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Tint NP, Hussain H. Near miss abdominal pain. BMJ Case Rep 2021; 14:14/2/e238883. [PMID: 33541988 PMCID: PMC7868178 DOI: 10.1136/bcr-2020-238883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
An 18-year-old adolescent with intermittent colicky abdominal pain for 4 months was admitted to a Medical Emergency Assessment Unit for further investigation of possible colitis, after being reviewed by a surgeon in Accident and Emergency. Initially he was treated for a urinary tract infection, however a CT of the abdomen revealed appendicular perforation with pelvic abscess formation. The patient required an urgent laparoscopy and was discharged without complications. Typically, appendicitis is an acute surgical problem whereas chronic abdominal pain is routinely considered a medical problem. This case demonstrates the importance of maintaining acute causes as part of the differentials list in young patients with unexplained recurrent abdominal pain as well as justifying the early use of CT when there is ambiguity surrounding a diagnosis.
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Affiliation(s)
- Nyan Phone Tint
- Acute Medicine, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
| | - Hamzah Hussain
- University of Nottingham, Nottingham, Nottinghamshire, UK
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Huckins DS, Copeland K. Diagnostic accuracy of combined WBC, ANC and CRP in adult emergency department patients suspected of acute appendicitis. Am J Emerg Med 2020; 44:401-406. [PMID: 32482481 DOI: 10.1016/j.ajem.2020.04.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 04/07/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES To assess the sensitivity, specificity, and negative predictive value (NPV) of normal total white blood cell count (WBC) and normal absolute neutrophil count (ANC) combined with a normal proprietary C-reactive protein (pCRP) level in adult emergency department (ED) patients with abdominal pain suspected of possible acute appendicitis. METHODS We prospectively enrolled patients ≥18 years of age at seven U.S. emergency departments with ≤72 h of abdominal pain and other signs and symptoms suggesting possible acute appendicitis. Sensitivity, specificity, and NPV for normal WBC and ANC combined with normal pCRP were correlated with the final diagnosis of acute appendicitis. RESULTS We enrolled 422 patients with a prevalence of acute appendicitis of 19.1%. The combination of normal WBC and pCRP exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), an NPV of 98.8% (95% CI, 95.9-99.7%) and a specificity of 50.0% (95% CI, 44.7-55.3%) for acute appendicitis. Normal ANC and pCRP resulted in a sensitivity of 100% (95% CI, 95.4-100%), a negative predictive value of 100% (95% CI, 97.5-100%) and a specificity of 44.4% (95% CI, 39.2-49.7%) for acute appendicitis. Normal WBC and pCRP correctly identified 171 of 342 (50.0%) patients who did not have appendicitis with 2 (2.5%) false negatives, while normal ANC and pCRP identified 150 of 338 (44.3%) of patients without appendicitis with no false negatives. CONCLUSION The combination of normal WBC and ANC with normal pCRP levels exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult patient cohort. Confirmation and validation of these findings with further study using commercially available CRP assays is needed.
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Affiliation(s)
- David S Huckins
- Division of Emergency Medicine, Newton-Wellesley Hospital, Newton, MA, United States of America.
| | - Karen Copeland
- Boulder Statistics, LLC, Boulder, CO, United States of America
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Evaluation of proadrenomedullin as a diagnostic or prognostic biomarker of acute appendicitis in children. Am J Emerg Med 2016; 34:2298-2305. [PMID: 27609121 DOI: 10.1016/j.ajem.2016.08.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 08/11/2016] [Accepted: 08/13/2016] [Indexed: 12/24/2022] Open
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Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis. Surg Endosc 2016; 31:1022-1031. [PMID: 27495334 PMCID: PMC5315733 DOI: 10.1007/s00464-016-5109-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/09/2016] [Indexed: 12/12/2022]
Abstract
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.
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Huckins DS, Simon HK, Copeland K, Milling TJ, Spandorfer PR, Hennes H, Allen C, Gogain J. Prospective validation of a biomarker panel to identify pediatric ED patients with abdominal pain who are at low risk for acute appendicitis. Am J Emerg Med 2016; 34:1373-82. [PMID: 27133536 DOI: 10.1016/j.ajem.2016.03.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/08/2016] [Accepted: 03/30/2016] [Indexed: 12/29/2022] Open
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de Oliveira Machado SL, Bagatini MD, da Costa P, Baldissarelli J, Reichert KP, de Oliveira LS, Lemos JG, Duarte T, Chitolina Schetinger MR, Morsch VM. Evaluation of mediators of oxidative stress and inflammation in patients with acute appendicitis. Biomarkers 2016; 21:530-7. [PMID: 27075266 DOI: 10.3109/1354750x.2016.1160426] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
CONTEXT This study aims to explore the potential of new inflammatory markers for improving the challenging diagnosis of acute appendicitis (AA). METHODS Levels of IL-1, IL-6, IL-8, IL-10, CRP, INF-γ, and TNF-α in serum were measured in 73 patients with AA. Oxidative stress and antioxidant enzymes were analyzed. RESULTS Serum levels of interleukins, TNF-α, and INF-γ were significantly elevated in patients with appendicitis (p < 0.0001), except for IL-10, which presented decreased levels. There were no significant differences in SOD (p = 0.29), CAT (p = 0.19), or TBARS levels (p = 0.18), whereas protein carbonyls presented significant increase (p < 0.0001). CONCLUSION Evaluating these biomarkers could aid in diagnosing AA.
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Affiliation(s)
| | | | - Pauline da Costa
- c Department of Biochemistry and Molecular Biology , Federal University of Santa Maria , Santa Maria , Brazil
| | - Jucimara Baldissarelli
- c Department of Biochemistry and Molecular Biology , Federal University of Santa Maria , Santa Maria , Brazil
| | - Karine Paula Reichert
- c Department of Biochemistry and Molecular Biology , Federal University of Santa Maria , Santa Maria , Brazil
| | - Lizielle Souza de Oliveira
- c Department of Biochemistry and Molecular Biology , Federal University of Santa Maria , Santa Maria , Brazil
| | - Jéssica Gonçalves Lemos
- c Department of Biochemistry and Molecular Biology , Federal University of Santa Maria , Santa Maria , Brazil
| | - Thiago Duarte
- d Department of Pharmacology , Federal University of Santa Maria , Santa Maria , Brazil
| | | | - Vera Maria Morsch
- c Department of Biochemistry and Molecular Biology , Federal University of Santa Maria , Santa Maria , Brazil
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7
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How do we approach an adult patient with suspected acute appendicitis? MEDICINA UNIVERSITARIA 2016. [DOI: 10.1016/j.rmu.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Xiao Z, Wilson C, Robertson HL, Roberts DJ, Ball CG, Jenne CN, Kirkpatrick AW. Inflammatory mediators in intra-abdominal sepsis or injury - a scoping review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:373. [PMID: 26502877 PMCID: PMC4623902 DOI: 10.1186/s13054-015-1093-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/07/2015] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Zhengwen Xiao
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Crystal Wilson
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Helen Lee Robertson
- Health Sciences Library, Health Sciences Centre, University of Calgary, 3330 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada.
| | - Derek J Roberts
- Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Community Health Sciences (Division of Epidemiology), University of Calgary, 3280 Hospital Drive Northwest, T2N 4Z6, Calgary, AB, Canada.
| | - Chad G Ball
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Craig N Jenne
- Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, 3134 Hospital Drive NW, T2N 5A1, Calgary, AB, Canada. .,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3280 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada.
| | - Andrew W Kirkpatrick
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, 3134 Hospital Drive NW, T2N 5A1, Calgary, AB, Canada.
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Correlation of serum C-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis. World J Emerg Surg 2012; 7:27. [PMID: 22866907 PMCID: PMC3469372 DOI: 10.1186/1749-7922-7-27] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/31/2012] [Indexed: 11/10/2022] Open
Abstract
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.
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Abstract
OBJECTIVES The objective was to describe the association between two novel biomarkers, calprotectin and leucine-rich alpha glycoprotein-1 (LRG), and appendicitis in children. METHODS This was a prospective, cross-sectional study of children 3 to 18 years old presenting to a pediatric emergency department (ED) with possible appendicitis. Blood and urine samples were assayed for calprotectin and LRG via enzyme-linked immunosorbent assay (ELISA). Final diagnosis was determined by histopathology or telephone follow-up. Biomarker levels were compared for subjects with and without appendicitis. Recursive partitioning was used to identify thresholds that predicted appendicitis. RESULTS Of 176 subjects, mean (±SD) age was 11.6 (±4.0) years and 52% were male. Fifty-eight patients (34%) were diagnosed with appendicitis. Median plasma calprotectin, serum LRG, and urine LRG levels were higher in appendicitis versus nonappendicitis (p < 0.008). When stratified by perforation status, median plasma calprotectin and serum LRG levels were higher in nonperforated appendicitis versus nonappendicitis (p < 0.01). Median serum LRG, urine LRG, and plasma calprotectin levels were higher in perforated appendicitis compared to nonperforated appendicitis (p < 0.05). Urine calprotectin did not differ among groups. A serum LRG < 40,150 ng/mL, a urine LRG < 42 ng/mL, and a plasma calprotectin < 159 ng/mL, each provided a sensitivity and negative predictive value of 100% to identify children at low risk for appendicitis, but with specificities ranging from 23% to 35%. The standard white blood cell (WBC) count achieved 100% sensitivity at a higher specificity than both novel biomarkers. CONCLUSIONS Plasma calprotectin and serum/urine LRG are elevated in pediatric appendicitis. No individual marker performed as well as the WBC count.
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Affiliation(s)
- Anupam B Kharbanda
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Kisacik B, Erol MF, Yilmaz G, Yilmaz FM, Maras Y, Kalyoncu U, Karadag O, Kiraz S, Ertenli I, Calguneri M. Resistin and visfatin: are they valuable enough to be the differential diagnosis in familial Mediterranean fever with acute appendicitis? Clin Rheumatol 2011; 31:225-9. [PMID: 21735058 DOI: 10.1007/s10067-011-1806-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/17/2011] [Accepted: 06/20/2011] [Indexed: 12/26/2022]
Abstract
Familial Mediterranean fever (FMF) is an autosomal recessive disease which predominantly affects certain ethnic groups mainly Sephardic Jews, Turks, Arabs, and Armenians. Differential diagnosis of an attack of FMF with appendicitis could be difficult in patients presenting with acute abdomen. Circulating levels of resistin and visfatin have been shown to increase in several inflammatory conditions. In this study we aimed to investigate the role of resistin and visfatin in diseases activity by monitoring these adipokines' levels in patients with FMF (attacks and attack-free period) and acute appendicitis. The study involves four groups: group 1-31 FMF patients at attack (M/F, 14/17), group 2-27 FMF patients at attack-free period (M/F, 9/18), group 3-29 acute appendicitis patients (M/F, 16/13), and group 4-20 healthy controls (M/F, 10/10). Erythrocyte sedimentation rate, C-reactive protein, white blood cell count, fibrinogen, resistin, visfatin, interleukin-1β, interleukin-6, interleukin-10, TNF-α, and IFN-γ were evaluated concurrently. Resistin level could be a useful test in diagnosis of FMF patients in attacks period but not in acute appendicitis as differential diagnosis. Measuring visfatin levels would not give additional information neither for attacks and attack-free period nor FMF attack and appendicitis.
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Affiliation(s)
- Bunyamin Kisacik
- Department of Internal Medicine Division of Rheumatology, Gaziantep University Faculty of Medicine, Gaziantep, Turkey.
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Reed JL, Strait RT, Kachelmeyer AM, Byczkowski TL, Ho ML, Huppert JS. Biomarkers to distinguish surgical etiologies in females with lower quadrant abdominal pain. Acad Emerg Med 2011; 18:686-91. [PMID: 21762231 DOI: 10.1111/j.1553-2712.2011.01108.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Lower abdominal pain is a common complaint in girls and young women presenting to a pediatric emergency department (PED). An extensive evaluation may be required to exclude surgical emergencies such as appendicitis and ovarian torsion. However, clinicians and families prefer to limit invasive procedures and radiation exposure. The literature suggests that serum biomarkers such as the cytokine interleukin-6 (IL-6) can predict ovarian torsion in adults, while the membrane glycoprotein cluster of differentiation-64 (CD64) has been linked with bacterial infections and sepsis. Therefore, the study objective was to assess whether plasma IL-6 or neutrophil CD64 surface levels would assist clinicians in distinguishing surgical diagnoses (ovarian torsion and appendicitis) from nonsurgical diagnoses in young females with lower abdominal pain. METHODS This study was a prospective, cross-sectional, pilot study of young females presenting with lower abdominal pain. Demographics, clinical and laboratory data, and final diagnoses were recorded. Plasma IL-6 and neutrophil CD64 were quantified. Nonparametric Kruskal-Wallis test was used to detect significant differences in IL-6 and CD64 values between surgical and nonsurgical patients. Further analysis was done to detect differences among the surgical patients (appendicitis vs. ovarian torsion). A bivariate analysis using the Wilcoxon rank sum was used to test for significant differences in IL-6 and CD64 by selected clinical factors. RESULTS There were 112 female subjects ages 6 to 21 years enrolled. Final diagnoses were grouped as appendicitis (n = 38, 34%), ovarian torsion (n = 15, 13%), and nonsurgical (n = 59, 53%). Surgical cases had significantly higher levels of IL-6 compared to nonsurgical cases (p < 0.0001), and appendicitis patients had significantly higher CD64 indexes compared to ovarian torsion patients (p = 0.007). The clinical characteristics of fever of ≥38°C (p = 0.0002) and constant pain (p = 0.02) were significantly associated with elevated IL-6. Fever of ≥38°C (p = 0.02) was significantly associated with a higher CD64 index. CONCLUSIONS Interleukin-6 was significantly elevated in surgical patients compared to nonsurgical patients in this sample of young females, and CD64 was significantly elevated in appendicitis patients compared to ovarian torsion patients. These data suggest that with larger sample sizes and future confirmatory studies, these biomarkers may be useful in the evaluation of young women with lower quadrant abdominal pain.
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Affiliation(s)
- Jennifer L Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, OH, USA.
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13
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Serum Markers in Acute Appendicitis. J Surg Res 2011; 168:70-5. [DOI: 10.1016/j.jss.2009.10.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 09/01/2009] [Accepted: 10/19/2009] [Indexed: 12/22/2022]
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Vaughan-Shaw PG, Rees JR, Bell E, Hamdan M, Platt T. Normal inflammatory markers in appendicitis: evidence from two independent cohort studies. JRSM SHORT REPORTS 2011; 2:43. [PMID: 21637404 PMCID: PMC3105453 DOI: 10.1258/shorts.2011.010114] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- P G Vaughan-Shaw
- Department of Lower GI Surgery, Southampton University Hospitals Foundation Trust , Southampton , UK
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An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis. Langenbecks Arch Surg 2009. [PMID: 19924436 DOI: 10.1007/s00423-009-0565-x.epub] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions. OBJECTIVE The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis. MATERIAL AND METHODS The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used. RESULTS AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively). CONCLUSIONS 1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.
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An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis. Langenbecks Arch Surg 2009; 395:1061-8. [PMID: 19924436 DOI: 10.1007/s00423-009-0565-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 10/16/2009] [Indexed: 12/29/2022]
Abstract
BACKGROUND Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions. OBJECTIVE The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis. MATERIAL AND METHODS The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used. RESULTS AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively). CONCLUSIONS 1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.
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Laméris W, van Randen A, Go PMNYH, Bouma WH, Donkervoort SC, Bossuyt PMM, Stoker J, Boermeester MA. Single and combined diagnostic value of clinical features and laboratory tests in acute appendicitis. Acad Emerg Med 2009; 16:835-42. [PMID: 19689484 DOI: 10.1111/j.1553-2712.2009.00486.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to evaluate the diagnostic accuracy of clinical features and laboratory test results in detecting acute appendicitis. METHODS Clinical features and laboratory test results were prospectively recorded in a consecutive series of 1,101 patients presenting with abdominal pain at the emergency department (ED) in six hospitals. Likelihood ratios (LRs) and the areas under the receiver operating characteristic curve (AUC) were calculated for the individual features. Variants of clinical presentation, based on different combinations of clinical features, were investigated and the accuracies of combinations of clinical features were evaluated. RESULTS The discriminative power (AUC) of the individual features in patients with suspected appendicitis ranged from 0.50 to 0.65. For five of the 23 predictor sets, the accuracy for appendicitis was more than 85%. This accuracy was only found in male patients. The relative frequency of these predictor sets ranged from 2% to 13% of patients with suspected appendicitis. A combination of the clinical features migration of pain to the right lower quadrant (RLQ), and direct tenderness in the RLQ, was present in only 28% (120/422) of clinically suspected patients, of whom no more than 85 patients had appendicitis (71%). A "classical" presentation (combination of migration of pain to the RLQ, tenderness in the RLQ, and rigidity) occurred in only 6% (25/422) of patients with suspected appendicitis and yielded an accuracy of 100% in males but only 46% in females. CONCLUSIONS The discriminative power (AUC) of individual clinical features and laboratory test results for appendicitis was weak in patients with suspected appendicitis. Combinations of clinical features and laboratory tests with high diagnostic accuracy are relatively infrequent in patients with suspected appendicitis.
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Affiliation(s)
- Wytze Laméris
- Department of Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
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18
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Sengupta A, Bax G, Paterson-Brown S. White cell count and C-reactive protein measurement in patients with possible appendicitis. Ann R Coll Surg Engl 2008; 91:113-5. [PMID: 19102827 DOI: 10.1308/003588409x359330] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Anshuman Sengupta
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.
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19
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Groselj-Grenc M, Repse S, Dolenc-Strazar Z, Hojker S, Derganc M. Interleukin-6 and lipopolysaccharide-binding protein in acute appendicitis in children. Scandinavian Journal of Clinical and Laboratory Investigation 2007; 67:197-206. [PMID: 17365999 DOI: 10.1080/00365510601010397] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of the study was to evaluate the diagnostic accuracy of interleukin-6 (IL-6) and lipopolysaccharide-binding protein (LBP) in children with acute appendicitis (AA) and to compare this with the diagnostic accuracy of routinely used C-reactive protein (CRP) and white blood cell (WBC) count. Eighty-two consecutive children admitted to our Department because of suspected AA were enrolled in this prospective study and classified into two groups: group 1 (49 children who underwent surgery for AA) and group 2 (33 children with no surgery with diagnosis of non-specific abdominal pain or sonographic mesenteric lymphadenitis). There were no negative appendectomies during the time of the study. The patients were further classified into three subgroups: subgroup 1A (43 patients with advanced AA), subgroup 2A (11 patients with mesenteric lymphadenitis) and subgroup 2B (10 patients with non-specific abdominal pain). The perforation rate was 32.7 %. WBC count and serum CRP, IL-6 and LBP were measured on admission. Area under receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity and predictive values were evaluated. Serum IL-6 and LBP were significantly higher in group 1 than in group 2. The highest AUC for AA was that for IL-6 (0.776), followed by WBC count (0.684), CRP (0.637) and LBP (0.635). In conclusion, only IL-6, determined on admission, showed medium diagnostic accuracy, while other laboratory markers showed low diagnostic accuracy for AA in children. The new laboratory markers therefore do not significantly improve the diagnosis of AA.
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Affiliation(s)
- M Groselj-Grenc
- Department of Paediatric Surgery and Intensive Care, University Medical Centre, Ljubljana, Slovenia
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20
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Sack U, Biereder B, Elouahidi T, Bauer K, Keller T, Tröbs RB. Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children. BMC Surg 2006; 6:15. [PMID: 17132173 PMCID: PMC1712352 DOI: 10.1186/1471-2482-6-15] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Accepted: 11/28/2006] [Indexed: 12/14/2022] Open
Abstract
Background Acute appendicitis (AA) is a common surgical problem that is associated with an acute-phase reaction. Previous studies have shown that cytokines and acute-phase proteins are activated and may serve as indicators for the severity of appendicitis. The aim of this study was to compare diagnostic value of different serum inflammatory markers in detection of phlegmonous or perforated appendicitis in children. Methods Data were collected prospectively on 211 consecutive children. Laparotomy was performed for suspected AA for 189 patients. Patients were subdivided into groups: nonsurgical abdominal pain, early appendicitis, phlegmonous or gangrenous appendicitis, perforated appendicitis. White blood cell count (WBC), serum C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor α (TNF-α), acid α1-glycoprotein (α1GP), endotoxin, and erythrocyte sedimentation reaction (ESR) were estimated ad the time of admission. The diagnostic performance was analyzed using receiver operating characteristic (ROC) curves. Results WBC count, CRP and IL-6 correlated significantly with the severity of appendiceal inflammation. Identification of children with severe appendicitis was supported by IL-6 or CRP but not WBC. Between IL-6 and CRP, there were no significant differences in diagnostic use. Conclusion Laboratory results should be considered to be integrated within the clinical assessment. If used critically, CRP and IL-6 equally provide surgeons with complementary information in discerning the necessity for urgent operation.
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Affiliation(s)
- Ulrich Sack
- Institute of Clinical Immunology and Transfusion Medicine, Medical Faculty of the University of Leipzig, Leipzig, Germany
| | - Birgit Biereder
- Department of Pediatric Surgery, Medical Faculty of the University of Leipzig, Leipzig, Germany
| | - Tino Elouahidi
- Department of Pediatric Surgery, Medical Faculty of the University of Leipzig, Leipzig, Germany
| | - Katrin Bauer
- Institute of Clinical Immunology and Transfusion Medicine, Medical Faculty of the University of Leipzig, Leipzig, Germany
| | | | - Ralf-Bodo Tröbs
- Department of Pediatric Surgery, Ruhr-University of Bochum, Marienhospital Herne, Herne, Germany
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Arfa N, Gharbi L, Marsaoui L, Ben Rhouma S, Farhati S, Bougamra S, Mannai S, Ghariani B, Mestiri H, Khalfallah MT. Douleurs aiguës de la fosse iliaque droite: intérêt de la surveillance clinique hospitalière. Presse Med 2006; 35:393-8. [PMID: 16550128 DOI: 10.1016/s0755-4982(06)74602-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Because of the potential severity of acute appendicitis, many authors recommend the broad use of appendectomy. In this case, 15 to 20% of appendectomies are ultimately found to have been unnecessary. Hospital observation with repeated clinical and laboratory exams can be useful for patients with atypical clinical presentation. This paper assesses our approach, in which some patients with pain in the right iliac fossa (RIF) are admitted for observation before a decision about appendectomy. PATIENTS AND METHODS All patients (205 cases) admitted from March 2002 through February 2003 for acute abdominal pain of the RIF were included in this prospective study. The 120 women and 85 men (sex ratio=0.7) had a mean age of 27 years. We classified the patients into 3 groups: those who had an emergency appendectomy, those who had surgery after an observation period, and those discharged without appendectomy after observation. RESULTS The first group included 110 patients: 63% had a (rectal) temperature greater than 38 degrees C; 44% had guarding of the RIF and 87% elevated white blood cell counts (>10000/mm3). At surgery, appendicitis was diagnosed in 92%. After a mean delay of 36 hours of observation, 50 of the patients in the second group underwent surgery: 44% with (rectal) temperature > 38 degrees C, RIF guarding in 8%, and elevated white blood cell count (>10000/mm3) in 74%. In this group, 94% were diagnosed with appendicitis during surgery. Forty-five patients were discharged without surgery after 36 hours of observation. COMMENTARY In this study, pain and RIF guarding, associated with temperature greater than 38 degrees C and elevated white blood cell counts, were predictive of appendicitis in 96% of cases. Admission for observation of patients with atypical presentation avoided 45 unnecessary appendectomies (22%).
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Affiliation(s)
- Nafaa Arfa
- Service de Chirurgie Générale, Hôpital Mongi Slim, La Marsa, Tunisie.
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Birchley D. Patients with clinical acute appendicitis should have pre-operative full blood count and C-reactive protein assays. Ann R Coll Surg Engl 2006; 88:27-32. [PMID: 16460636 PMCID: PMC1963644 DOI: 10.1308/003588406x83041] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The role of inflammatory markers in the diagnosis of acute appendicitis has not been clearly defined. The aims of this prospective audit were to define the role of the serum markers of inflammation total white cell count, neutrophil count and C-reactive protein in the diagnosis of acute appendicitis with particular reference to the discrimination between uncomplicated and complicated appendicitis, and the prediction of abscess. PATIENTS AND METHODS The author compiled a prospective database over a 13-month period of all appendicectomies performed. After five exclusions (three having no notes for review and two having confounding second morbidity in the presence of a normal appendix), the data relating to 75 patients were analysed. RESULTS In patients judged on clinical grounds to require laparotomy for suspected acute appendicitis, white cell count and neutrophil count distinguish acute appendicitis from normal appendices when used as categorical variables, though they do not reflect the presence of abscess. C-reactive protein neither distinguishes appendicitis from normal, nor predicts abscess when used as a categorical variable, though higher levels suggest abscess. CONCLUSIONS Laboratory tests of the white cell count, neutrophil count and C-reactive protein are more effective in supporting a clinical diagnosis of acute appendicitis in patients with typical clinical features than in excluding the diagnosis.
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Affiliation(s)
- D Birchley
- Department of Vascular Surgery, Torbay Hospital, Torquay, UK.
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Abstract
Inflammation is an important indicator of tissue injury. In the acute form, there is usually accumulation of fluids and plasma components in the affected tissues. Platelet activation and the appearance in blood of abnormally increased numbers of polymorphonucleocytes, lymphocytes, plasma cells and macrophages usually occur. Infectious disorders such as sepsis, meningitis, respiratory infection, urinary tract infection, viral infection, and bacterial infection usually induce an inflammatory response. Chronic inflammation is often associated with diabetes mellitus, acute myocardial infarction, coronary artery disease, kidney diseases, and certain auto-immune disorders, such as rheumatoid arthritis, organ failures and other disorders with an inflammatory component or etiology. The disorder may occur before inflammation is apparent. Markers of inflammation such as C-reactive protein (CRP) and urinary trypsin inhibitors have changed our appraisal of acute events such as myocardial infarction; the infarct may be a response to acute infection and (or) inflammation. We describe here the pathophysiology of an anti-inflammatory agent termed urinary trypsin inhibitor (uTi). It is an important anti-inflammatory substance that is present in urine, blood and all organs. We also describe the anti-inflammatory agent bikunin, a selective inhibitor of serine proteases. The latter are important in modulating inflammatory events and even shutting them down.
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Almagor M, Mintz A, Sibirsky O, Durst A. Preoperative and postoperative levels of interleukin-6 in patients with acute appendicitis: comparison between open and laparoscopic appendectomy. Surg Endosc 2004; 19:331-3. [PMID: 15645323 DOI: 10.1007/s00464-003-9311-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2003] [Accepted: 06/17/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cytokine interleukin-6 (IL-6) is an early marker of systemic inflammatory response and tissue damage. This study aimed to evaluate the levels of IL-6 after open and laparoscopic appendectomy to compare the degree of surgical stress associated with these procedures. METHODS The levels of IL-6 were measured pre- and postoperatively in the plasma of 37 consecutive patients with a diagnosis of acute appendicitis. After preoperative randomization, 22 patients underwent open appendectomy, and 15 patients underwent laparoscopic appendectomy. RESULTS The preoperative concentrations of IL-6 were 7.2 +/- 5.6 pg/ml in the open appendectomy group, as compared with 12.1 +/- 9.7 pg/ml in the laparoscopic appendectomy group (p < 0.05). The postoperative levels were 16.9 +/- 15.7 and 23.2 +/- 19.4 pg/ml, respectively. The mean postoperative to preoperative ratio of IL-6 was slightly higher for open (2.7 +/- 2.4) than for laparoscopic (2.3 +/- 1.6) appendectomy, but the difference did not reach statistical significance. CONCLUSION The operative stress in open as compared with laparoscopic appendectomy is not reflected by circulating levels of IL-6.
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Affiliation(s)
- M Almagor
- Division of Clinical Laboratories, Bikur Cholim Hospital, 5 Strauss Street, Jerusalem, 91002, Israel.
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25
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Abstract
BACKGROUND The importance of specific elements in the clinical diagnosis of appendicitis is controversial. This review analyses the diagnostic value of elements of disease history, clinical findings and laboratory test results in suspected appendicitis. METHODS A systematic Medline search was made of all published studies on the clinical and laboratory diagnosis of appendicitis in patients admitted to hospital with suspected disease. Meta-analyses of receiver-operator characteristic (ROC) areas, and positive and negative likelihood ratios, of 28 diagnostic variables described in 24 studies are presented. RESULTS Inflammatory response variables (granulocyte count, proportion of polymorphonuclear blood cells, white blood cell count and C-reactive protein concentration), descriptors of peritoneal irritation (rebound and percussion tenderness, guarding and rigidity) and migration of pain were the strongest discriminators, with ROC areas of 0.78 to 0.68. The discriminatory power of the inflammatory variables was particularly strong for perforated appendicitis, with ROC areas of 0.85 to 0.87. Appendicitis was likely when two or more inflammatory variables were increased and unlikely when all were normal. CONCLUSION Although all clinical and laboratory variables are weak discriminators individually, they achieve a high discriminatory power when combined. Laboratory examination of the inflammatory response, clinical descriptors of peritoneal irritation, and a history of migration of pain yield the most important diagnostic information and should be included in any diagnostic assessment.
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Affiliation(s)
- R E B Andersson
- Department of Surgery, County Hospital Ryhov, SE-551 85 Jönköping, Sweden.
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