Accuracy of serum C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon's clinical impression

A study of C-reactive protein and D-dimer in patients of appendicitis

Background:

Acute appendicitis is the most common abdominal surgical emergencies across the world.

Objective:

The aim of this study was to determine the value of C-reactive protein (CRP) and D-dimer as diagnostic markers of acute appendicitis.

Study Design:

It was a Prospective observational clinical study.

Method:

The present study was carried out in General Surgical Unit of University Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi from September 2015 to July 2017. All data including patient's demography, clinical examination, laboratory test results, and appendix histology were summarized. Receiver operating characteristic (ROC) curve of TLC, CRP, and D-dimer was analyzed.

Results:

Total 65 patients who presented with periumbilical pain or pain in right iliac fossa (RIF) were included in the study. The mean age of the patients was 31.18 ± 14.59 years (range: 15 to 65 years) with male : female ratio was 2.21:1. The most common symptom was pain in right iliac fossa (100%) followed by nausea/vomiting (69.2%). The mean leucocyte count, CRP, and D-dimer levels were significantly raised in appendicitis group as compared to negative appendicectomy group (P = 0.025, P = 0.036, and P = 0.025, respectively). The receiver operating characteristic (ROC) curve for TLC was not helpful for differentiating between appendicitis and negative appendicitis (P = 0.073). In addition, D-dimer was helpful for differentiating between appendicitis and negative appendicitis (P = 0.002). However, CRP was also found to be helpful for differentiating between appendicitis and negative appendicitis (P = 0.030).

Conclusion:

The diagnosis of appendicitis remains multifactorial and biochemical markers like CRP and D-dimer may help to guide the surgeon in the decision making.

A proposal for a comprehensive approach to infections across the surgical pathway

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

C-reactive protein binds to integrin α2 and Fcγ receptor I, leading to breast cell adhesion and breast cancer progression

C-reactive protein (CRP) is an acute phase protein synthesized upon the inflammatory responses, associated with breast cancer. The process of tumor cell invasion and metastasis involves the adherence of cells to the extracellular matrix via integrin as a receptor for matrix molecules. The present study investigated the role of CRP in the adhesive phenotype of breast cells and the underlying mechanisms. Here, we first showed that CRP induces adhesion of MCF10A human breast epithelial cells through the activation of integrin α2 signaling. Expression of integrin α2 was induced by CRP in which transcription factors c-fos and SP1 may be involved. Binding of CRP with integrin α2 leads to the activation of focal adhesion kinase (FAK), paxillin and ERKs. CRP also binds to an Fcγ receptor Fcγ receptor I (FcγRI), and induces activation of paxillin, FAK and ERKs. Integrin α2 and FAK have crucial roles in the adhesive and invasive phenotypes as well as MMP-9 upregulation induced by CRP in MCF10A cells. Treatment with an inflammatory lipid sphingosine-1-phosphate induced CRP, which may be secreted and exert an autocrine effect by binding to FcγRI and integrin α2. Involvement of CRP in adhesion, invasion, anchorage-independent growth and upregulation of integrin α2, paxillin and FAK was observed in MDA-MB-231 triple-negative human breast cancer (TNBC) cells. Using an in vivo invasion model and an orthotopic mouse tumor model with MDA-MB-231 cells, we showed that CRP has an important role in intravasation and tumor growth in vivo, demonstrating the in vivo relevance of our in vitro results. The present study elucidates a critical molecular basis between CRP, integrin α2 and FcγRI pathways in MCF10A breast cells and MDA-MB-231 TNBC cells, thereby providing useful information on CRP-induced aggressiveness of breast cells in the inflammatory microenvironment.

Efficacy of the Evaluation of Inflammatory Markers for the Reduction of Negative Appendectomy Rates

Unnecessary appendectomy can cause complications; ways of reducing negative appendectomy rates (NAR) using biochemical and imaging methods are desirable. We retrospectively examined 640 patients who underwent appendectomy for suspected AA. Patients with histologically confirmed appendicitis were designated the positive appendectomy group (n = 565), whereas those with unconfirmed appendicitis were designated the negative appendectomy group (n = 75). The positive appendectomy group was subdivided into the non-perforated (n = 511) and perforated (n = 54) appendectomy groups according to pathology reports. We compared the age, sex, lymphocyte count, neutrophil percentage, pathologic positivity or negativity for appendicitis, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) of the patients. When the perforated, non-perforated, and negative appendectomy groups were compared, the highest CRP level, NLR, and PLR were evident in the perforated appendectomy group (p = 0.001), whereas the lowest neutrophil percentage was found in the non-perforated appendectomy group (p = 0.001). Multiple logistic regression analysis identified neutrophil percentage, CRP value, and NLR as independent variables and demonstrated that AA could be diagnosed with 88.9 % accuracy using the cutoff values determined. In patients with suspected AA, particularly in rural areas with limited access to advanced imaging modalities, the evaluation of neutrophil percentage, CRP level, and NLR, in combination with the findings of a physical examination, may aid diagnosis and reduce NAR.

Inflammatory mediators in intra-abdominal sepsis or injury - a scoping review

Introduction

Inflammatory and protein mediators (cytokine, chemokine, acute phase proteins) play an important, but still not completely understood, role in the morbidity and mortality of intra-abdominal sepsis/injury. We therefore systematically reviewed preclinical and clinical studies of mediators in intra-abdominal sepsis/injury in order to evaluate their ability to: (1) function as diagnostic/prognostic biomarkers; (2) serve as therapeutic targets; and (3) illuminate the pathogenesis mechanisms of sepsis or injury-related organ dysfunction.

Methods

We searched MEDLINE, PubMed, EMBASE and the Cochrane Library. Two investigators independently reviewed all identified abstracts and selected articles for full-text review. We included original studies assessing mediators in intra-abdominal sepsis/injury.

Results

Among 2437 citations, we selected 182 studies in the scoping review, including 79 preclinical and 103 clinical studies. Serum procalcitonin and C-reactive protein appear to be useful to rule out infection or monitor therapy; however, the diagnostic and prognostic value of mediators for complications/outcomes of sepsis or injury remains to be established. Peritoneal mediator levels are substantially higher than systemic levels after intra-abdominal infection/trauma. Common limitations of current studies included small sample sizes and lack of uniformity in study design and outcome measures. To date, targeted therapies against mediators remain experimental.

Conclusions

Whereas preclinical data suggests mediators play a critical role in intra-abdominal sepsis or injury, there is no consensus on the clinical use of mediators in diagnosing or managing intra-abdominal sepsis or injury. Measurement of peritoneal mediators should be further investigated as a more sensitive determinant of intra-abdominal inflammatory response. High-quality clinical trials are needed to better understand the role of inflammatory mediators.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1093-4) contains supplementary material, which is available to authorized users.

Neutrophil-to-lymphocyte ratio has a close association with gangrenous appendicitis in patients undergoing appendectomy

The purpose of this study was to clarify the clinical features most closely associated with gangrenous appendicitis. From among 314 patients who had undergone open appendectomy in our collected database, 222 for whom sufficient data were evaluable were enrolled. The results of univariate analysis revealed that age (≤40/>40 years), sex (female/male), fever (≤37°/>37°C), the serum levels of C-reactive protein and albumin, the Glasgow prognostic score (0, 1/2), and the neutrophil-to-lymphocyte ratio (NLR) (≤8/>8) were associated with gangrenous appendicitis. Among these 7 clinical features, multivariate analysis disclosed that age (≤40/>40 years) (odds ratio, 3.435; 95% confidence interval 1.744-6.766; P < 0.001) and NLR (≤8/>8) (odds ratio, 3.016; 95% confidence interval 1.535-5.926; P = 0.001) were associated with gangrenous appendicitis. The sensitivity and specificity of these two clinical features were 65% and 27%, and 73% and 39%, respectively. NLR (>8) shows a significant association with gangrenous appendicitis in patients undergoing appendectomy.

Diagnostic role of procalcitonin in patients with suspected appendicitis

BACKGROUND

The aim of this study was to assess the diagnostic value of procalcitonin (PCT) in emergency department (ED) patients with suspected appendicitis.

METHODS

A prospective observational study was carried out in the emergency department of a university hospital between July 2007 and June 2008. Adult patients who presented to the ED with clinically suspected appendicitis were enrolled. Each patient underwent serum PCT, C-reactive protein (CRP), and Alvarado score evaluation on admission. The results of these three measurements were analyzed in relation to the final diagnosis determined by histopathological findings or compatible computed tomography findings.

RESULTS

Of the 214 study patients, 113 (52.8 %) had a confirmed diagnosis of appendicitis and 58 had complicated appendicitis (phlegmon, perforation, or gangrene). For the diagnosis of appendicitis, the area under the receiving operating characteristic (ROC) curve is 0.74 for Alvarado score, 0.69 for PCT, and 0.61 for CRP. Overall, the Alvarado score has the best discriminative capability among the three tested markers. We adopted two cutoff point approaches to harness both ends of the diagnostic value of a biomarker. PCT levels were significantly higher in patients with complicated appendicitis. For diagnosis of complicated appendicitis, a cutoff value of 0.5 ng/mL had a sensitivity of 29 % and a specificity of 95 %, while a cutoff value of 0.05 ng/ml had a sensitivity of 85 % and a specificity of 30 % in diagnosing complicated appendicitis. For those with a PCT value in the gray zone, clinical findings may play a more important role.

CONCLUSION

The study does not support the hypothesis that the PCT test may be useful for screening ED patients for appendicitis. However, determination of the PCT level may be useful for risk assessment of ED patients with suspected complicated appendicitis.

Correlation of serum C-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis of acute appendicitis is based on careful history, physical examination, laboratory and imaging investigation. The aim of the study is to analyze the role of C-reactive protein (CRP), white blood count (WBC) and Neutrophil percentage (NP) in improving the accuracy of diagnosis of acute appendicitis and to compare it with the intraoperative assessment and histopathology findings.

MATERIALS AND METHODS

This investigation was a prospective double blinded clinical study. The study was done on 173 patients surgically treated for acute appendicitis. The WBC, NP, and measurement of CRP were randomly collected pre-operatively from all involved patients. Macroscopic assessment was made from the operation. Appendectomy and a histopathology examination were performed on all patients. Gross description was compared with histopathology results and then correlated with CRP, WBC, and NP.

RESULTS

The observational accuracy was 87,3%, as compared to histopathological accuracy which was 85.5% with a total of 173 patients that were operated on. The histopathology showed 25 (14.5%) patients had normal appendices, and 148 (85.5%) patients had acutely inflamed, gangrenous, or perforated appendicitis. 52% were male and 48% were female, with the age ranging from 5 to 59 with a median of 19.7. The gangrenous type was the most frequent (52.6%). The WBC was altered in 77.5% of the cases, NP in 72.3%, and C-reactive protein in 76.9% cases. In those with positive appendicitis, the CRP and WBC values were elevated in 126 patients (72.8%), whereas NP was higher than 75% in 117 patients (67.6%). Out of 106 patients with triple positive tests, 101 (95.2%) had appendicitis. The sensitivity, specificity, and positive predictive values of the 3 tests in combination were 95.3%, 72.2%, and 95.3%, respectively.

CONCLUSION

The raised value of the CRP was directly related to the severity of inflammation (p-value <0.05). CRP monitoring enhances the diagnostic accuracy of acute appendicitis. The diagnostic accuracy of CRP is not significantly greater than WBC and NP. A combination of these three tests significantly increases the accuracy. We found that elevated serum CRP levels support the surgeon's clinical diagnosis.

An analysis of factors influencing accuracy of the diagnosis of acute appendicitis

The aim of the study was to "refresh" the knowledge about the course of acute appendicitis, to confront the classical clinical picture with the practice, analyze its fluctuations and identify factors influencing these.

MATERIAL AND METHODS

All patients admitted to the Department of General Surgery in Grudziądz District Hospital with the suspicion of acute appendicitis, who underwent appendectomy and in whom the appendicitis was confirmed in pathologic examination were included in the study. There were 85 patients, 49 men (58%) and 36 women (42%) in a mean age of 30 years (range 10-75). Symptoms, signs and results of biochemical tests (leukocyte rate and CRP) were considered in the analysis.

RESULTS

The commonest constellation of symptoms and signs, occurring in at least of 3/4 patients consisted of pain and tenderness localized in right lower quadrant (100%), which exacerbates at movements (98%), felling unwell (93%), loss of appetite (88%), and rebound tenderness in right lower quadrant (74%).

CONCLUSIONS

No particular fluctuation of clinical features in relation to gender, age, duration of symptoms, biochemical parameters and morphological severity of the inflammation was observed. Relevant findings included relatively fast development (<12 hrs) of advanced appendicitis in 18% of adult patients and more than a half patients with normal body temperature, regardless true appendicitis.

The diagnostic value of D-dimer, procalcitonin and CRP in acute appendicitis

BACKGROUND

The early diagnosis of acute abdomen is of great importance. To date, several inflammatory markers have been used for the diagnosis of acute abdominal conditions, including acute appendicitis. The aim of this study was to evaluate the diagnostic utility of D-dimer, Procalcitonin (PCT) and C-reactive protein (CRP) measurements in the acute appendicitis.

METHODS

This prospective study was conducted between March 1(st), 2010 and July 1(st), 2011. In this period, seventy-eight patients were operated with the diagnosis of acute appendicitis, and D-dimer, PCT and CRP levels of the patients were measured. The patients were grouped as phlegmonous appendicitis (Group 1), gangrenous appendicitis (Group 2), perforated appendicitis (Group 3) and negative appendectomy (Group 4) according to the surgical findings and histopathological results.

RESULTS

Of 78 patients, 54 (69.2 %) were male and 24 (30.8 %) were female, and the mean age was 25.4 ± 11.1 years (range, 18 to 69 years). 66 (84.6 %) patients had increased leukocyte count (white blood cell count). The PCT values were higher than the upper normal limit in 20 (25.6%) patients, followed by D-dimer in 22 (28.2 %) patients and CRP in 54 (69.2 %) patients. The diagnostic value of leukocyte count and CRP in acute appendicitis was higher than that of the other markers, whereas leukocyte count showed very low specificity. CRP values were higher in perforated appendicitis when compared with the phlegmonous appendicitis (p < 0.05). However, PCT and D-dimer showed lower diagnostic values (26% and 31%, respectively).

CONCLUSION

An increase in CRP levels alone is not sufficient to make the diagnosis of acute appendicitis. However, CRP levels may differentiate between phlegmonous appendicitis and perforated appendicitis. Due to their low sensitivity and diagnostic value, PCT and D-dimer are not better markers than CRP for the diagnosis of acute appendicitis.

Normal inflammatory markers in appendicitis: evidence from two independent cohort studies

OBJECTIVES

Acute appendicitis is a common surgical condition which can lead to severe complications. Recent work suggested that patients experiencing right lower abdominal pain, with normal white cell count (WCC) and C-reactive protein (CRP) are unlikely to have acute appendicitis and can be discharged. We present two independent data-sets that suggest that this strategy may not be risk-free.

DESIGN

Retrospective cohort study of consecutive patients from two district general hospitals. Sensitivity and specificity of CRP, WCC and neutrophil count (NC) in predicting appendicitis were calculated. Markers were analysed using Fisher's exact test and Kruskul-Wallace test.

SETTING

Two district general hospitals in the UK.

PARTICIPANTS

Patients undergoing appendicectomy for suspected appendicitis.

MAIN OUTCOME MEASURES

Inflammatory markers and appendix histology.

RESULTS

A total of 297 patients were included. Appendicitis occurred in four patients with normal CRP, WCC and NC in centre A and 13 patients in centre B. The sensitivity of all three markers combined was 94% (centre A) and 92% (centre B). The specificity was 60% (centre A) and 64% (centre B). No single marker could differentiate uncomplicated and complicated appendicitis, but a raised NC or a CRP >35.5 mg/l predicted complicated appendicitis. CRP, WCC and NC combined differentiated between patients with a normal appendix, uncomplicated appendicitis and complicated appendicitis.

CONCLUSIONS

Appendicitis in the presence of normal inflammatory markers is not uncommon. We disagree with the view of Sengupta et al. who suggest that patients with normal WCC and CRP are unlikely to have appendicitis, and recommend that clinicians be wary of normal inflammatory markers in patients with a high clinical suspicion of appendicitis.

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.

Total leucocyte count, C-reactive protein and neutrophil count: diagnostic aid in acute appendicitis

BACKGROUND/AIM

Acute appendicitis is one of the most common acute intraabdominal affections seen in surgical departments, which can be treated easily if an accurate diagnosis is made in time. Otherwise, delay in diagnosis and treatment can lead to diffuse peritonitis.

MATERIALS AND METHODS

A study was conducted on 110 patients who were operated for acute appendicitis to determine the role and predictive value of the total leucocyte count (TLC), C-reactive protein (CRP) and percentage of neutrophil count in the diagnosis of acute appendicitis. Preoperative TLC, CRP and percentage of neutrophil count were determined and were compared with the results of the histopathology of the removed appendix.

RESULTS

Of all the patients studied, 92 had histopathologically positive appendicitis. The TLC was found to be significantly high in 90 patients who proved to have acute appendicitis, whereas CRP was high in only 88 patients and neutrophil percentage was raised in 91; four had a normal CRP level. Thus, TLC had a sensitivity, specificity and positive predictive value of 97.82%, 55.55% and 91.8%, respectively. CRP had a sensitivity, specificity and positive predictive value of 95.6%, 77.77% and 95.6% respectively. Percentage of neutrophil count had a sensitivity, specificity and positive predictive value of 98.9%, 38.88% and 89.21%, respectively. When used in combination, there was a marked improvement in the specificity and the positive predictive value to 88.04% and 98.7%, respectively.

CONCLUSION

The inflammatory markers, i.e., TLC, CRP and neutrophil count can be helpful in the diagnosis when measured together as this increases their specificity and positive predictive value.

White cell count and C-reactive protein measurement in patients with possible appendicitis

INTRODUCTION

Clinical assessment outweighs the use of investigations in the diagnosis of acute appendicitis. Nevertheless, white cell count (WCC) and C-reactive protein (CRP) are regularly measured in patients with suspected appendicitis. The aim of this study was to assess the utility of these markers in patients presenting with acute lower abdominal pain.

PATIENTS AND METHODS

WCC and CRP were measured prospectively in 98 patients presenting with lower abdominal pain, and the results were correlated with each patient's outcome.

RESULTS

No patients with WCC and CRP both in the normal range had acute appendicitis. Raised WCC and CRP were poor positive predictors of appendicitis, both alone and in combination, and correlated poorly with the development of complications.

CONCLUSIONS

This result may have important clinical and economic implications. We suggest that patients experiencing lower abdominal pain, with normal WCC and CRP values, are unlikely to have acute appendicitis and can be safely sent home.

[Right iliac fossa pain and Alvarado Score]

INTRODUCTION

Unsuspected or undiagnosed acute appendicitis could progress to a perforation or could lead to the removal of a normal appendix.

OBJECTIVES

using a clinical score system as a diagnostic tool for this pathology and can decrease negative appendectomies.

MATERIAL AND METHOD

Prospective and protocolized study.

SETTING

National Clinicas Hospital. Córdoba. Argentina. Between May 2007 and June 2007 224 patients were studied of which 117 were male and 107 were female with a mean age of 26.65 years. An Alvarado score was performed on all patients on admission. Based on the clinical evidence and a second assessment with the Alvarado Score, surgical exploration was decided in 207 patients. The remaining 17 were excluded due to other pathology. The diagnosis of acute appendicitis was confirmed by surgical finding and histopathological studies.

RESULTS

In the surgical findings it was shown that 189 (91%) patients had acute appendicitis. There was no surgical mortality. As regards morbidity, 3.86% had medical and 27% had surgical complications. The histopathology reports showed a normal caecal appendix in 18. Whereas the incidence of negative appendicectomy was about 8.69%.

CONCLUSIONS

The use of the Alvarado Score together with the surgical and histopathology findings confirmed it was sensitive from 6 points for the diagnosis of acute appendicitis.

Usefulness of laboratory data in the management of right iliac fossa pain in adults

PURPOSE

This study examined the usefulness of inflammatory markers in the management of patients with right iliac fossa pain.

PATIENTS AND METHODS

A single site, prospective observational study was conducted from October 2001 to April 2003. Patients with right iliac fossa pain referred to the surgeon were included. Blood samples were obtained for C-reactive protein, leukocyte, and granulocyte analysis. Clinical, surgical, and histopathologic data were collected. Analysis of inflammatory parameters was performed with logistic regression and areas under the receiver operating characteristic curve were compared.

RESULTS

C-reactive protein increased with the severity of appendicitis and predicted accurately perforation (r(2) = 0.613; P < 0.0005), showing the highest accuracy among inflammatory markers (areas under the receiver operating characteristics curve were 0.846, 0.753, and 0.685 for C-reactive protein, leukocyte and granulocytes, respectively; P < 0.001). Accuracy improved when C-reactive protein and leukocytes were combined; positive and negative predictive values were 93.2 percent and 92.3 percent, respectively.

CONCLUSIONS

C-reactive protein is a helpful marker in the management of patients with right iliac fossa pain; the predictive value improves when combined with leukocyte count. A patient with normal C-reactive protein and leukocytes has a very low probability of appendicitis and should not undergo surgery.

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

Improving the diagnosis of acute appendicitis in order to prevent unnecessary surgery is crucial. This study was intended to identify the role of serum inflammatory markers in patients with preliminary diagnosis of acute appendicitis with a retrospective design. Eighty-five patients with the preliminary diagnosis of acute appendicitis were recruited in this study within the period of November-December 2003. The average age was 31.8 years (ranged from 15 to 85). There were 62 males (72.9%) and 23 females (27.1%). In addition to performing routine tests, preoperative serum samples were obtained from the patients to measure C-reactive protein, interleukin-6, and interleukin-10. All the patients were operated on for a clinical suspicion of acute appendicitis. Depending on the macroscopic evidence during the operation and the histopathological examination of the specimen, the patients were separated into two groups: the ones who did not have acute appendicitis as the cause for acute abdomen (group I; n = 14) and the ones who had acute appendicitis (group II; n = 71). The ones who had acute appendicitis (group II) were further grouped as noncomplicated appendicitis (group IIA; n = 44) and complicated appendicitis (group IIB; n = 27). Being a male with elevated levels of leukocytes (white blood cells, WBC); C-reactive protein (CRP), interleukin-6 (IL-6); and interleukin-10 increased the probability of having acute appendicitis in patients with evidences of acute abdomen. The risk of complication of acute appendicitis significantly increased when patients had increased levels of C-reactive protein, increased erythrocyte sedimentation rate, and increased interleukin-6 levels, had symptoms for more than 24 h, and were female. Interleukin-10 levels within normal range might be helpful in eliminating the possibility of acute appendicitis. Thus, elevated levels of WBC, IL-6 and CRP might be helpful in confirming a potential diagnosis of acute appendicitis. In addition, normal levels of IL-10 might be of additional help to possibly rule out the diagnosis of acute appendicitis.

Significance of preoperative C-reactive protein as a parameter of the perioperative course and long-term prognosis in squamous cell carcinoma and adenocarcinoma of the oesophagus

AIM: C-reactive protein (CRP) is an acute-phase reactant and a known indicator of the malignant potential of the tumour. The aim of this study was to investigate the significance of preoperative CRP as a parameter of the perioperative course and long-term prognosis in patients with squamous cell carcinoma and adenocarcinoma of the oesophagus.

METHODS: Serum CRP was determined preoperatively in 291 of 371 patients undergoing oesophagectomy for cancer from December 1989 to March 2004. Median patient age was 59 (28-79) year, 82.5% of patients were males. Squamous cell carcinoma was diagnosed in 151 (51.9%) and adenocarcinoma in 122 patients. Transhiatal oesophagectomy was done in 151 (51.9%) patients and 134 (46.0%) patients underwent the abdominothoracic procedure.

RESULTS: In 127 (43.6%) patients the preoperative serum CRP concentration was within the normal range (< 5 mg/dL), elevated CRP levels were measured in 164 (56.4%) patients. Tumour extension (P < 0.0005) and the number of lymph nodes affected by metastatic spread (P = 0.015) were significantly increased in the group with elevated CRP levels. Among the perioperative parameters both the number of blood transfusions (P = 0.006) and the general complication rate (P = 0.002) were higher in patients with elevated preoperative CRP levels. The long-term survival rate of 13.6 (0-109.8) mo was poorer in the group with elevated CRP levels compared to 18.9 (0-155.4) mo in the group with normal CRP levels (log-rank test: P = 0.107). Multivariate analysis with backward variables selection identified preoperative CRP as an independent prognostic factor of the long-term prognosis in patients with oesophageal carcinoma, with a hazard ratio of 1.182 (95% confidence interval: 1.030-1.356).

CONCLUSION: The preoperative serum CRP-level is an easily determined independent prognostic marker in patients with squamous cell carcinoma and adenocarcinoma of the oesophagus.

Predictive value of C-reactive protein at different cutoff levels in acute appendicitis

Determining the different cutoff values of C-reactive protein (CRP) on the basis of how long the patient's symptoms were present can be used to early predict acute appendicitis. We analyzed retrospectively from 2001 to 2004 the hospital records of 568 patients who underwent appendectomies for suspected appendicitis. Receiver operating characteristic analysis has shown that CRP measurement can increase the diagnostic accuracy in acute appendicitis. The cutoff values of CRP concentration taken as the first, second, and third days after onset of symptoms that distinguish acute appendicitis from other acute abdominal diseases were 1.5, 4.0, and 10.5 mg/dL, respectively; the values that distinguish perforated appendicitis from other acute abdominal diseases were 3.3 mg/dL (first day), 8.5 mg/dL (second day), and 12.0 mg/dL (third day). The different cutoff values of CRP concentration may serve as a useful predictive parameter in the early diagnosis of acute appendicitis on the first 3 days after the onset of symptoms.

[CRP in the management of bacterial infections in emergency]

OBJECTIVES

To assess the interest of measuring CRP in emergency for diagnosing bacterial infections and making decisions about antibiotics and to compare its practical usefulness with clinicians' conclusions.

METHODS

Systematic CRP measurements in 80 consecutive patients admitted to emergency ward with possible bacterial infection.

RESULTS

were not transmitted to the physician in charge. Patients' files were analyzed retrospectively in two phases. In phase 1, two senior physicians assessed the diagnosis and need for antibiotics on the basis of the admission (emergency unit) files. In phase 2, a panel of experts examined the complete files (including discharge notes) to determine the likelihood of infection (obvious or probable, unlikely or excluded) and appropriateness of emergency antibiotics. Their recommendations were used as the standard, against which the usefulness of the laboratory indicators (including CRP) and decisions of the emergency physicians were assessed. ROC curves were used to determine threshold values for CRP and body temperature. We then calculated the sensitivity, positive predictive value and negative predictive value of these cutoffs and compared them with those for the phase 1 clinician recommendations.

RESULTS

The study included 76 patients (mean age: 74 years): 28 presented obvious or possible infections and 21 required emergency antibiotic therapy. Mean leukocyte values did not differ between groups. For diagnosis, the threshold value of CRP was 85 mg/L and of body temperature 37.8 degrees C; for prescribing antibiotics, the values were 130 mg/L and 38 degrees C, respectively. The sensitivity, specificity, negative and positive predictive values of CRP were, respectively, 79, 81, 76, and 83% for diagnosis of bacterial infection and 71, 71, 48 and 87% for prescription of an emergency antibiotic. These values were lower than those of clinician's conclusions.

CONCLUSION

Because of the variability in the thresholds used in its interpretation, the lack of specificity, and its poor predictive value for treatment decisions, CRP is of little interest in the diagnosis and treatment of patients with bacterial infections in intensive care. The cost generated by this examination is therefore not justified.

Can ruptured appendicitis be detected preoperatively in the ED?

PURPOSE

The purpose of this study is to determine which clinical symptoms/signs and computed tomography (CT) signs can help in distinguishing ruptured from simple appendicitis.

MATERIALS AND METHODS

The medical records and CT findings of 202 consecutive patients with surgically proven acute appendicitis were retrospectively reviewed and compared between 2 groups with and without appendiceal rupture.

RESULTS

Longer duration of symptoms ( P < .001), peritoneal sign ( P = .004), and higher C-reactive protein ( P < .001) are significant clinical factors for predicting appendiceal rupture in acute appendicitis. Abscess, extraluminal air, wall defect, peritoneal enhancement, extraluminal appendolith, phlegmon, localized fluid, fascial thickening, ascites, stool impaction, and 4 patterns of bowel wall thickening ( P < .001 to P = .047) are significant CT signs for predicting appendiceal rupture. The appendiceal diameter is larger in patients with ruptured appendicitis than in those with simple appendicitis (13.2 +/- 3.2 vs 11.3 +/- 2.4 mm, P < .001). The appendolith size is larger in patients with ruptured appendicitis than in those with simple appendicitis (7.1 +/- 4.4 vs 5.1 +/- 2.8 mm, P = .018).

CONCLUSION

Besides some clinical findings, CT scan can accurately determine appendiceal rupture in acute appendicitis and can further demonstrate the presence of local inflammatory mass, facilitating management decision in the emergency department (ED).

Colorectal Cancer and Serum C-reactive Protein Levels: a Case-control Study Nested in the JACC Study

BACKGROUND: Recently, it has been hypothesized that inflammation increases the risk of colorectal cancer. We investigated whether serum levels of C-reactive protein (CRP), a biomarker of inflammation, are associated with colorectal cancer, using serum samples collected in the Japan Collaborative Cohort Study (JACC Study).

METHODS: We conducted a nested case-control study in the JACC Study, investigating the relationship between the risk for colorectal cancer and serum levels of CRP determined by a high-sensitivity CRP enzyme immunoassay. The subjects recruited were 141 patients with colorectal cancer (63 males and 78 females) and 327 controls with no history of cancer (148 males and 179 females). Each case of colorectal cancer was matched for sex, age and participating institution to 2 or 3 controls. We used t-test to analyze mean differences in CRP levels between colorectal cancer cases and controls. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated using a conditional logistic regression model after adjusting for the potential confounding factors.

RESULTS: Serum CRP levels were not clearly associated with the risk of colorectal cancer. The OR of the highest serum CRP levels was 1.18 (95% CI: 0.68-2.06) for colorectal cancer and 1.42 (95% CI: 0.73-2.74) for colon cancer, compared to subjects with lowest serum levels. The OR for incidence of colorectal cancer showed a similar trend, but the difference was not significant. Thus, high serum CRP levels did not appear to increase the risk of colorectal cancer.

CONCLUSIONS: The present results suggest that high serum CRP levels are not associated with the risk of colorectal cancer in the JACC Study.

Appendicitis: selective use of abdominal CT reduces negative appendectomy rate

BACKGROUND

Recent literature supports the use of CT for all patients with right lower quadrant pain to improve diagnostic accuracy and reduce hospital cost. Our current practice at a large teaching hospital is to use CT only for patients whose diagnosis remains in question after a thorough history, physical examination, and focused laboratory assessment. In consideration of a more liberal use of CT for right lower quadrant pain, we reviewed our experience with selective CT and the effect this has had on our practice, paying particular attention to perforation rate and negative appendectomy rate.

MATERIALS AND METHODS

A retrospective chart review was performed for all patients who underwent appendectomy in 1995 and 1998. These two patient populations were evaluated for patient demographics, use of CT scan, perforation rate, and incidence of negative appendectomy.

RESULTS

Three hundred ninety-four patients underwent appendectomy in 1995 versus 372 in 1998. Gender (64% male in 1995 vs. 60% in 1998), age (mean 24.9 vs. 25.5) and perforation rate (31% in 1995 vs. 29% in 1998) did not change. The use of CT increased in 1998 (12% vs. 34%, p < 0.001) and overall nontherapeutic appendectomy decreased (14% vs. 7%, p < 0.005). This decrease was seen in patients who were operated without CT (13% vs. 7%, p < 0.03) and after CT (19% vs. 6%, p < 0.02).

CONCLUSION

Selective use of CT scan in patients presenting with right lower quadrant pain is helpful in reducing the incidence of nontherapeutic appendectomy.

[Leukocyte count, C reactive protein, alpha-1 acid glycoprotein and erythrocyte sedimentation rate in acute appendicitis]

BACKGROUND

The diagnosis of acute appendicitis is clinic, but in some cases, it can present unusual symptoms. The diagnostic difficulties still lead surgeons to unnecessary laparotomies, which reach rates from 15% to 40%. Laboratory exams, then, may become important to complement appendicitis diagnosis. The leucocyte count seems to be the most important value, but measurement of acute phase proteins, specially, the C-reactive protein, is object of several studies.

PATIENTS AND METHODS

This was a prospective study, involving 63 patients submitted to appendecectomies for acute appendicitis suspicion, in "Hospital das Clínicas", Federal University of Uberlândia, MG, Brazil, in whose blood were made dosages of acute phase proteins and the leucocyte count.

RESULTS

The sample was composed by 44 male and 19 female patients, and the majority of them was between 11 and 30 years of age. The flegmonous type was the most freq ent (52.4%). The leucocyte count was altered in 74.6% of the cases and C-reactive protein elevation was observed in 88.9%. The alfa-1 acid glycoprotein and the erithrocyte sedimmentation rate were predominantly normal. The C-reactive protein was augmented in more than 80% of the cases in all ages. Leucocyte count and C-reactive protein were altered in 80% of the patients with the limit of 24 hours from the beginning of symptoms. With clinical evolution time superior than 24 hours, the leucocyte count was altered in 69.7% of the cases, whereas C-reactive protein was in 97%. Sensibility and specificity of the leucocyte count were 88.7% and 20%. For the C-reactive protein, the values were, respectively, 88.9% and 10%. C-reactive protein dosage presented more sensible in cases with more than 24 hours of evolution (96.9%), although with no specificity. The alfa-1 acid glycoprotein and erithrocyte sedimmentation rate presented low sensitivity and specificity.

CONCLUSION

The leucocyte count and the C-reactive protein present significantly altered in acute appendicitis cases, independent from genre or age interval. The leucocyte count and, mainly, the C-reactive protein must be considered in individuals with more than 24 hours of clinical evolution. Augmented values, as a matter of fact, should never substitute the doctor's clinical examination, but complement it. The erithrocyte sedimmentation rate and the alfa-1 acid glycoprotein do not contribute to acute appendicitis diagnosis.

Serum C-reactive protein correlates with survival in colorectal cancer patients but is not an independent prognostic indicator

BACKGROUND

C-reactive protein (CRP) is an acute-phase protein synthesized in liver and up-regulated by pro-inflammatory cytokines, such as interleukin-6 (IL-6), interleukin-8 (IL-8) and tumour necrosis factor (TNF). Elevated CRP has been reported to be associated with reduced crude survival rates in patients with colorectal cancer.

OBJECTIVE

To investigate the prognostic significance of preoperative serum CRP in relation to the disease-specific survival rate and expression of different cytokines.

METHODS

One hundred and seventy-two consecutive patients with colorectal cancer, whose primary lesions were resected, were selected from April 1995 to December 1999. Preoperative serum CRP levels were measured, and the relationship between the elevation of CRP and clinicopathological factors was investigated. Prognostic significance was analysed by univariate and multivariate tests.

RESULTS

One-third of patients had increased CRP levels, and this was associated with larger tumour size, lymph node or liver metastasis, and advanced Dukes' stage. Higher CRP levels were also related to the elevation of IL-6 and IL-8. The most important prognostic factor predicting survival was Dukes' stage (P < 0.001). Multivariate analysis indicated that CRP level is not an independent factor predicting survival.

CONCLUSIONS

A preoperative elevation of serum CRP does not have the independent prognostic significance reported by earlier studies. Whether the elevated CRP can predict the development of cachexia or whether this association characterizes a pattern in tumour behaviour remains to be determined.

Serum interleukin-6 measurement in the diagnosis of acute appendicitis

BACKGROUND

Many attempts have been made to determine ways of decreasing the negative laparotomy rate after a clinical diagnosis of acute appendicitis. The aim of the present study was to determine the effectiveness of serum interleukin-6 (IL-6) concentration in the diagnosis of appendicitis, and in the prevention of non-therapeutic laparotomy in patients with right iliac fossa pain.

METHODS

Serum IL-6 concentrations were measured at admission in 77 consecutive patients who were operated on for the treatment of acute appendicitis. The final diagnosis was established by histopathological examination. The sensitivity, specificity and accuracy of IL-6 concentrations in the diagnosis of appendicitis were calculated.

RESULTS

The negative laparotomy rate was 17% (13/77) in this series. The IL-6 level was elevated in seven of 13 patients (54%; false positive) with a normal appendix. The IL-6 level was normal in 10/64 patients (16%; false negative) with acute appendicitis. The IL-6 level was highly elevated in all patients with perforated appendicitis. The sensitivity, specificity, accuracy, and positive and negative predictive values were calculated as 84, 46, 78, and 89 and 38%, respectively.

CONCLUSIONS

Unacceptably high false negative and positive rates decrease the accuracy of the serum IL-6 test for appendicitis. Serum IL-6 measurement is not of benefit in increasing the accuracy of the diagnosis of appendicitis. Serum IL-6 results are not useful for preventing negative laparotomies in the majority of patients with right iliac fossa pain.

Preoperative elevation of serum C-reactive protein is related to impaired immunity in patients with colorectal cancer

The significance of a preoperative elevation of serum C-reactive protein (CRP) as an indicator of the malignant potential and prognosis in colorectal cancer is reported. The reduction of circulating lymphocytes reflects the immunosuppressive conditions of patients with neoplasms. The aim of the current study was to elucidate the significance of a preoperative elevation of serum CRP as an indicator of the impaired immunity of the patients with colorectal cancer. The subjects were 155 consecutive patients with colorectal cancer who were treated with surgical resection. The preoperative serum CRP level and the proportion of circulating lymphocytes in peripheral blood were measured and the relationship between these values was investigated. The mean value of lymphocytes percentages in patients with the preoperative elevation of serum CRP was 25.2 +/- 8.7%, which was significantly lower than that (33.4 +/- 9.3%) in patients without the preoperative elevation of serum CRP (p < 0.01). In summary, preoperative elevation of serum CRP was significantly related to the reduction of lymphocyte percentages in peripheral blood, and it can be an indicator of impaired immunity in the patients with colorectal cancer.

C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in children

PURPOSE

The aim of this study was to analyze the diagnostic accuracy of C-reactive protein and its possible advantage, if any, over leukocyte counts in acute appendicitis in children.

METHODS

We performed a retrospective study of 124 children (72 males) with a mean age of 9.3 (range, 2-14) years operated on under a clinical diagnosis of acute appendicitis. The diagnosis of acute appendicitis, confirmed by pathologic examination of the removed appendix, was then correlated with C-reactive protein, leukocyte count, and a combination of both C-reactive protein and leukocyte count, with a logistic regression model. C-reactive protein serum measurements were performed by an immunoturbidimetric test. The patients were divided into two groups according to the pathologic features of the removed appendix: Group A (n = 104), patients with acute appendicitis, and Group B (n = 20), patients without acute appendicitis. To assess the accuracy of C-reactive protein, leukocyte counts, and a combination of both parameters, receiver operating characteristic curves were used. The areas under the curve were compared using the maximum likelihood estimation method.

RESULTS

There were 95 cases (76.6 percent) of nonperforated appendicitis, 9 cases (7.3 percent) of perforated appendicitis and 20 cases (16.1 percent) of normal appendix. Mean C-reactive protein in Group A was 4.3 (standard deviation, 6.6) and in Group B was 1.2 (standard deviation, 1.7; P = 0.03). The C-reactive protein and leukocyte count values were correlated with the pathologic diagnosis of acute appendicitis. Mean C-reactive protein values increase as the pathologic inflammation type progresses (P = 0.007). The C-reactive protein receiver operating characteristic curve shows that the C-reactive protein value with highest accuracy was 1.7 mg/dl. The sensitivity, specificity, and accuracy rates calculated in the 1.7 cutoff were 58, 80, and 83.8 percent, respectively. A comparison of the respective receiver operating characteristic curves demonstrates that C-reactive protein, leukocyte count, and the combination of both tests all have a good diagnostic value but without any significant difference (P = 0.2).

CONCLUSIONS

In children, 1) serum C-reactive protein is increased in acute appendicitis; 2) such increase is related to the severity of the appendiceal inflammation; and 3) although serum C-reactive protein has an adequate diagnostic accuracy, neither individually nor in combination with the leukocyte count is it significantly better than the leukocyte count alone.

Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis

BACKGROUND

The aim of the present work was to study the preoperative leucocyte counts and C-reactive protein (CRP) values in three groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendicectomy: an uninflamed appendix, uncomplicated acute appendicitis or complicated acute appendicitis. In particular, patients with acute appendicitis but a normal leucocyte count and CRP level were sought.

METHODS

In this retrospective study, the mean preoperative leucocyte count and CRP value in 100 consecutive patients with an uninflamed appendix (group A), in 100 consecutive patients with uncomplicated acute appendicitis (group B) and in 100 consecutive patients with complicated acute appendicitis (group C) were calculated. The numbers of patients with (1) both values normal, (2) only leucocyte count raised, (3) only CRP level raised and (4) both values raised were calculated in each of the three groups.

RESULTS

The increase in leucocyte count was an early marker of appendiceal inflammation, whereas the CRP value increased markedly only after appendiceal perforation or abscess formation. Group A (uninflamed appendix) contained 24 patients in whom both values were normal. Neither group B (uncomplicated acute appendicitis) nor group C (complicated acute appendicitis) contained any patient with both values in the normal range.

CONCLUSION

Acute appendicitis is very unlikely when both the leucocyte count and CRP value are normal.

Significance of preoperative elevation of serum C-reactive protein as an indicator for prognosis in colorectal cancer

BACKGROUND

C-reactive protein (CRP) is a product synthesized in hepatocytes and has been reported to be upregulated by such proinflammatory cytokines as interleukin-1, interleukin-6, and tumor necrosis factor. The significance of a preoperative serum elevation in CRP as a predictive indicator for the malignant potential and prognosis in colorectal cancer has not been elucidated.

METHOD

One hundred and twenty consecutive patients with colorectal cancer, whose local lesions were resected in our department, were selected. Any patients with inflammatory diseases such as infection or collagen diseases were excluded from the current study. The preoperative serum CRP level was measured, and the relationship between the serum elevation of CRP and both the clinicopathologic factors and prognosis of the patients was investigated.

RESULTS

The incidences of liver metastases, peritonitis carcinomatosa, histopathologic lymph nodes metastasis, and intravascular invasion in patients with a preoperatively elevated serum CRP level were significantly more frequent than in those with a negative serum protein level. The survival rates of the patients without a preoperative elevation of the serum CRP proved to be significantly more favorable than that of the patients with such an elevation (P <0.001).

CONCLUSIONS

A preoperative serum elevation of CRP was thus found to be an indicator of the malignant potential of the tumor as well as a predictor of the prognosis of patients with colorectal cancer.

Have the evaluation and treatment of acute appendicitis changed with new technology?

The evaluation and treatment of acute appendicitis remain essentially unchanged for the majority of individuals who present with this disease. Although advancements have been made in laboratory analysis as well as imaging via ultrasonography and CT, nothing can replace careful evaluation by an experienced surgeon. Appendicitis remains a diagnosis based primarily on history and physical examination, with further studies being useful adjuncts in atypical cases--more likely to occur in the very young or very old and most cost effective when ordered by the surgical consultant. Improvement in outcomes has not been demonstrated with routine use of "new technology." The treatment of acute appendicitis continues to be early surgical intervention. Although laparoscopic appendectomy may offer advantages in women of childbearing age and in obese individuals, its routine use is not indicated based upon current reports in the literature. Debate continues regarding the optimal treatment of the periappendiceal mass. Further clinical research regarding early operation compared with intravenous antibiotics with or without drainage, as well as comparison of outcomes with or without interval appendectomy, needs to be performed. With continued research and definition of populations likely to benefit from advances in technology, a more focused application will be possible. This will lead to improved outcomes and decreased overall cost. The issue of delay in treatment, a major determinant of morbidity associated with appendicitis, warrants further evaluation and should be addressed on a population-specific basis. Emphasis should remain on the early clinical diagnosis of acute appendicitis with its associated low morbidity and mortality.