Diagnostic value of hyperfibrinogenemia as a predictive factor for appendiceal perforation in acute appendicitis

The Role of Vascular Cell Adhesion Molecule-1 (VCAM-1) in Predicting Complicated Appendicitis in Children

BACKGROUND

Acute appendicitis is a common abdominal emergency observed in emergency departments (ED). Distinguishing between uncomplicated and complicated appendicitis is important in determining a treatment strategy. Serum soluble vascular cell adhesion molecule-1 (VCAM-1) is an inflammatory biomarker. We aimed to determine the role of VCAM-1 in predicting complicated appendicitis in children.

METHODS

Pediatric patients with suspected appendicitis admitted to the ED were enrolled in this prospective study. Pre-surgical serum VCAM-1 was tested in children with acute appendicitis within 72 h of symptoms (from day 1 to day 3). Serum VCAM-1 levels were further analyzed and compared between patients with and without complicated appendicitis.

RESULTS

Among the 226 pediatric appendicitis patients, 70 had uncomplicated appendicitis, 138 had complicated appendicitis, and 18 had normal appendices. The mean serum VCAM-1 levels in patients with perforated appendicitis were higher than in those with simple appendicitis (p < 0.001). On day 1 to day 3, the mean VCAM-1 levels in patients with complicated appendicitis were all significantly higher than in those with uncomplicated appendicitis (all p < 0.001).

CONCLUSION

Serum VCAM-1 levels may be helpful in differentiating uncomplicated and complicated appendicitis in children and could predict appendiceal perforation.

Predicting complicated appendicitis is possible without the use of sectional imaging-presenting the NoCtApp score

PURPOSE

Appendicitis is among the most common acute conditions treated by general surgery. While uncomplicated appendicitis (UA) can be treated delayed or even non-operatively, complicated appendicitis (CA) is a serious condition with possible long-term morbidity that should be managed with urgent appendectomy. Distinguishing both conditions is usually done with computed tomography. The goal of this study was to develop a model to reliably predict CA with widespread available clinical and laboratory parameters and without the use of sectional imaging.

METHODS

Data from 1132 consecutive patients treated for appendicitis between 2014 and 2021 at a tertiary care hospital were used for analyses. Based on year of treatment, the data was divided into training (n = 696) and validation (n = 436) samples. Using the development sample, candidate predictors for CA-patient age, gender, body mass index (BMI), American Society of Anesthesiologist (ASA) score, duration of symptoms, white blood count (WBC), total bilirubin and C-reactive protein (CRP) on admission and free fluid on ultrasound-were first investigated using univariate logistic regression models and then included in a multivariate model. The final development model was tested on the validation sample.

RESULTS

In the univariate analysis age, BMI, ASA score, symptom duration, WBC, bilirubin, CRP, and free fluid each were statistically significant predictors of CA (each p < 0.001) while gender was not (p = 0.199). In the multivariate analysis BMI and bilirubin were not predictive and therefore not included in the final development model which was built from 696 patients. The final development model was significant (x2 = 304.075, p < 0.001) with a sensitivity of 61.7% and a specificity of 92.1%. The positive predictive value (PPV) was 80.4% with a negative predictive value (NPV) of 82.0%. The receiver operator characteristic of the final model had an area under the curve of 0.861 (95% confidence interval 0.830-0.891, p < 0.001. We simplified this model to create the NoCtApp score. Patients with a point value of ≤ 2 had a NPV 95.8% for correctly ruling out CA.

CONCLUSIONS

Correctly identifying CA is helpful for optimizing patient treatment when they are diagnosed with appendicitis. Our logistic regression model can aid in correctly distinguishing UA and CA even without utilizing computed tomography.

Hyperfibrinogenemia and hyponatremia as predictors of perforated appendicitis in children: A retrospective cohort study

PURPOSE

The aim of this study was to investigate the predictive value of hyperfibrinogenemia and hyponatremia for perforated appendicitis in children.

METHODS

A retrospective review of 521 pediatric patients (≤ 15 years) with acute appendicitis confirmed by histopathology from January 2017 to December 2020 was performed. Patients were divided in two groups, those with non-perforated (n = 379; 73%) and perforated appendicitis (n = 142; 27%). The serum values of sodium and fibrinogen were taken before surgery. We performed the receiver operating characteristic analysis for the two biochemical markers. The sensitivity, specificity, positive and negative predictive values for perforated appendicitis in the presence of hyponatremia and hyperfibrinogenemia were calculated.

RESULTS

Hyperfibrinogenemia (≥ 4.0 g/L) was found in 58.45% of perforated appendicitis and 104 of 142 (73.34%) children with perforated appendicitis had hyponatremia (≤ 135 mmol/L). The perforated appendicitis group had a higher mean fibrinogen concentration (P = 0.001). There was a statistically significant difference in mean serum sodium levels between the perforated appendicitis and non-perforated appendicitis groups (P = 0.016). Receiver operating characteristic curve analysis for fibrinogen, sodium and combination of the both markers shown the combination had the largest area under the curve in identifying children with perforated acute appendicitis (0.858) (95% CI, 0.82-0.90) compared with fibrinogen (0.815) (95% CI, 0.77-0.86) and sodium 0.818 (95% CI, 0.78-0.86) alone. Furthermore, the combination of both markers had the best positive and negative predictive value for appendix perforation compared to fibrinogen and sodium.

CONCLUSION

Hyponatremia and/or hyperfibrinogenemia are excellent markers for predicting perforated appendicitis in children. We propose that plasma sodium and/or fibrinogen concentrations be utilized as a supplementary to guide individual treatment decisions in children with appendicitis, such as surgery timing and nonoperative management options.

Fibrinogen as a Marker of Overall and Complicated Acute Appendicitis: A Systematic Review and Meta-Analysis

INTRODUCTION

We performed a systematic review and meta-analysis to evaluate the diagnostic value of fibrinogen (FB) for acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.

METHODS

A search of electronic information sources was conducted to identify all studies reporting FB in patients with clinical suspicion or confirmed diagnosis of acute appendicitis. We considered two comparisons: (1) appendicitis versus no appendicitis and (2) uncomplicated appendicitis versus complicated appendicitis. To assess the diagnostic value of FB, sensitivity, specificity, diagnostic odds ratios, summary receiver operating characteristic curves, area under the curve, and 95% confidence intervals (95% CIs) were estimated.

RESULTS

Seven studies (917 confirmed appendicitis and 1026 controls) for overall appendicitis and eight studies (602 complicated appendicitis and 1386 uncomplicated appendicitis) for complicated appendicitis were identified. The pooled sensitivity and specificity of FB for the diagnosis of appendicitis were 0.62 (95% CI: 0.58-0.65) and 0.79 (95% CI: 0.77-0.82), respectively. FB was more accurate in diagnosing complicated appendicitis, with a pooled sensitivity of 0.74 (95% CI: 0.69-0.78), specificity of 0.76 (95% CI: 0.73-0.78), and the area under the curve was 0.84.

CONCLUSIONS

As per this meta-analysis, FB has a potential diagnostic value in overall appendicitis and that it has a higher diagnostic value in the diagnosis of complicated appendicitis. Future well-designed prospective studies are needed to corroborate the findings.

Evaluation of plasma level of fibrinogen as a diagnostic criterion in acute appendicitis; cohort study

Background

Acute appendicitis (AA) is the most common etiology of abdominal operation worldwide. Despite advances in diagnostic guidelines there are still missed patients. This study evaluates assumption of plasma fibrinogen as a diagnostic criterion in AA.

Method

All patients over 12 years who were referred to emergency department and underwent index open appendectomy were enrolled in this cohort study. Histopathologically confirmed positive reports for presence of AA were allocated in a group. Controls experienced open appendectomy although pathological study was negative for AA. In addition to registering demographic data, plasma sample was examined for fibrinogen, quantitative C-reactive protein (CRP), and complete blood count preoperatively. Variables were compared. The ROC curve was customized and correlation coefficient for study markers was measured.

Results

Total 168 patients were enrolled. From all, 96 (57.1%) had confirmed AA, histopathologically. Gender, age, race, and body mass index had no difference between study groups (p > 0.05). In almost all patients increasing in white cell counts and left cellular shift was observed (p > 0.05). However, plasma level of fibrinogen and CRP reached to 389.2 ± 229.99 mg/dL (p = 0.001) and 33.06 ± 16.29 mg/L (p = 0.03) respectively, which both were significantly elevated in positive AA. Analysis showed area under the curve of serum fibrinogen was 0.892 (p < 0.001) with a cut-off point of 272 mg/dL had about 66.7% (95% CI:58.2–73.3) sensitivity, 92.8% (95% CI: 89.5–96.1) specificity, and 0.698 (p = 0.04) correlation coefficient for diagnosis of AA.

Conclusion

Amounts of elevated serum fibrinogen could imply on the diagnosis of AA specifically when concordance of clinical findings except for increasing CRP is unremarkable.

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Despite advances in diagnostic guides for acute appendicitis (AA), discordance between clinical and laboratory findings leads to doubtful diagnosis.

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Plasma fibrinogen elevates concurrently with C-reactive protein (CRP) in AA while has further specificity.

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Measurement of serum fibrinogen could when CRP is elevated and diagnosis of AA is in doubt.

The Diagnostic Value of Coagulation Indicators and Inflammatory Markers in Distinguishing Between Strangulated and Simple Intestinal Obstruction

BACKGROUND

Intestinal obstruction with strangulation can be life-threating, and it is critical to make an accurate and timely diagnosis for emergency surgery.

OBJECTIVE

This was aimed to investigate the value of coagulation indicators and inflammatory markers in distinguishing between strangulated and simple intestinal obstruction.

MATERIALS AND METHODS

Fifty-four patients with intestinal obstruction were retrospectively studied. The correlation between coagulation indicators and inflammatory markers with intestinal obstruction was analyzed. Receiver operating characteristic curves were created to assess their ability in discriminative diagnosis.

RESULTS

Levels of fibrinogen (Fib), C-reactive protein (CRP), neutrophil ratio, and D-Dimer were significantly greater, while thrombin time was significantly shorter in strangulated intestinal obstruction compared with simple intestinal obstruction. Furthermore, Fib levels in the necrosis subgroup of strangulated intestinal obstruction were significantly higher than those in the ischemia subgroup and simple intestinal obstruction group. The areas under the receiver operating characteristic curve were 0.58 for white blood cells, 0.78 for CRP, and 0.80 for Fib. Using the optimal cutoff values of Fib (3.71 g/L) and CRP (14.54 mg/L), the sensitivity, specificity, positive predictive value, and negative predictive value in discriminating between strangulated intestinal obstruction and simple intestinal obstruction were 51.43%, 100%, 100%, and 52.78% for Fib, and 56.25%, 94.44%, 94.74%, and 54.84% for CRP, respectively.

CONCLUSIONS

Fib and CRP demonstrate good performance in predicting strangulation and are indicative of intestinal necrosis and ischemia. The combination of this coagulation indicator and inflammatory marker holds potential for better discrimination between strangulated and simple intestinal obstruction.

Plasma Fibrinogen: An Independent Predictor of Pediatric Appendicitis

Aims

Appendicitis, in spite of all the diagnostic advances, achieving an accurate and timely diagnosis of this common condition in children remains a challenge. Plasma fibrinogen (FB) is an acute inflammatory mediator and has been proposed and evaluated as an adjunct laboratory marker for improving diagnostic accuracy. The study evaluates the plasma values of Se FB along with other serum markers in pediatric appendicitis patients, to determine their diagnostic accuracy.

Methods

Prospective observational study on 120 patients between the age group of 5 and 12 years. All eligible enrolled cases underwent total leukocyte count (TLC), plasma FB, C reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), absolute neutrophil count (ANC), and erythrocyte sedimentation rate on admission along with pediatric appendicitis score. Final confirmation of diagnosis and allotment of cohort was made by intra operative findings and histopathological confirmation. Two groups were defined: (1) Histopathologically confirmed acute appendicitis-Cases (2) Nonspecific abdominal pain-Controls. Laboratory results were statistically analyzed between the case and the control groups for diagnostic accuracy.

Results

Study reflected strong statistical significance in terms of leukocyte count, ANC, NLR, CRP, and FB levels. However, plasma FB (value above 4.02 g/L) had the highest diagnostic accuracy rate of 82.50% compared to other laboratory values (TLC-70.83%, CRP-70.00%).

Conclusion

Plasma FB has emerged as an accurate diagnostic tool and its diagnostic accuracy is superior to all other laboratory parameter studied (TLC, CRP, NLR, and ANC). Plasma FB values above 4.02 g/L is an independent predictor of appendicitis and can help in reducing negative laparotomy in pediatric age group.

Haemostatic indexes for predicting intestinal necrosis in children with intussusception

BACKGROUND

To determine risk factors for intestinal necrosis in intussusception cases among children with failed non-surgical reduction for intussusception.

METHODS

Totally, 540 hospitalized individuals with unsuccessful air-enema reduction in our hospital between November 2010 and November 2020 were assessed in this retrospective study. The 540 intussusception cases were divided into the intestinal necrosis and non-intestinal necrosis groups. Haemostatic parameters, demographic and clinical features were assessed. Predictors of intestinal necrosis were examined by univariable and multivariable logistic regression analyses.

RESULTS

Of the 540 patients included, 113 showed intestinal necrosis. This intestinal necrosis group had a longer duration of symptom or length of illness, younger ages, higher platelet counts, fibrinogen amounts and d-dimer levels (all P = 0.000) compared with the non-intestinal necrosis group. Multivariable analysis revealed that duration of symptom (odds ratio (OR) 1.12; 95% confidence interval (CI) 1.16-1.23, P = 0.000), fibrinogen (OR 1.26; 95% CI 1.10-1.31, P = 0.010) and d-dimer (OR 2.07; 95% CI 1.91-2.28, P = 0.000) independently predicted intestinal necrosis in individuals undergoing surgical reduction for intussusception. Receiver operating characteristic curve analysis showed that d-dimer amounts had the largest area under the curve for predicting intestinal necrosis.

CONCLUSION

On admission, long duration of symptom, high fibrinogen and d-dimer levels are critical risk factors for intestinal necrosis development in children with unsuccessful non-surgical reduction. d-Dimer levels have the best predictive value for intestinal necrosis.

Prognostic significance of preoperative plasma fibrinogen levels in primary gastrointestinal stromal tumours: a retrospective cohort study

BACKGROUND

Improved prediction of prognosis for gastrointestinal stromal tumours (GISTs) has become increasingly important since the introduction of targeted therapy. Here, we aimed to evaluate the prognostic significance of preoperative plasma fibrinogen (Fib) levels in patients with primary GISTs and to analyse their correlations with clinicopathological characteristics.

METHODS

A total of 201 previously untreated patients with primary GISTs who had undergone radical surgery at our institution between October 2004 and July 2018 were enrolled. The optimal cut-off value for Fib levels was calculated using time-dependent receiver-operating characteristic curve analysis. RFS, the primary endpoint, was calculated by the Kaplan-Meier method and compared by the log-rank test. Univariate and multivariate Cox regression models were calculated.

RESULTS

High preoperative plasma Fib levels were detected as an independent adverse prognostic factor (p = 0.008, hazard ratio 3.136, 95% CI 1.356‒7.256). Furthermore, high preoperative plasma Fib levels also indicated a poor prognosis within the modified National Institutes of Health (mNIH) high-risk subgroup (p = 0.041). In addition, preoperative plasma Fib levels showed a positive correlation with several prognostic factors and even a linear relationship with tumour size (Spearman correlation coefficient [r] = 0.411, p < 0.001).

CONCLUSIONS

Our results suggest that high preoperative plasma Fib levels may indicate a poor prognosis in patients with primary GISTs. As a cost-effective biomarker, preoperative assessment of plasma Fib levels may help to further risk stratify patients with mNIH high-risk GISTs and instruct the application of targeted therapy.

The Role of Serum Fibrinogen Level in the Diagnosis of Acute Appendicitis

INTRODUCTION

Acute appendicitis is the most common indication for emergent surgery and affects a wide range of patients at any age group. However, inspite of the presence of various imaging modalities, biochemical markers, and scoring systems the negative appendectomy rate remain high. Serum fibrinogen, an acute inflammatory mediator is usually raised in any acute inflammatory condition and the same is expected to rise in acute appendicitis, which may be used as a new inflammatory marker in the diagnosis and more importantly in decision making of management of acute appendicitis.

AIM

To determine the relationship between the rise in the level of serum fibrinogen and acute appendicitis and its role in reducing the negative appendectomy rate.

MATERIALS AND METHODS

A total of 82 patients with clinical signs and symptoms of acute appendicitis who underwent emergency appendectomy were included in the study, the serum fibrinogen level were measured just before the operation and the sensitivity and the specificity was calculated. The final diagnosis was based on the histopathological examination.

RESULTS

In our study, the Mean±SD of serum fibrinogen in mg/dl in those patient proved to be having acute appendicitis by histopathology was 436.6±40.6 while those with normal appendix was 391.91±66.54. The area under the curve was 0.697 i.e., it has an accuracy of around 70% and this is statistically significant (p=0.018). On further sub-analysis when the cut off level of fibrinogen level was reduced to 397, it resulted in a sensitivity of 82% and specificity of 60% and if the level was further reduced to 375 it increased the sensitivity to 88% with a specificity of 55%.

CONCLUSION

In the diagnosis of acute appendicitis, use of fibrinogen blood level may be a new diagnostic acute-phase reactant with possible role in reducing negative appendectomy rate.

Hyperfibrinogenemia is associated with inflammatory mediators and poor prognosis in patients with gastric cancer

PURPOSE

Hyperfibrinogenemia is associated with poor prognosis in various cancers; however, its clinical relevance in gastric cancer has not been well analyzed. We conducted this study to assess the clinicopathological significance and prognostic value of hyperfibrinogenemia in patients with gastric cancer.

METHODS

Plasma fibrinogen levels were measured preoperatively in 315 patients undergoing surgery for gastric cancer. We then evaluated the clinicopathological significance of hyperfibrinogenemia and its relationship with several biomarkers, including white blood cell (WBC), C-reactive protein (CRP), platelet count, prothrombin time (PT) and activated partial thromboplastin time (APTT). Postoperative plasma levels were compared with preoperative levels. The multivariate prognostic value of hyperfibrinogenemia was calculated using the Cox proportional hazards model.

RESULTS

Tumor progression was significantly associated with hyperfibrinogenemia, as were the CRP level and platelet counts. Plasma fibrinogen levels decreased significantly after radical surgery. Adjusting for TNM factors, multivariate analysis indicated that hyperfibrinogenemia was an independent prognostic factor for poor survival (hazard ratio = 2.607, 95 % confidence interval = 1.180-5.761, P = 0.018).

CONCLUSION

Preoperative hyperfibrinogenemia was associated with tumor progression, inflammatory mediators, and poor overall survival in patients with gastric cancer.

Predictive Factors to Distinguish Between Patients With Noncomplicated Appendicitis and Those With Complicated Appendicitis

Purpose

Recently, randomized controlled trials have reported that conservative therapy can be a treatment option in patients with noncomplicated appendicitis. However, preoperative diagnosis of noncomplicated appendicitis is difficult. In this study, we determined predictive factors to distinguish patients with noncomplicated appendicitis from those with complicated appendicitis.

Methods

A total of 351 patients who underwent surgical treatment for acute appendicitis from January 2011 to December 2012 were included in this study. We classified patients into noncomplicated or complicated appendicitis groups based on the findings of abdominal computed tomography and pathology. We performed a retrospective analysis to find factors that could be used to discriminate between noncomplicated and complicated appendicitis.

Results

The mean age of the patients in the complicated appendicitis group (54.5 years) was higher than that of the patients in the noncomplicated appendicitis group (40.2 years) (P < 0.001), but the male-to-female ratios were similar. In the univariate analysis, the appendicocecal junction's diameter, appendiceal maximal diameter, appendiceal wall enhancement, periappendiceal fat infiltration, ascites, abscesses, neutrophil proportion, C-reactive protein (CRP), aspartate aminotransferase, and total bilirubin were statistically significant factors. However, in the multivariate analysis, the appendiceal maximal diameter (P = 0.018; odds ratio [OR], 1.129), periappendiceal fat infiltration (P = 0.025; OR, 5.778), ascites (P = 0.038; OR, 2.902), and CRP (P < 0.001; OR, 1.368) were statistically significant.

Conclusion

Several factors can be used to distinguish between noncomplicated and complicated appendicitis. Using these factors, we could more accurately distinguish patients with noncomplicated appendicitis from those with complicated appendicitis.