The role of serum inflammatory markers in acute appendicitis and their success in preventing negative laparotomy

Predictive Value of Neutrophil-to-Lymphocyte Ratio in Differentiating Perforated from Non-perforated Appendicitis: A Cross-Sectional Study in a Tertiary Care Hospital, Tamil Nadu

Introduction Acute appendicitis is a common reason for acute abdominal pain. It has a high perforation rate of 20%. Diagnosis of acute appendicitis is usually through well-known clinical signs and symptoms. Radiologic imaging is by and large carried out in peculiar cases with indistinct signs and symptoms. Although various scoring methods are available for screening and diagnosis, those have inadequate validity to accurately predict the severity of acute appendicitis. From the differential counts, the neutrophil-to-lymphocyte ratio (NLR) is an economical and straightforward measure of subclinical inflammation. NLR may be a useful marker for predicting the onset and severity of appendicitis because of the insight it gives into immunological and inflammatory pathways. In this study, we aimed to determine the association between NLR and acute appendicitis among adult patients to differentiate between perforated and non-perforated appendicitis in a tertiary care hospital in Tamil Nadu, India. Methods This was a cross-sectional study conducted in the Department of General Surgery of a deemed university in Chennai, Tamil Nadu. The study was conducted from March 2022 to December 2022. Patients aged 18 years and above undergoing appendicectomy surgery were included in the study. Patients with hematology disorders, chronic kidney disease, chronic liver disease, chronic obstructive pulmonary disease, asthma, cancer, or auto-immune diseases, and any viral, bacterial, or parasitic infections were excluded. Pregnant women were also excluded from the study. After obtaining informed consent from the patients, blood samples were collected as and when they were diagnosed as acute appendicitis. Laboratory analysis for complete hemogram including white blood cell (WBC) count, neutrophil, and lymphocyte count was carried out using an automated hematology analyzer. Prevalence of perforated appendicitis was reported as a percentage. The receiver-operating characteristic (ROC) curve was developed for NLR in differentiating perforated and non-perforated appendicitis. Data were entered in Microsoft Excel 2023. These analyses were carried out in STATA 12.0 (StataCorp, College Station, Texas, USA). Results A total of 212 patients aged 18 years and above were included in the study. Among them 93 (43.9%) were male and 119 (56.1%) were female. Prevalence of perforated appendicitis observed intra-operatively was 29.7% and non-perforated appendicitis was 70.3%. The mean (SD) of NLR among patients with perforated appendicitis was 8.8 (5.1) and non-perforated appendicitis was 3.2 (2.4) with a statistically significant difference (p-value < 0.0001). ROC curve with a cut-off value of 3.78 NLR, had sensitivity of 65.9% and specificity of 93.1% in differentiating perforated and non-perforated appendicitis. The positive predictive value (PPV) and negative predictive values (NPV) were reported as 85.7% and 81.2%, respectively. Conclusion NLR has a reasonable validity in differentiating perforated and non-perforated appendicitis. NLR may be useful in low-resource settings where routine confirmatory radiological procedures like computed tomography scans are not available.

Investigation of Serum Interleukin 6, High-Sensitivity C-Reactive Protein and White Blood Cell Levels during the Diagnosis and Treatment of Paediatric Appendicitis Patients Before and during the COVID-19 Pandemic

Introduction

In this study, we prospectively investigated changes in serum interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP) and full white blood cell (WBC) counts during the diagnosis and treatment of paediatric patients with appendicitis. We also investigated the effects of the COVID-19 pandemic on the diagnosis and treatment processes of paediatric appendicitis patients.

Materials and Methods

A non-perforated appendicitis group (n = 110), a perforated appendicitis group (n = 35) and an appendicitis + COVID-19 group (n = 8) were formed. Blood samples were taken upon admission and every day until the three studied parameters returned to normal values. To investigate the effects of the COVID-19 pandemic on paediatric appendicitis patients, the perforated appendicitis rates and the times from the onset of the first symptoms to the operation before and during the pandemic were compared.

Results

WBC, IL-6, and hsCRP dropped below the upper limits on the second postoperative day in the non-perforated appendicitis group, four to six days postoperatively in the perforated appendicitis group, and three to six days postoperatively in the appendicitis + COVID-19 group. These parameters were not within normal range in patients who developed complications during follow-up. The time from the onset of abdominal pain to the surgery was significantly longer during than before the pandemic in both the non-perforated appendicitis group and the perforated appendicitis group.

Conclusions

Our results show that WBC, IL-6, and hsCRP are useful laboratory parameters that can complete clinical examinations in the diagnosis of appendicitis in paediatric patients and the identification of complications that may develop postoperatively.

Diagnostic Algorithm Based on Machine Learning to Predict Complicated Appendicitis in Children Using CT, Laboratory, and Clinical Features

To establish a diagnostic algorithm for predicting complicated appendicitis in children based on CT and clinical features.

METHODS

This retrospective study included 315 children (<18 years old) who were diagnosed with acute appendicitis and underwent appendectomy between January 2014 and December 2018. A decision tree algorithm was used to identify important features associated with the condition and to develop a diagnostic algorithm for predicting complicated appendicitis, including CT and clinical findings in the development cohort (n = 198). Complicated appendicitis was defined as gangrenous or perforated appendicitis. The diagnostic algorithm was validated using a temporal cohort (n = 117). The sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) from the receiver operating characteristic curve analysis were calculated to evaluate the diagnostic performance of the algorithm.

RESULTS

All patients with periappendiceal abscesses, periappendiceal inflammatory masses, and free air on CT were diagnosed with complicated appendicitis. In addition, intraluminal air, transverse diameter of the appendix, and ascites were identified as important CT findings for predicting complicated appendicitis. C-reactive protein (CRP) level, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and body temperature also showed important associations with complicated appendicitis. The AUC, sensitivity, and specificity of the diagnostic algorithm comprising features were 0.91 (95% CI, 0.86-0.95), 91.8% (84.5-96.4), and 90.0% (82.4-95.1) in the development cohort, and 0.7 (0.63-0.84), 85.9% (75.0-93.4), and 58.5% (44.1-71.9) in test cohort, respectively.

CONCLUSION

We propose a diagnostic algorithm based on a decision tree model using CT and clinical findings. This algorithm can be used to differentiate between complicated and noncomplicated appendicitis and to provide an appropriate treatment plan for children with acute appendicitis.

Metabolomics and Inflammatory Mediator Profiling for the Differentiation of Life-Threatening and Non-Severe Appendicitis in the Pediatric Population

While children with appendicitis often have excellent clinical outcomes, some develop life-threatening complications including sepsis and organ dysfunction requiring pediatric intensive care unit (PICU) support. Our study applied a metabolomics and inflammatory protein mediator (IPM) profiling approach to determine the bio-profiles of children who developed severe appendicitis compared with those that did not. We performed a prospective case-control study of children aged 0-17 years with a diagnosis of appendicitis. Cases had severe disease resulting in PICU admission. Primary controls had moderate appendicitis (perforation without PICU); secondary controls had mild appendicitis (non-perforated). Serum samples were analyzed using Proton Nuclear Magnetic Resonance (¹H NMR) Spectroscopy and Gas Chromatography-Mass Spectrometry (GC-MS); IPM analysis was performed using plasma bead-based multiplex profiling. Comparisons were made using multivariate data statistical analysis. Fifty-three children were included (15 severe, 38 non-severe). Separation between severe and moderate appendicitis demonstrated excellent sensitivity and specificity (100%, 88%; 14 compounds), separation between severe and mild appendicitis also showed excellent sensitivity and specificity (91%, 90%; 16 compounds). Biomarker patterns derived from metabolomics and IPM profiling are capable of distinguishing children with severe appendicitis from those with less severe disease. These findings provide an important first step towards developing non-invasive diagnostic tools for clinicians in early identification of children who are at a high risk of developing severe appendicitis.

An observational study of innate immune responses in patients with acute appendicitis

Acute appendicitis is a common surgical emergency worldwide. Exaggerated immune responses could be associated with appendicitis. This study aimed at characterizing immune responses towards a large variety of gut commensals and pathogens, and pattern recognition receptor (PRR) ligands, and investigating the course of systemic inflammation in a prospective cohort of acute appendicitis patients. PBMC responses of 23 patients of the cohort and 23 healthy controls were characterized more than 8 months post-surgery. Serum cytokine levels were measured in 23 patients at the time of appendicitis and after one month. CRP, WBC and percentage of neutrophils were analyzed in the total cohort of 325 patients. No differences in PBMC responses were found between patients and controls. Stronger IL-10 responses were found following complicated appendicitis. A trend towards lower IL-8 responses was shown following gangrenous appendicitis. Serum IL-10 and IL-6 were significantly elevated at presentation, and IL-6, IL-8 and TNF-α levels were higher in complicated appendicitis. Routine biomarkers could predict severity of appendicitis with high specificities, but low sensitivities. Cytokine responses in patients following acute appendicitis did not differ from healthy controls. Higher serum cytokine levels were found in acute complicated and gangrenous cases. Further research into discriminative biomarkers is warranted.

Diagnostic Value of Serum Urokinase-Type Plasminogen Activator Receptor in Children With Acute Appendicitis

OBJECTIVES

Acute appendicitis (AA) is the most common surgical emergency in children. The accurate and timely diagnosis of AA in children can be challenging, and delayed diagnosis rates have been reported to range from 5.9% to 27.6%. Although combining clinical history and repeated physical examination with laboratory tests and radiographic imaging modalities help reach the diagnosis, novel biomarkers can support the surgeons' decision as well. The aims of this study were to evaluate a new plasma marker, urokinase-type plasminogen activator receptor (uPAR), to improve diagnostic accuracy in AA patients, and to determine a cutoff value of uPAR, which can safely include/exclude the diagnosis of AA.

METHODS

We conducted a prospective study of children who underwent surgery for AA. Patients were categorized into the following 3 groups: group 1, controls consisted of 32 healthy volunteers; group 2, patients underwent surgery for nonperforated AA (n = 35); and group 3, patients underwent surgery for perforated AA (n = 21). Blood was sampled from group 1 at the admission and from group 2 and 3 before appendectomy. Serum uPAR, white blood cell count, absolute neutrophil count (ANC), and C-reactive protein concentrations were measured.

RESULTS

Urokinase-type plasminogen activator receptor, ANC, and white blood cell count values were significantly higher in group 2 and 3 than group 1, but there was no significant difference between group 2 and 3. C-reactive protein values were significantly higher only in group 3 than other groups. The cutoff value for uPAR is 2.2 ng/mL with sensitivity of 85.7% and specificity of 84.3% and ANC is 5900 cells/mm with sensitivity of 91.1% and specificity of 96.9% to diagnose appendicitis. The specificity was 81.3% and sensitivity was raised to 98.2% when evaluated together.

CONCLUSIONS

The incorporation of uPAR count and ANC could be a strong predictor of AA in children.

Possible cytokine biomarkers in pediatric acute appendicitis

BACKGROUND

Diagnosis of acute appendicitis (AA) and decisions about its treatment remain among the most common dilemmas of pediatric surgical teams. Monitoring of immune response may be of importance for this purpose. Our aim was to measure and analyze serum and peritoneal fluid cytokines, in children who had undergone surgery for suspected AA.

METHODS

Prospective investigation of serum and peritoneal fluid cytokine values was performed in 127 consecutive patients. According to the pathohistological findings, patients were divided into three groups: normal/early, uncomplicated and complicated AA. Determination of cytokine concentrations for 20 different cytokines was done using a commercial flow cytometry kit: Human Inflammation 20 plex BMS 819.

RESULTS

Statistically significant differences in serum cytokine values between pathohistological groups were found for IP-10, MIP-1α and IL-10. Preoperative cut-off values of IP-10, MIP-1α and IL-10 between groups were obtained using ROC curve analysis. Positive correlations between serum and peritoneal concentrations were recorded for most of the analyzed cytokines.

CONCLUSION

IP-10, MIP-1α and IL-10 showed potential in assessment of AA in children. Confirmatory studies with a larger number of patients are required to prove reliability of these biomarkers.

Cytokines and Chemokines in Pediatric Appendicitis: A Multiplex Analysis of Inflammatory Protein Mediators

OBJECTIVES

We aimed to demonstrate the potential of precision medicine to describe the inflammatory landscape present in children with suspected appendicitis. Our primary objective was to determine levels of seven inflammatory protein mediators previously associated with intra-abdominal inflammation (C-reactive protein-CRP, procalcitonin-PCT, interleukin-6 (IL), IL-8, IL-10, monocyte chemoattractant protein-1-MCP-1, and serum amyloid A-SAA) in a cohort of children with suspected appendicitis. Subsequently, using a multiplex proteomics approach, we examined an expansive array of novel candidate cytokine and chemokines within this population.

METHODS

We performed a secondary analysis of targeted proteomics data from Alberta Sepsis Network studies. Plasma mediator levels, analyzed by Luminex multiplex assays, were evaluated in children aged 5-17 years with nonappendicitis abdominal pain (NAAP), acute appendicitis (AA), and nonappendicitis sepsis (NAS). We used multivariate regression analysis to evaluate the seven target proteins, followed by decision tree and heat mapping analyses for all proteins evaluated.

RESULTS

185 children were included: 83 with NAAP, 79 AA, and 23 NAS. Plasma levels of IL-6, CRP, MCP-1, PCT, and SAA were significantly different in children with AA compared to those with NAAP (p < 0.001). Expansive proteomic analysis demonstrated 6 patterns in inflammatory mediator profiles based on severity of illness. A decision tree incorporating the proteins CRP, ferritin, SAA, regulated on activation normal T-cell expressed and secreted (RANTES), monokine induced by gamma interferon (MIG), and PCT demonstrated excellent specificity (0.920) and negative predictive value (0.882) for children with appendicitis.

CONCLUSIONS

Multiplex proteomic analyses described the inflammatory landscape of children presenting to the ED with suspected appendicitis. We have demonstrated the feasibility of this approach to identify potential novel candidate cytokines/chemokine patterns associated with a specific illness (appendicitis) amongst those with a broad ED presentation (abdominal pain). This approach can be modelled for future research initiatives in pediatric emergency medicine.

The Use of Metabolomics and Inflammatory Mediator Profiling Provides a Novel Approach to Identifying Pediatric Appendicitis in the Emergency Department

Multiplexed profiling approaches including various ‘omics’ platforms are becoming a new standard of biomarker development for disease diagnosis and prognosis. The present study applied an integrated metabolomics and cytokine profiling approach as a potential aid to the identification of pediatric appendicitis. Metabolic analysis using serum (n = 121) and urine (n = 102) samples, and cytokine analysis using plasma (n = 121) samples from children presenting to the Emergency Department with abdominal pain were performed. Comparisons between children with appendicitis vs. non-appendicitis abdominal pain, and with perforated vs. non-perforated appendicitis were made using multivariate statistics. Serum and urine biomarker patterns were statistically significantly different between groups. The combined serum metabolomics and inflammatory mediator model revealed clear separation between appendicitis and non-appendicitis abdominal pain (AUROC: 0.92 ± 0.03) as well as for perforated and non-perforated appendicitis (AUROC: 0.88 ± 0.05). Urine metabolic analysis also demonstrated distinction between the groups appendicitis and non-appendicitis abdominal pain (AUROC: 0.85 ± 0.04), and perforated and non-perforated appendicitis (AUROC: 0.98 ± 0.02). In children presenting to the Emergency Department with abdominal pain, metabolomics and inflammatory mediator profiling are capable of distinguishing children with appendicitis from those without. The approach also differentiates between severities of disease. These results provide an important first step towards a potential aid for improving appendicitis identification.

How to diagnose an acutely inflamed appendix; a systematic review of the latest evidence

Acute appendicitis is the most common condition that presents with an acute abdomen needing emergency surgery. Despite this common presentation, correctly diagnosing appendicitis remains a challenge as clinical signs or positive blood results can be absent in 55% of the patients. The reported proportion of missed diagnoses of appendicitis ranges between 20% and 40%. A delay or mis-diagnosis of appendicitis can result in severe complications such as perforation, abscess formation, sepsis, and intra-abdominal adhesions. Literature has shown that patients who had a negative appendectomy suffer post-op complications and infections secondary to hospital stays; there have even been reported cases of fatality. It is therefore crucial that timely and accurate diagnosis of appendicitis is achieved to avoid complications of both non-operating as well as unnecessary surgical intervention. The aim of this review is to systematically report and analyse the latest evidence on the different approaches used in diagnosing appendicitis. We include discussions of clinical scoring systems, laboratory tests, latest innovative bio-markers and radiological imaging.

Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis

Background

Acute appendicitis is the most common surgical emergency and can represent a challenging diagnosis, with a negative appendectomy rate as high as 20 %. This review aimed to evaluate the clinical utility of individual biomarkers in the diagnosis of appendicitis and appraise the quality of these studies.

Methods

A systematic review of the literature between January 2000 and September 2015 using of PubMed, OvidMedline, EMBASE and Google Scholar was conducted. Studies in which the diagnostic accuracy, statistical heterogeneity and predictive ability for severity of several biomarkers could be elicited were included. Information regarding costs and process times was retrieved from the regional laboratory. European surgeons blinded to these reviews were independently asked to rank which characteristics of biomarkers were most important in acute appendicitis to inform a cost–benefit trade-off. Sensitivity testing and the QUADAS-2 tool were used to assess the robustness of the analysis and study quality, respectively.

Results

Sixty-two studies met the inclusion criteria and were assessed. Traditional biomarkers (such as white cell count) were found to have a moderate diagnostic accuracy (0.75) but lower costs in the diagnosis of acute appendicitis. Conversely, novel markers (pro-calcitonin, IL 6 and urinary 5-HIAA) were found to have high process-related costs including analytical times, but improved diagnostic accuracy. QUADAS-2 analysis revealed significant potential biases in the literature.

Conclusion

When assessing biomarkers, an appreciation of the trade-offs between the costs and benefits of individual biomarkers is needed. Further studies should seek to investigate new biomarkers and address concerns over bias, in order to improve the diagnosis of acute appendicitis.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-016-5109-1) contains supplementary material, which is available to authorized users.

Evaluation of mediators of oxidative stress and inflammation in patients with acute appendicitis

CONTEXT

This study aims to explore the potential of new inflammatory markers for improving the challenging diagnosis of acute appendicitis (AA).

METHODS

Levels of IL-1, IL-6, IL-8, IL-10, CRP, INF-γ, and TNF-α in serum were measured in 73 patients with AA. Oxidative stress and antioxidant enzymes were analyzed.

RESULTS

Serum levels of interleukins, TNF-α, and INF-γ were significantly elevated in patients with appendicitis (p < 0.0001), except for IL-10, which presented decreased levels. There were no significant differences in SOD (p = 0.29), CAT (p = 0.19), or TBARS levels (p = 0.18), whereas protein carbonyls presented significant increase (p < 0.0001).

CONCLUSION

Evaluating these biomarkers could aid in diagnosing AA.

Predicting Postoperative Complications After Pediatric Perforated Appendicitis

PURPOSE

Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA.

MATERIAL AND METHODS

The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions.

RESULTS

Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001).

CONCLUSIONS

Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.

Etiology of Appendicitis in Children: The Role of Bacterial and Viral Pathogens

BACKGROUND

Although acute appendicitis is the most common cause for abdominal surgery in children, its etiology is still largely unknown. The aim of this study was to evaluate the role of bacterial and viral pathogens for the etiology of appendicitis in children.

METHODS

Between 2000 and 2010, 277 children underwent appendectomy in our institution. On this collective, a retrospective study was performed on to identify the presence of bacterial or viral pathogens.

RESULTS

Intraoperatively, 39% of cases showed acute, 9% of cases chronic, and 41% of cases ulcerous inflammation. Bowel perforation was found in 7% of cases and four percent of the children had no inflammation of the appendix at all. Escherichia coli was the predominant bacterium with an incidence of 27.4%, followed by streptococci (9.8%). Concerning viral pathogens, adenovirus was the most common with an incidence of 5.4% followed by rotavirus (4.7%). Significant correlations between histopathological findings and present pathogens were found: in cases of bowel perforation there were significantly more infections with E. coli bacteria (32.2%, p < .001), streptococci (12.2%, p < 0.001), and Pseudomonas aeruginosa (6.7%, p < .001) whereas chronic inflammations were accompanied with a significantly elevated rate of yersinia infections (2.5%, p = .016). Acute inflammations were significantly more often associated with campylobacter (1.7%, p = .011) and oxyures infections (6.1%, p < .001). In relation to the patients' age, a significant accumulation of different pathogens was observed. CRP- and leukocyte counts showed differences between viral and bacterial inflammations.

CONCLUSIONS

Our data indicates that appendicitis in children might be triggered by bacterial and viral pathogens and that the type of pathogen directly correlates with patient age, type of inflammation, and level of inflammation values. To confirm and further evaluate these findings, additional studies need to be conducted.

Can new inflammatory markers improve the diagnosis of acute appendicitis?

BACKGROUND

The diagnosis of appendicitis is difficult and resource consuming. New inflammatory markers have been proposed for the diagnosis of appendicitis, but their utility in combination with traditional diagnostic variables has not been tested. Our objective is to explore the potential of new inflammatory markers for improving the diagnosis of appendicitis.

METHODS

The diagnostic properties of the six most promising out of 21 new inflammatory markers (interleukin [IL]-6, chemokine ligand [CXCL]-8, chemokine C-C motif ligand [CCL]-2, serum amyloid A [SAA], matrix metalloproteinase [MMP]-9, and myeloperoxidase [MPO]) were compared with traditional diagnostic variables included in the Appendicitis Inflammatory Response (AIR) score (right iliac fossa pain, vomiting, rebound tenderness, guarding, white blood cell [WBC] count, proportion neutrophils, C-reactive protein and body temperature) in 432 patients with suspected appendicitis by uni- and multivariable regression models.

RESULTS

Of the new inflammatory variables, SAA, MPO, and MMP9 were the strongest discriminators for all appendicitis (receiver operating characteristics [ROC] 0.71) and SAA was the strongest discriminator for advanced appendicitis (ROC 0.80) compared with defence or rebound tenderness, which were the strongest traditional discriminators for all appendicitis (ROC 0.84) and the WBC count for advanced appendicitis (ROC 0.89). CCL2 was the strongest independent discriminator beside the AIR score variables in a multivariable model. The AIR score had an ROC area of 0.91 and could correctly classify 58.3 % of the patients, with an accuracy of 92.9 %. This was not improved by inclusion of the new inflammatory markers.

CONCLUSION

The conventional diagnostic variables for appendicitis, as combined in the AIR score, is an efficient screening instrument for classifying patients as low-, indeterminate-, or high-risk for appendicitis. The addition of the new inflammatory variables did not improve diagnostic performance further.

Correlation between the serum and tissue levels of oxidative stress markers and the extent of inflammation in acute appendicitis

OBJECTIVES

To determine the serum and tissue levels of markers of impaired oxidative metabolism and correlate these levels with the histopathology and Alvarado score of acute appendicitis patients.

METHOD

Sixty-five acute appendicitis patients (mean age, 31.4±12.06 years; male/female, 30/35) and 30 healthy control subjects were studied. The Alvarado score was recorded. Serum samples were obtained before surgery and 12 hours postoperatively to examine the total antioxidant status, total oxidant status, paraoxonase, stimulated paraoxonase, arylesterase, catalase, myeloperoxidase, ceruloplasmin, oxidative stress markers (advanced oxidized protein products and total thiol level) and ischemia-modified albumin. Surgical specimens were also evaluated.

RESULTS

The diagnoses were acute appendicitis (n = 37), perforated appendicitis (n = 8), phlegmonous appendicitis (n = 12), perforated+phlegmonous appendicitis (n = 4), or no appendicitis (n = 4). The Alvarado score of the acute appendicitis group was significantly lower than that of the perforated+phlegmonous appendicitis group (p = 0.004). The serum total antioxidant status, total thiol level, advanced oxidized protein products, total oxidant status, catalase, arylesterase, and ischemia-modified albumin levels were significantly different between the acute appendicitis and control groups. There was no correlation between the pathological extent of acute appendicitis and the tissue levels of the markers; additionally, there was no correlation between the tissue and serum levels of any of the parameters.

CONCLUSIONS

The imbalance of oxidant/antioxidant systems plays a role in the pathogenesis acute appendicitis. The Alvarado score can successfully predict the presence and extent of acute appendicitis.

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.

An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis

BACKGROUND

Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions.

OBJECTIVE

The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis.

MATERIAL AND METHODS

The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used.

RESULTS

AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively).

CONCLUSIONS

1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.

An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis

BACKGROUND

Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions.

OBJECTIVE

The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis.

MATERIAL AND METHODS

The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used.

RESULTS

AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively).

CONCLUSIONS

1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.

C-Reactive protein is an independent surgical indication marker for appendicitis: a retrospective study

Background

This study is an attempt to clarify the role of C-reactive protein (CRP) as a surgical indication marker for appendicitis.

Methods

One hundred and fifty patients who underwent appendectomies and had pathologically confirmed appendicitis were reviewed between May 1, 1999 and September 31, 2007. The correlation between preoperative clinical factors and the actual histological severity, and identify surgical indication markers were assessed by univariate and multivariate analyses.

Results

Univariate analysis showed that only the CRP level significantly differ between the surgical treatment necessary group (gangrenous appendicitis) and the possible non-surgical treatment group (catarrhalis and phlegmonous appendicitis). Multivariate analysis indicated only the CRP level to be a surgical indication marker for acute appendicitis. The receiver-operating characteristic (ROC) curve indicated that the cutoff value of CRP for surgical indication of appendicitis is 4.95 mg/dl.

Conclusion

Only the CRP level is consistent with the severity of appendicitis, and considered to be a surgical indication marker for acute appendicitis.