The value of serum fibrinogen level in the diagnosis of acute appendicitis

The predictive value of neutrophil, C-reactive protein, fibrinogen, and chloride for acute complicated appendicitis in children: a multicenter retrospective study

OBJECTIVES

This study aimed to develop a diagnostic model utilizing clinical and laboratory data to identify complicated appendicitis in pediatric patients, improving acute appendicitis management.

METHODS

Retrospective analysis of pediatric acute appendicitis cases (2018-2023) at two hospitals collected medical history, clinical criteria, and blood samples. Patients were divided into complicated and uncomplicated appendicitis groups for comparison. Significant variables were identified using the Least Absolute Shrinkage and Selection Operator (LASSO), and incorporated into a logistic regression model to construct a nomogram. The effectiveness of the model was assessed based on sensitivity, specificity, accuracy, and comparison with existing scoring systems.

RESULTS

Among 323 patients, four variables (neutrophil (NEU), C-reactive protein (CRP), fibrinogen (Fg), and chlorine (Cl)) were identified as significant. The recommended cutoff value of nomogram was 0.730, exceeding that of Alvarado and PAS, with higher sensitivity (81.7%), specificity (82.6%), and accuracy (82.0%), as well as better performance in both internal and external validations. Furthermore, it demonstrated excellent calibration and clinical utility.

CONCLUSIONS

NEU, CRP, Fg, and Cl are effective markers for diagnosing complicated appendicitis in children. The nomogram model can be considered to be incorporated into the diagnosis process of appendicitis as an auxiliary means of surgical intervention decision-making in complex appendicitis cases.

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.

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.

sB7H3 in Children with Acute Appendicitis: Its Diagnostic Value and Association with Histological Findings

Background

Several efforts have been made to find out a valuable marker to assist the diagnosis and differentiation of gangrenous/perforated appendicitis. We aimed to determine the diagnostic capacity of soluble B7H3 (sB7H3) in acute appendicitis (AA) and its accuracy as a predictor of the severity of appendicitis.

Methods

182 children were allocated into four groups as follows: control group (CG, 90), simple appendicitis (SA, 12), purulent appendicitis (PA, 49), and gangrenous appendicitis (GA, 31). Prior to appendectomy, blood was collected and sent for analysis of routine examination and cytokines (sB7H3 and TNF-α). We compared values of all measured parameters according to histological findings. Furthermore, we assigned AA patients into the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic effects of significant markers were assessed by ROC curves.

Results

Only the levels of CRP, FIB, and sB7H3 had a remarkable rising trend in AA-based groups, while differences in the levels of CRP and FIB between simple appendicitis and purulent appendicitis were not statistically significant. In addition, sB7H3 was found as the only marker in children with AA, which was markedly associated with the degree of histological findings of the appendix. Furthermore, sB7H3 had a high diagnostic value in predicting AA and complex appendicitis (PA+GA) in children. However, the diagnostic performance of sB7H3 for distinguishing PA from GA was not remarkable. Additionally, only the levels of CRP and sB7H3 were statistically different between the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic performance of CRP and sB7H3 could not merely predict perforation of AA in children; however, the diagnostic performance was improved after combination.

Conclusions

sB7H3 could be used as a valuable marker to predict the presence of AA and complex AA in children. However, the diagnostic value of sB7H3 to predict gangrenous/perforated appendicitis was not found to be remarkable. The combination of sB7H3 and CRP might improve the prediction of perforated appendicitis.

The evaluation of ENA-78 and fibrinogen levels for the differential diagnosis of familial Mediterranean fever and acute appendicitis

Background

Familial Mediterranean fever (FMF) is a disorder mainly present in the Mediterranean region, characterized by abdominal attacks that mimic acute peritonitis. Therefore, FMF might be confused with other conditions presenting with acute abdominal pain, particularly acute appendicitis (AA). We aimed to evaluate whether epithelial-derived neutrophil-activating peptide-78 (ENA-78) and fibrinogen levels and white blood cell (WBC) counts could be used as potential markers in the differential diagnosis of acute FMF attacks and AA.

Methods

The study involved three groups: patients with AA who underwent surgery (group 1, n = 30), patients with FMF attacks (group 2, n = 30), and patients with FMF who were attack-free (n = 30, controls), which included patients who were diagnosed as having FMF previously but had no attacks for a month.

Results

Significant differences were detected in the ENA-78 and fibrinogen levels between group 1 and group 2. No significant difference was found in the WBC count between group 1 and group 2. It was concluded that the WBC count was more sensitive (66%) for group 1, and fibrinogen showed higher sensitivity (86%) and specificity (96%) for group 2 compared with the other parameters.

Conclusions

We suggest that AA can be distinguished in patients with signs of peritonitis who were diagnosed as having FMF previously with the use of ENA-78 and fibrinogen levels; fibrinogen and ENA-78 might be helpful in discriminating between FMF attacks and AA.

Evaluation of the Alvarado scoring system in the management of acute appendicitis

OBJECTIVE

In this study, we aimed to show the effectiveness of Alvarado score and its components to predict the correct diagnosis of acute appendicitis and to find an optimum cut-off value for Alvarado score.

MATERIAL AND METHODS

The patients who underwent surgical operation between January 2011 and January 2012 with the suspicion of acute appendicitis were included in the study. Their demographic and clinical features and histopathological results were retrieved from the medical records. They were divided into three groups according to their Alvarado scores. With the use of "receiver operating characteristic" curve analysis, the optimum cut-off value needed to make a correct diagnosis of acute appendicitis was determined.

RESULTS

In all, 156 patients were included into the study. The mean age was 31.41±13.27 years. Histopathologically, acute appendicitis was detected in 125 (80.1%) patients, and negative appendectomy was found in 31 patients (19.8%). Mean Alvarado score was 6.44±1.49. There was a significant correlation between negative appendectomy and low Alvarado score (p<0.001). The main component of Alvarado score that makes the difference was rebound. Fever higher than 37.3°C, rebound, loss of appetite, and existence of shifting pain were statistically differential components (p=0.042, p<0.001, p=0.045, p<0.001, respectively). The rate of correct diagnosis of acute appendicitis was maximum in group 3 (100%) and minimum in group 1 (21.7%). Optimum cut-off value for Alvarado score was 7.

CONCLUSION

Patients with an Alvarado score of over 7 can be taken into surgical operation without the need of imaging methods.

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.

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.

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.

The comparison of the effectiveness of tomography and Alvarado scoring system in patients who underwent surgery with the diagnosis of appendicitis

OBJECTIVE

The aim of this study is to compare the effectiveness of computed tomography and Alvarado scoring system in the diagnosis of acute appendicitis in patients who underwent appendectomy with the preliminary diagnosis of acute appendicitis.

MATERIAL AND METHODS

One hundred and one patients who underwent appendectomy with the diagnosis of acute appendicitis between January and December 2011 were included in the study. Alvarado scores were calculated, and abdominal tomography scans were obtained for each patient before surgery. Patients with Alvarado score ≥7 were considered to have appendicitis while patients with a score <7 were considered not to have appendicitis. Patients were classified into two groups based on the presence of appendicitis findings on abdominal tomography. Histopathological examination of the appendices was performed following appendectomy. All patients were classified into groups according to pathology results, Alvarado score and tomography findings. The effectiveness of Alvarado score and tomography were compared using the McNemar test.

RESULTS

Sixty patients (59.4%) were male and 41 (40.6%) were female, with a mean age of 32 years (5-85 years). The rate of negative appendectomy was 3.9%. In 78 patients (77.3%) the Alvarado score was ≥7, while 23 patients (22.7%) had Alvarado scores <7. The presence of appendicitis was determined by histopathology in 22 out of 23 patients whose Alvarado score was <7. Tomography indicated appendicitis in 97 patients (95.9%) whereas four patients (4.1%) exhibited no signs of appendicitis by tomography. However, histopathological evaluation indicated the presence of appendicitis in those four patients as well.

CONCLUSION

The study results imply that tomography is a more effective means of diagnosing acute appendicitis as compared to the Alvarado scoring system.

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.