Role of C-Reactive Protein, White Blood Cell Counts, Bilirubin Levels, and Imaging in the Diagnosis of Acute Appendicitis as a Cause of Right Iliac Fossa Pain

Abstract

BackgroundRight iliac fossa (RIF) pain is one of the most common modalities of presentation to surgical emergency. It remains a challenge to the treating clinicians to accurately diagnose or to rule out appendicitis.ObjectiveThe aim of the study was to compare the efficacy of clinical impression, biochemical markers, and imaging in the diagnosis of RIF pain with special reference to appendicitis and their implication in reducing the negative appendicectomy rates.MethodsAll patients presenting to casualty with RIF pain were included in the study. Blood investigations including C-reactive protein (CRP), serum bilirubin, white blood cell counts (WBC), and ultrasound (USG) were done. Based on the clinical impression, patients were either posted for appendicectomy or observed in equivocal cases. Patients who had recurrent pain on follow-up underwent appendicectomy or underwent contrast-enhanced computed tomography (CECT) in equivocal cases. Patients who only had a single self-limiting episode with no other alternative diagnosis or had a normal CECT report were included in a non-specific RIF pain group.ResultsThe negative appendicectomy rate was 8.2%. The mean value of WBC counts (9.57x109/L vs 7.88x109/L; p<0.05) and that of serum bilirubin (1.37 mg/dl vs 0.89mg/dl; p<0.05) in the appendicitis and non-appendicitis group, respectively, were statistically significant. The percentage of CRP positivity was higher in the appendicitis group (51.9% vs 15%; p<0.05). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for USG (84.2%, 77.17%, 85.4%, and 75.5%), for CRP (51.8%, 85%, 82%, and 57%), for WBC count (45.1%, 88%, 86.6%, and 48.3%), and for serum bilirubin (69.2%, 75%, 81.4%, and 60.5%) were statistically significant between the groups.ConclusionImaging and biochemical investigations including bilirubin can act as useful adjuncts to the clinical diagnosis of appendicitis.

A comparative study on the diagnostic validity of three scoring systems in the diagnosis of acute appendicitis in emergency centres

“…The diagnostic scoring systems along with laboratory and biochemical tests have been more reliable to diagnose acute appendicitis in some studies. C-reactive protein (CRP) is an inflammatory marker which has been used to increase the accuracy of diagnostic scoring systems [ [3] , [4] , [5] ]. However, its diagnostic accuracy has been variable in different studies [ 7 , 8 ].…”

Comparison of Demographic and Clinical Features of Pregnant and Non-pregnant Patients Undergoing Appendectomy

“…Bacteria's hepatic involvement via portal vein following proliferation inside appendix lumen leading to the limitation in hepatic uptake and excretion and cytokine-mediated inhibition of bile salt transport have been shown previously. [24][25][26][27][28] Besides, hemolysis related to systemic infection has also been shown to result in an increase of bilirubin load. Many studies show a relatively higher increase in total bilirubin levels in complicated and uncomplicated AAp cases when compared with NA and the highest increase in complicated AAp.…”

“…Many studies show a relatively higher increase in total bilirubin levels in complicated and uncomplicated AAp cases when compared with NA and the highest increase in complicated AAp. [24][25][26][27][28] However, some studies report a relatively increased bilirubin level among AAp group without any significant difference between complicated and non-complicated AAp groups. [28] Bilirubin level has also been shown to be predicting factor for perforation and other complications related to AAp.…”

“…[24][25][26][27][28] However, some studies report a relatively increased bilirubin level among AAp group without any significant difference between complicated and non-complicated AAp groups. [28] Bilirubin level has also been shown to be predicting factor for perforation and other complications related to AAp. To our knowledge, none of the pregnant AAp studies analyzed the relation between bilirubin level and AAp.…”

Serum Bilirubin level and its correlation with white blood cells as risk factor for cardiovascular disease in adult healthy population.

“…Another mechanism of low serum bilirubin and high WBC counts is an enhanced free radical production by later that depletes the former natural anti oxidant. 19 Still another postulated mechanism says an indirect linking factor might be influencing the inverse association of serum bilirubin and WBC counts. [11][12][13][14] A previous study 11 proposed the inverse correlation of serum bilirubin and metabolic syndrome is because of the regulatory effects of serum bilirubin upon the insulin resistance that is the core defect of pathophysiology of the metabolic syndrome.…”