Abdominal pain and jaundice: Appendiceal perforation an important differential

Abstract

Clinicians must be aware of atypical presentations of common conditions. Appendiceal perforation with peritonitis and sepsis presenting with cholestatic jaundice is an important example, given the prevalence of the condition and the mortality associated with delayed diagnosis. The authors describe a case seen at their hospital.

The value of hyperbilirubinaemia in the diagnosis of acute appendicitis

“…There have been several reports of hyperbilirubinaemia in appendicitis. [20][21][22] Estrada et al hypothesised that hyperbilirubinaemia may be associated with appendiceal perforation and showed that more patients with a perforated or gangrenous appendix had hyperbilirubinaemia than those with simple acute appendicitis. 5 Sand et al showed that hyperbilirubinaemia had a specificity of 86% for appendiceal perforation or gangrene, compared with a specificity of only 35% for CRP.…”

Is hyperbilirubinaemia in appendicitis a better predictor of perforation than C-reactive protein? — a prospective study

“…Recently some researchers have proposed that hyperbilirubinaemia could be used to support the diagnosis of perforated appendicitis [19,20]. They argument that the cause of elevated bilirubin is directly related to the pathogenesis of appendicitis and the invasion of gram-negative bacteria into muscularis propria of the appendix, leading to direct invasion or translocation into the portal venous system and into the hepatic parenchyma interfering with the excretion of bilirubin into the bile canaliculi by a mechanism caused by the bacterial endotoxin [19].…”

“…The most commonly laboratory tests used to support the diagnosis of appendicitis are white blood cell count (WBC) and C-reactive protein (CRP) [11,17,18], these markers have been studied together with other parameters in an effort to improve and predict the preoperative diagnosis of perforated appendicitis, nonetheless only an elevated CRP, a prolonged period of symptom's evolution, and fever have been identifi ed as useful markers of perforation [17,18]. Recently, it has been proposed that an elevated total bilirubin (TB) level could be used as a specifi c marker for the prediction of perforated appendicitis [19,20]. The rationale for this proposal is based on the hepatic dysfunction occurring during bacterial sepsis secondary to Gram negative bacteria [21], such as Escherichia coli, which is the main bacteria present in patients with appendicitis [22,23].…”

Hiperbilirrubinemia en apendicitis: ¿Es un factor predictivo de perforación?

“…En estos casos los niveles de BT sufren un aumento leve a moderado como en sepsis de cualquier otra causa. Recientemente se ha propuesto que la hiperbilirrubinemia sea utilizada para apoyar el diagnóstico de AP 22,23 , argumentando que la causa de la hiperbilirrubinemia se encuentra directamente relacionada a la patogénesis de la apendicitis y a la invasión de bacterias Gram negativas en la muscularis propia del apéndice, lo que lleva a la invasión directa o translocación hacia el sistema venoso portal y hacia el parénquima hepático interfiriendo con la excreción de bilirrubina en el canalículo biliar a causa de la endotoxina bacteriana 22 . Aunque este argumento tiene sentido y la disfunción hepática en la sepsis bacteriana ha sido fehacientemente probada 24,27,41 , el uso de la BT para apoyar el diagnóstico de AP no parece tener sentido porque, como hemos demostrado, otros marcadores serológicos (PCR) y variables clínicas (SIRS y la evolución clínica), tienen un mejor rendimiento que la BT en el análisis con curvas ROC, con una mejor sensibilidad para predecir perforación en pacientes con apendicitis.…”

“…Sólo una PCR elevada, el tiempo prolongado de evolución de los síntomas y la fiebre alta, han sido identificados como marcadores útiles para predecir AP 20,21 . Recientemente, se ha propuesto a la bilirrubina total (BT) como un marcador específico de AP 22,23 . La razón de esta proposición se basa en la disfunción hepática que ocurre durante la sepsis bacteriana secundaria a bacterias Gram-negativas 24 , como la Escherichia Coli, que es la bacteria principal presente en pacientes con apendicitis 25,26 .…”