with acute appendicitis than in patients without appendicitis.

CONCLUSIONS

Both clinical findings and laboratory tests are unable to reliably distinguish between patients with acute appendicitis and those without. If both WBC count and CRP are normal, acute appendicitis is very unlikely. The current results emphasize the role of CT imaging in patients with suspected acute appendicitis.

Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging?

BACKGROUND

One of the main aims of appendicitis research is the differential diagnostics between complicated and uncomplicated acute appendicitis that enable provision of the optimal treatment for each patient.

METHODS

Data in the present study were collected prospectively in our randomized antibiotic treatment for uncomplicated acute appendicitis trial (APPAC) comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (NCT01022567). We evaluated 705 patients who had acute appendicitis on computed tomography. Patients with uncomplicated acute appendicitis (n = 368) were compared with all complicated acute appendicitis patients (n = 337), and subgroup analyses were performed between uncomplicated acute appendicitis and an appendicolith appendicitis (CA1; n = 256) and uncomplicated acute appendicitis and perforation and/or abscess (CA2; n = 78). Age, sex, body temperature (°C), duration of symptoms, white blood cell count (E9/L), and C-reactive protein (mg/L) were recorded on admission. Receiver operating characteristic curves were calculated for white blood cell count, C-reactive protein, and temperature.

RESULTS

CA2 patients had significantly greater C-reactive protein levels (mean 122 and 47, respectively, P < .001) and longer duration of symptoms than uncomplicated acute appendicitis patients; 81% of CA2 patients and 38% of uncomplicated acute appendicitis patients had symptoms >24 hours before admission (P < .001). In receiver operating characteristic analysis, C-reactive protein and temperature had clinically significant results only in comparison with uncomplicated acute appendicitis and CA2 (area under the curve >0.7), but no optimum cutoff points could be identified.

CONCLUSION

In clinical decision making, neither clinical findings nor laboratory markers are reliable enough to estimate the severity of the acute appendicitis accurately or to determine the presence of an appendicolith. The current results emphasize the role of computed tomography in the differential diagnosis of complicated and uncomplicated acute appendicitis.

Surgeon's clinical valuation and accuracy of ultrasound in the diagnosis of acute appendicitis: A comparison with intraoperative evaluation. Five years experience

INTRODUCTION

Acute appendicitis is the most common cause of acute abdomen in adolescents, with an overall incidence of 7%. Two such tools are used to diagnose acute appendicitis: ultrasound and Computer Tomography imaging. End point of this study was to verify the accuracy of ultrasound imaging in the diagnosis of acute appendicitis with respect to intraoperative observations and the respective clinical and laboratory findings in young and in the elderly.

METHODS

We considered all the appendectomies for acute appendicitis performed between 1 January 2010 and 1 January 2015. We evaluated clinical symptoms, laboratory findings, ultrasound findings, intraoperative signs, and anatomical and pathological findings. In the study we compared the ultrasound and intraoperative findings and then compared these with the respective clinical and laboratory data.

RESULTS

In a comparison of diagnostic accuracy, the difference between clinical and ultrasound examinations was not significant. The differences between the diagnostic accuracy of clinical and laboratory findings and between ultrasound and laboratory investigations were statistically significant.

CONCLUSION

We defined white blood cells and C protein levels as non-diagnostic of the type of acute inflammation but rather as indicators of the severity of the inflammatory process. We also agree with the authors who proposed the incorporation of ultrasonography into routine practice in the diagnosis of acute appendicitis, but only and exclusively to support other diagnostic procedures and preferably within emergency departments. A thorough clinical examination of patients with suspected acute appendicitis is still the best diagnostic procedure available to us.

Accuracy of White Blood Cell Count and C-reactive Protein Levels Related to Duration of Symptoms in Patients Suspected of Acute Appendicitis

OBJECTIVES

Low levels of white blood cell (WBC) count and C-reactive protein (CRP) have been suggested to sufficiently rule out acute appendicitis. The diagnostic value of these tests is likely to depend on the duration of complaints. The aim of this study was to evaluate the accuracy of these inflammatory markers in relation to duration of symptoms in patients suspected of acute appendicitis.

METHODS

Patients suspected of having acute appendicitis were retrospectively selected from five prospective cohorts of patients with acute abdominal pain presenting at the emergency department (ED) in two European countries. Only adult patients with clinical suspicion of acute appendicitis based on medical history, physical examination, and laboratory studies at the time of registration in the original cohorts were included in this analysis. WBC count and CRP level were determined in all patients and a final diagnosis was assigned to every patient by an expert panel based on all available clinical data and follow-up. For categories based on symptom duration, the diagnostic accuracy of single and combined cutoff values was determined, and negative predictive values (NPV) and positive predictive values (PPV) were calculated. Subgroup analyses for age (<40 years or ≥40 years) and sex were performed.

RESULTS

A total of 1,024 patients with clinically suspected acute appendicitis were included, of whom 580 (57%) were assigned a final diagnosis of appendicitis. No value of WBC count, CRP level, or their combination resulted in a NPV of more than 90%, regardless of the duration of symptoms. A WBC count of >20 × 10(9) /L in combination with symptoms for more than 48 hours was associated with a PPV of 100%. However, only eight of the 1,024 patients (1%) fulfilled these criteria, limiting the clinical applicability. No other cutoff level of WBC count, CRP level, or their combination resulted in a PPV of more than 80%, regardless of the duration of symptoms. In female patients, normal levels of CRP and WBC count more accurately excluded the diagnosis of appendicitis than normal levels did in male patients.

CONCLUSIONS

No WBC count or CRP level can safely and sufficiently confirm or exclude the suspected diagnosis of acute appendicitis in patients who present with abdominal pain of 5 days or less in duration.

Factors Associated with Perforated Appendicitis in Elderly Patients in a Tertiary Care Hospital

Background. The incidence of perforated appendicitis in elderly patients is high and carries increased morbidity and mortality rates. The aim of this study was to identify risk factors of perforation in elderly patients who presented with clinical of acute appendicitis. Methods. This was a retrospective study, reviewing medical records of patients over the age of 60 years who had a confirmed diagnosis of acute appendicitis. Patients were classified into two groups: those with perforated appendicitis and those with nonperforated appendicitis. Demographic data, clinical presentations, and laboratory analysis were compared. Results. Of the 206 acute appendicitis patients over the age of 60 years, perforated appendicitis was found in 106 (50%) patients. The four factors which predicted appendiceal rupture were as follows: male; duration of pain in preadmission period; fever (>38°C); and anorexia. The overall complication rate was 34% in the perforation group and 12.6% in the nonperforation group. Conclusions. The incidence of perforated appendicitis in elderly patients was higher in males and those who had certain clinical features such as fever and anorexia. Duration of pain in the preadmission period was also an important factor in appendiceal rupture. Early diagnosis may decrease the incidence of perforated appendicitis in elderly patients.

Hyperbilirubinaemia in appendicitis: the diagnostic value for prediction of appendicitis and appendiceal perforation

AIM

The aim of this study is to evaluate the diagnostic value of pre-operative bilirubin levels in the diagnosis of acute appendicitis and appendiceal perforation.

METHOD

A retrospective analysis of 557 patients undergoing emergency appendicectomy over a 24-month period at a large teaching hospital. Hyperbilirubinaemia was defined as >25 µmol/L. Data were analysed using descriptive statistics.

RESULTS

484 of the 557 (86.9 %) operated cases were found histologically to be appendicitis. 116 cases of the 484 were perforated (24 %). Bilirubin levels were significantly higher in the group with appendicitis versus the group found to have a normal appendix at histology, [median (IQR) 12.0 µmol/L (9.00) vs. 8.0 µmol/L (7.00) respectively, p < 0.001], despite being within normal serum bilirubin range. Sensitivity of hyperbilirubinaemia for acute appendicitis was only 8 %, however specificity was 94 %. PPV was 85 % and NPV was 26 %. Whilst bilirubin was higher in patients with a perforated appendix versus acute appendicitis [median (IQR) 13.0 µmol/L (9.00) vs. 11.0 µmol/L (9.00), respectively], statistically, there was no significant difference in pre-operative bilirubin levels between the perforated appendicitis cases and the non-perforated appendicitis cases (p = 0.326). However, the specificity of hyperbilirubinaemia for perforated appendicitis was 93 %, sensitivity 9.4 %, PPV 24 % and NPV 82 %.

CONCLUSION

Bilirubin levels may be high, but remain within normal range, in cases of appendicitis. Therefore, bilirubin levels may be a useful measurement when investigating a patient with suspected appendicitis. Hyperbilirubinaemia is highly specific with regards to perforation, a finding supported by other studies. However, possibly because of the few perforated cases in this study, we cannot recommend that hyperbilirubinaemia be used to predict perforation.

Prediction of the grade of acute cholecystitis by plasma level of C-reactive protein

Background:

Acute cholecystitis is the most common complication of gallbladder stones. Today, Tokyo guidelines criteria are recommended for diagnosis, grading, and management of acute cholecystitis.

Objectives:

We aimed to evaluate the levels of C-reactive protein (CRP) at different cut-off values to predict the severity of the disease and its possible role in grading the disease with regard to the guideline.

Patients and Methods:

This is a retrospective study, analyzing 682 cases out of consecutive 892 patients with acute cholecystitis admitted to two different general surgery clinics in Istanbul, Turkey. Records of patients diagnosed with acute cholecystitis were screened retrospectively from the hospital computer database between January 2011 and July 2014. A total of 210 patients with concomitant diseases causing high CRP levels were excluded from the study. The criteria of Tokyo guidelines were used in grading the severity of acute cholecystitis, and patients were divided into 3 groups. CRP values at the time of admission were analyzed and compared among the groups.

Results:

Mean CRP levels of groups were found to be significantly different, 18.96 mg/L in Group I, 133.51 mg/L in Group II, and 237.23 mg/L in Group III (P < 0.001). Having examined CRP values among the groups, they were found to be highly and significantly correlated with the disease grade (P < 0.0001). After evaluating CRP levels according to the grade of the disease, group 2 was distinguished from group 1 with a cut-off CRP level of 70.65 mg/L, and from group 3 with a value of 198.95 mg/L. Those results were found to be statistically significant (P < 0.001).

Conclusions:

CRP, a well-known acute phase reactant that increases rapidly in various inflammatory processes, can be accepted as a strong predictor in classifying different grades of the disease, and treatment can be reliably planned according to this classification.

High admission C-reactive protein level and longer in-hospital delay to surgery are associated with increased risk of complicated appendicitis

PURPOSE

Debate on the effect of in-hospital delay on the risk of perforation in appendicitis persists, and the results from previous studies are controversial. The aims of this study were to present the effect of in-hospital delay on the risk of perforation in appendicitis and to assess the utility of C-reactive protein (CRP) measurement in detecting the patients with complicated appendicitis.

METHODS

Prospectively collected data of 389 adult patients who underwent surgery for acute appendicitis were analyzed in order to find the most accurate method for recognizing the pre-hospital perforations. The effect of in-hospital delay on the further risk of perforation in patients with not yet perforated acute appendicitis was then analyzed.

RESULTS

Out of 389 patients with appendicitis, 91 patients (23.4 %) had complicated appendicitis, 23 with abscess, and 68 with free perforation. Admission CRP level of 99 mg/l or higher was 90.3 % specific for complicated appendicitis. In patients with admission CRP less than 99 mg/l, the incidence of perforation doubled from 9.5 to 18.9 % when the in-hospital delay increased from less than 6 h to more than 12 h.

CONCLUSIONS

Complicated appendicitis can be identified with a high CRP level on admission. Delaying surgery can increase the risk of perforation.

Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014

Introduction

Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review.

Methods

We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis.

Results

Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied.

Conclusion

While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.

A model to select patients who may benefit from antibiotic therapy as the first line treatment of acute appendicitis at high probability

BACKGROUND

Randomized studies indicated that 88-95% of patients with acute appendicitis recover on antibiotics without surgery, although it is unclear which patient would benefit with high probability on antibiotics. We hypothesized that patients with phlegmonous appendicitis should be a group where antibiotics may be a sufficient treatment. Accordingly, our aim was to propose a model to support treatment application for unselected patients with acute appendicitis.

METHODS

Retrospective analyses of preoperative clinical and laboratory variables in 384 consecutive adult patients, who underwent appendectomy with histological examination of the appendix, were evaluated by logistic regressions. The proposed mathematical model was then evaluated on a prospectively collected population based material of 581 consecutive patients offered antibiotics as their first line treatment of acute appendicitis.

RESULTS

Patients with assumed appendicitis who fulfilled all criteria with CRP <60 g/L, WCC <12 × 10(9)/L, and age <60 years had 89% probability to have phlegmonous appendicitis. When these criteria were applied retrospectively on a prospective material, 88% of operated patients had phlegmonous inflammation and 89% had recovered on antibiotics without surgery.

CONCLUSION

Standard clinical and laboratory tests are individually weak predictors of phlegmonous appendicitis, but can be used in combinations as a bedside instrument to select patients suitable for antibiotic therapy.

Utility of immature granulocyte percentage in pediatric appendicitis

BACKGROUND

Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis.

MATERIALS AND METHODS

We identified all patients with appendicitis from July 2012-June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis.

RESULTS

A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P=0.0063), C-reactive protein (CRP) (P<0.0001), and IG% (P=0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40-8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09-6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis.

CONCLUSIONS

IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.

Evaluation of the diagnostic accuracy of plasma markers for early diagnosis in patients suspected for acute appendicitis

OBJECTIVES

The main objective of this study was to evaluate the diagnostic accuracy of two novel biomarkers, calprotectin (CP) and serum amyloid A (SAA), along with the more traditional inflammatory markers C-reactive protein (CRP) and white blood cell count (WBC), in patients suspected of having acute appendicitis (AA). The secondary objective was to compare diagnostic accuracy of these biomarkers with a clinical scoring system and radiologic imaging.

METHODS

A total of 233 patients with suspected AA, presenting to the emergency department (ED) between January 2010 and September 2010, and 52 healthy individuals serving as controls, were included in the study. Blood was drawn and CP and SAA-1 concentrations were measured using enzyme-linked immunosorbent assay (ELISA). CRP and WBC concentrations were routinely measured and retrospectively abstracted from the electronic health record, together with physical examination findings and radiologic reports. The Alvarado score was calculated as a clinical scoring system for AA. Final diagnosis of AA was based on histopathologic examination. The Mann-Whitney U-test was used for between-group comparisons. Receiver operating characteristic (ROC) curves were used to measure the diagnostic accuracy for the tests and to determine the best cutoff points.

RESULTS

Seventy-seven of 233 patients (33%) had proven AA. Median plasma levels for CP and SAA-1 were significantly higher in patients with AA than in those with another final diagnosis (CP, 320.9 ng/mL vs. 212.9 ng/mL; SAA-1, 30 mg/mL vs. 0.6 mg/mL; p < 0.001). CRP and WBC were significantly higher in patients with AA as well. The Alvarado score was helpful at the extremes (<3 or >7). Ultrasound (US) had a sensitivity of 84% and a specificity of 94%. Computed tomography (CT) had a sensitivity of 100% and a specificity of 91%. The area under the ROC (95% confidence interval [CI]) was 0.67 (95% CI = 0.60 to 0.74) for CP, 0.76 (95% CI = 0.70 to 0.82) for SAA, 0.71 (95% CI = 0.64 to 0.78) for CRP, and 0.79 (95% CI = 0.73 to 0.85) for WBC. No cutoff points had high enough sensitivity and specificity to accurately diagnose AA. However, a high sensitivity of 97% was shown at 7.5 × 10(9) /L for WBC and 0.375 mg/mL for SAA.

CONCLUSIONS

CP, SAA-1, CRP, and WBC were significantly elevated in patients with AA. None had cutoff points that could accurately discriminate between AA and other pathology in patients with suspected AA. A WBC < 7.5 × 10(9) /L, with a low level of clinical suspicion for AA, can identify a subgroup of patients who may be sent home without further evaluation, but who should have available next-day follow-up.

Elevated serum bilirubin in assessing the likelihood of perforation in acute appendicitis: a diagnostic meta-analysis

Hyperbilirubinemia associates with perforated acute appendicitis, but the precise test characteristics have not been determined by sufficiently powered studies. A systematic literature search of reports on hyperbilirubinemia in acute appendicitis was performed. After review and quality assessment of eight studies encompassing a total of 4974 patients the sensitivity, specificity and other measures of accuracy of hyperbilirubinemia as a predictor of perforation in acute appendicitis were pooled using a random-effects model. Summary estimates for hyperbilirubinemia (cutoff 1 mg/dl) as a predictor of perforation in acute appendicitis were as follows: sensitivity, 0.49 (95% confidence interval [CI], 0.45-0.52); specificity, 0.82 (95% CI, 0.80-0.83); positive likelihood ratio, 2.51 (95% CI, 1.58-4.00); negative likelihood ratio, 0.58 (95% CI, 0.44-0.76); diagnostic odds ratio was 4.42 (95% CI, 2.21-8.83). In summary receiving operating characteristic (SROC) analysis, the area under curve was 0.73. The presence of hyperbilirubinemia does not alone distinguish a perforation in acute appendicitis. Serum bilirubin level is of some value as a predictor of appendiceal perforation. Patients with hyperbilirubinemia combined with symptoms and signs consistent with severe acute appendicitis should be considered for early appendectomy.

The diagnostic value of white cell count, C-reactive protein and bilirubin in acute appendicitis and its complications

INTRODUCTION

Inflammatory markers such as white cell count (WCC) and C-reactive protein (CRP) and, more recently, bilirubin have been used as adjuncts in the diagnosis of appendicitis. The aim of this study was to determine the diagnostic accuracy of the above markers in acute and perforated appendicitis as well as their value in excluding the condition.

METHODS

A retrospective analysis of 1,169 appendicectomies was performed. Patients were grouped according to histological examination of appendicectomy specimens (normal appendix = NA, acute appendicitis = AA, perforated appendicitis = PA) and preoperative laboratory test results were correlated. Receiver operating characteristic (ROC) curve area analysis (area under the curve [AUC]) was performed to examine diagnostic accuracy.

RESULTS

ROC analysis of all laboratory variables showed that no independent variable was diagnostic for AA. Good diagnostic accuracy was seen for AA when all variables were combined (WCC/CRP/bilirubin combined AUC: 0.8173). In PA, the median CRP level was significantly higher than that of AA (158mg/l vs 30mg, p<0.0001). CRP also showed the highest sensitivity (100%) and negative predictive value (100%) for PA. CRP had the highest diagnostic accuracy in PA (AUC: 0.9322) and this was increased when it was combined with WCC (AUC: 0.9388). Bilirubin added no diagnostic value in PA. Normal levels of WCC, CRP and bilirubin could not rule out appendicitis.

CONCLUSIONS

CRP provides the highest diagnostic accuracy for PA. Bilirubin did not provide any discriminatory value for AA and its complications. Normal inflammatory markers cannot exclude appendicitis, which remains a clinical diagnosis.

Diagnostic role of procalcitonin in patients with suspected appendicitis

BACKGROUND

The aim of this study was to assess the diagnostic value of procalcitonin (PCT) in emergency department (ED) patients with suspected appendicitis.

METHODS

A prospective observational study was carried out in the emergency department of a university hospital between July 2007 and June 2008. Adult patients who presented to the ED with clinically suspected appendicitis were enrolled. Each patient underwent serum PCT, C-reactive protein (CRP), and Alvarado score evaluation on admission. The results of these three measurements were analyzed in relation to the final diagnosis determined by histopathological findings or compatible computed tomography findings.

RESULTS

Of the 214 study patients, 113 (52.8 %) had a confirmed diagnosis of appendicitis and 58 had complicated appendicitis (phlegmon, perforation, or gangrene). For the diagnosis of appendicitis, the area under the receiving operating characteristic (ROC) curve is 0.74 for Alvarado score, 0.69 for PCT, and 0.61 for CRP. Overall, the Alvarado score has the best discriminative capability among the three tested markers. We adopted two cutoff point approaches to harness both ends of the diagnostic value of a biomarker. PCT levels were significantly higher in patients with complicated appendicitis. For diagnosis of complicated appendicitis, a cutoff value of 0.5 ng/mL had a sensitivity of 29 % and a specificity of 95 %, while a cutoff value of 0.05 ng/ml had a sensitivity of 85 % and a specificity of 30 % in diagnosing complicated appendicitis. For those with a PCT value in the gray zone, clinical findings may play a more important role.

CONCLUSION

The study does not support the hypothesis that the PCT test may be useful for screening ED patients for appendicitis. However, determination of the PCT level may be useful for risk assessment of ED patients with suspected complicated appendicitis.

Clinical manifestations of acute appendicitis in hemodialysis patients

PURPOSE

Acute appendicitis has been suggested to be more aggravated in hemodialysis (HD) patients in comparison to non-HD patients but only scanty evidence demonstrates the conditions.

METHODS

A retrospective cohort study was done for HD and non-HD patients with a discharge diagnosis of acute appendicitis in a single medical center.

RESULTS

Patients with acute appendicitis on HD (n = 11), and non-HD (n = 40) were enrolled. The patients in the HD group, demonstrated older age, less leukocytosis, shorter preoperative diagnostic delay, but with no improvement of perforation rate and poor prognosis such as longer hospital stay and higher morbidity rate in comparison to the non-HD group. The differences between the HD and non-HD group still existed even with an age- and gender-matched non-HD group. A higher C-reactive protein level was a helpful index in early diagnosis and predicting the possibility of perforation. Hyponatremia was an important prognostic factor associated with a longer preoperative delay, longer hospital stay and higher morbidity rate in the HD group.

CONCLUSIONS

The diagnosis of AA in HD patients was earlier than in non-HD patients. HD patients with AA had atypical presentations and a poor prognosis especially those that presented with hyponatremia and a perforated appendicitis. Higher C-reactive protein was associated with the development of perforated appendicitis in HD patients.

Clinical value of total white blood cells and neutrophil counts in patients with suspected appendicitis: retrospective study

Introduction

Acute appendicitis (AA) is common surgical problem associated with acute-phase reaction. Blood tests role in decision-making process is unclear. This retrospective study aimed to determine diagnostic value of preoperative evaluation of white blood cells (WBCs) and neutrophils and its value in predicting AA severity.

Methods

Medical records of 456 patients who underwent appendectomy during 4-years period were retrospectively reviewed. Patients were subdivided according to histological finding into: normal appendix (n = 29), uncomplicated inflamed appendix (n = 350), complicated appendicitis (n = 77). Diagnostic performances of WBCs and neutrophils were analyzed using receiver operating characteristic (ROC) curves.

Results

WBCs and neutrophils counts were higher in patients with inflamed and complicated appendix than normal appendix and in complicated than inflamed appendix. In patients, WBCs count 9.400 × 10³/mL had sensitivity of 76.81%, specificity of 65.52%, positive predictive value (PPV) of 97.0%, negative predictive value (NPV) of 16.1%, positive likelihood ratio [LR(+)] of 2.23, negative LR(−) of 0.35. Neutrophil count 7.540 × 10³/mL had sensitivity of 70.96%, specificity of 65.52%, PPV of 96.8%, NPV of 13.3%, LR(+) of 2.06, LR(−) of 0.44. Areas under ROC curve were 0.701, 0.680 for elevated WBCs and neutrophils count.

Conclusions

Clinicians should not rely on either elevated WBCs or neutrophils count as appendicitis indicator as clinical data are superior in decision-making appendectomy.

Correlation of serum C-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis of acute appendicitis is based on careful history, physical examination, laboratory and imaging investigation. The aim of the study is to analyze the role of C-reactive protein (CRP), white blood count (WBC) and Neutrophil percentage (NP) in improving the accuracy of diagnosis of acute appendicitis and to compare it with the intraoperative assessment and histopathology findings.

MATERIALS AND METHODS

This investigation was a prospective double blinded clinical study. The study was done on 173 patients surgically treated for acute appendicitis. The WBC, NP, and measurement of CRP were randomly collected pre-operatively from all involved patients. Macroscopic assessment was made from the operation. Appendectomy and a histopathology examination were performed on all patients. Gross description was compared with histopathology results and then correlated with CRP, WBC, and NP.

RESULTS

The observational accuracy was 87,3%, as compared to histopathological accuracy which was 85.5% with a total of 173 patients that were operated on. The histopathology showed 25 (14.5%) patients had normal appendices, and 148 (85.5%) patients had acutely inflamed, gangrenous, or perforated appendicitis. 52% were male and 48% were female, with the age ranging from 5 to 59 with a median of 19.7. The gangrenous type was the most frequent (52.6%). The WBC was altered in 77.5% of the cases, NP in 72.3%, and C-reactive protein in 76.9% cases. In those with positive appendicitis, the CRP and WBC values were elevated in 126 patients (72.8%), whereas NP was higher than 75% in 117 patients (67.6%). Out of 106 patients with triple positive tests, 101 (95.2%) had appendicitis. The sensitivity, specificity, and positive predictive values of the 3 tests in combination were 95.3%, 72.2%, and 95.3%, respectively.

CONCLUSION

The raised value of the CRP was directly related to the severity of inflammation (p-value <0.05). CRP monitoring enhances the diagnostic accuracy of acute appendicitis. The diagnostic accuracy of CRP is not significantly greater than WBC and NP. A combination of these three tests significantly increases the accuracy. We found that elevated serum CRP levels support the surgeon's clinical diagnosis.

Local and systemic expressions of MMP-9, TIMP-1 and PAI-1 in patients undergoing surgery for clinically suspected appendicitis

BACKGROUND/AIMS

To examine, compare and correlate the expressions of matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinase 1 (TIMP-1) and plasminogen activator inhibitor type 1 (PAI-1) in appendiceal tissue and pre- and postoperative blood samples in patients undergoing surgery for clinically suspected appendicitis.

METHODS

Fifty-seven patients with complete tissue and blood samples were included and divided into groups of noninflamed appendix/lymphadenitis (n = 7), phlegmonous appendicitis (n = 30), gangrenous appendicitis (n = 11) and perforated appendicitis (n = 9). The protein expressions were assessed with ELISAs. The local expressions of MMP-9, TIMP-1 and PAI-1 were correlated with the systemic expressions at the time of surgery while the systemic individual differences between surgery and recovery were compared.

RESULTS

There was a positive correlation between tissue and plasma PAI-1 (p < 0.05). The individual differences for plasma MMP-9 and PAI-1 were statistically nonsignificant, while they were higher for TIMP-1 in patients with perforated appendicitis compared with phlegmonous (p < 0.0001) and gangrenous appendicitis (p < 0.01).

CONCLUSIONS

Plasma PAI-1 reflected the levels in appendiceal tissue at the time of surgery. Systemic TIMP-1 could have the potential of distinguishing perforated from nonperforated appendicitis.

Factors predicting significant pathology on ultrasonography in women presenting with non-specific lower abdominal pain

INTRODUCTION

Ultrasonography is used frequently to exclude significant pathology in young women presenting with non-specific lower abdominal pain (NSLAP). This study examined parameters that predicted the likelihood of significant findings on ultrasonography. These results could be used to select patients for priority imaging or identify those who could be managed with no ultrasonography.

METHODS

A total of 65 women with NSLAP were identified from 283 admissions. Group 1 (n=42) consisted of patients with normal imaging. Group 2 (n=23) included patients with 'positive' scans requiring treatment. White cell count (WCC), C-reactive protein (CRP) levels, platelet count, age, duration of pain and length of stay in hospital were compared between the groups.

RESULTS

The median WCC and CRP were greater in Group 2 than in Group 1: 15 x 10(9)/l and 123 mg/l versus 11 x 10(9)/l and 72 mg/l respectively (p=0.01 and p=0.05). CRP was a weak predictor of positive pathology on ultrasonography (area under curve [AUC]=0.66, p=0.027) and WCC was a strong predictor of abnormal pathology on ultrasonography (AUC=0.7, p=0.005). A WCC of >12.8 x 10(9)/l was 65% sensitive and 71% specific in predicting subsequent pathology on ultrasonography. The median wait for ultrasonography was 24 hours (range: 1-96 hours).

CONCLUSIONS

This study failed to define any criteria that could select patients not requiring ultrasonography. Since ultrasonography is a relatively cheap and safe investigation, its continued use to screen women with NSLAP is justified. WCC should be used to prioritise imaging.