Evaluation of the diagnostic value of serum level of total bilirubin in patients with suspected acute appendicitis
Keywords:
Bilirubin, Appendicitis, Diagnosis, ComplicationAbstract
Introduction: Clinical diagnosis of acute appendicitis still remains a problem. Delays in diagnosis of acute appendicitis may cause perforation and septic peritonitis which result in increasing morbidity and mortality. The aim of this study was to determine the sensitivity, specificity and the diagnostic value of total serum bilirubin levels as a predictor of acute appendicitis.
Methods: In this cross-sectional study, patients who underwent appendectomy with the diagnosis of acute appendicitis from April 2012 to March 2013 at Emam Reza Hospital in Mashhad (Iran) were enrolled. Serum bilirubin -Total and Direct-, were measured. Then based on the final pathologic reports, patients were categorized into five groups of normal appendix, chronic inflammatory changes, acute appendicitis, gangrenous and/or necrotic changes, and perforated appendicitis. Independent sample t-test, ANOVA, and Chi-square test were used for data analysis by SPSS version 16.
Results: There were 174 patients studied, (117 male, 57 female) with a mean age of 27.15±0.7 years. All of the patients had rebound tenderness; 75.3% had nausea, 58.6% had anorexia and 21.3% had fever. The histological reports of all patients showed 76.4% acute appendicitis. Analyzing p-values for SGPT, SGOT, WBC was (p=0.903) and differential count was (p=0.959). The study showed no significant difference between the pathological groups. However, there were no significant differences in serum total bilirubin levels between the pathological groups. Total bilirubin showed sensitivity of 48% and specificity of 61% in the diagnosis of acute appendicitis. Total serum bilirubin more than 0.85 mg/dl was the cut-off value with the best performance for diagnosis of appendicitis.
Conclusion: Bilirubin levels are reliable, sensitive and specific to diagnosis and a prediction of complicated appendicitis.
References
Chaudhary P, Kumar A, Saxena N, Biswal UC. Hyperbilirubinemia as a predictor of gangrenous/perforated
appendicitis: a prospective study. Ann Gastroenterol. 2013; 26(4): 325-31. PMID: 24714371, PMCID:
PMC3959475.
Vaziri M, Pazouki A, Tamannaie Z, Maghsoudloo F, Pishgahroudsari M, Chaichian S. Comparison of pre- operative bilirubin level in simple appendicitis and perforated appendicitis. Med J Islam Repub Iran. 2013;
(3): 109-12. PMID: 24791119, PMCID: PMC3917482.
Hong YR, Chung CW, Kim JW, Kwon CI, Ahn DH, Kwon SW, et al. Hyperbilirubinemia is a significant
indicator for the severity of acute appendicitis. J Korean Soc Coloproctol. 2012; 28(5): 247-52. doi:
3393/jksc.2012.28.5.247. PMID: 23185704, PMCID: PMC3499425.
Khan S. The diagnostic value of hyperbilirubinemia and total leukocyte count in the evaluation of acute
appendicitis. J Clin Diagn Res. 2009; 3(4): 1647-52.
Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986; 15(5):
-64. doi: 10.1016/S0196-0644(86)80993-3. PMID: 3963537.
Beltran MA, Mendez PE, Barrera RE, Contreras MA, Wilson CS, Cortes VJ, et al. Is hyperbilirubinaemia
in appendicitis a better predictor of perforation than C-reactive protein? - a prospective study. Indian J
Surg. 2009; 71(5): 265-72. doi: 10.1007/s12262-009-0074-8. PMID: 23133170, PMCID: PMC3452791.
Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, et al. US or CT for Diagnosis of
Appendicitis in Children and Adults? A Meta-Analysis. Radiology. 2006; 241(1): 83-94. doi:
1148/radiol.2411050913. PMID: 16928974.
Raman SS, Lu DS, Kadell BM, Vodopich DJ, Sayre J, Cryer H. Accuracy of nonfocused helical CT for the
diagnosis of acute appendicitis: a 5-year review. AJR Am J Roentgenol. 2002; 178(6): 1319-25. doi:
2214/ajr.178.6.1781319. PMID: 12034591.
Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic
imaging. J Am Coll Surg. 2005; 201(6): 933-9. doi: 10.1016/j.jamcollsurg.2005.04.039. PMID: 16310698.
Noh H, Chang SJ, Han A. The diagnostic values of preoperative laboratory markers in children with
complicated appendicitis. J Korean Surg Soc. 2012; 83(4): 237-41. doi: 10.4174/jkss.2012.83.4.237. PMID:
, PMCID: PMC3467390.
Son CS, Jang BK, Seo ST, Kim MS, Kim YN. A hybrid decision support model to discover informative
knowledge in diagnosing acute appendicitis. BMC Med Inform Decis Mak. 2012; 12: 17. doi:
1186/1472-6947-12-17. PMID: 22410346, PMCID: PMC3314559.
Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis:
association with age and sex of the patient and with appendicectomy rate. Eur J Surg. 1992; 158(1): 37-41.
PMID: 1348639.
Panagiotopoulou I, Parashar D, Lin R, Antonowicz S, Wells AD, Bajwa FM, et al. The diagnostic value of
white cell count, C-reactive protein and bilirubin in acute appendicitis and its complications. Ann R Coll
Surg Engl. 2013; 95(3): 215-21. doi: 10.1308/003588413X13511609957371. PMID: 23827295, PMCID:
PMC4165248.
Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? a
population-based analysis. Jama. 2001; 286(14): 1748-53. doi: 10.1001/jama.286.14.1748. PMID:
Bickell NA, Aufses AH, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am
Coll Surg. 2006; 202(3): 401-6. doi: 10.1016/j.jamcollsurg.2005.11.016. PMID: 16500243.
Fike FB, Mortellaro VE, Juang D, Sharp SW, Ostlie DJ, St Peter SD. The impact of postoperative abscess
formation in perforated appendicitis. J Surg Res. 2011; 170(1): 24-6. doi: 10.1016/j.jss.2011.03.038. PMID:
Farooqui W, Pommergaard HC, Burcharth J, Eriksen JR. The diagnostic value of a panel of serological
markers in acute appendicitis. Scand J Surg. 2015; 104(2): 72-8. doi: 10.1177/1457496914529273. PMID:
Emmanuel A, Murchan P, Wilson I, Balfe P. The value of hyperbilirubinaemia in the diagnosis of acute
appendicitis. Ann R Coll Surg Engl. 2011; 93(3): 213-7. doi: 10.1308/147870811X566402. PMID:
, PMCID: PMC3291137.
Andersson RE. Meta‐analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;
(1): 28-37. doi: 10.1002/bjs.4464. PMID: 14716790.
Birchley D. Patients with clinical acute appendicitis should have pre-operative full blood count and Creactive protein assays. Ann R Coll Surg Engl. 2006; 88(1): 27-32. doi: 10.1308/003588406X83041.
PMID: 16460636, PMCID: PMC1963644.
Körner H, Söreide JA, Söndenaa K. Diagnostic accuracy of inflammatory markers in patients operated on
for suspected acute appendicitis: a receiver operating characteristic curve analysis. Eur J Surg. 1999;
(7): 679-85. doi: 10.1080/11024159950189744. PMID: 10452263.
Vaughan-Shaw PG, Rees JR, Bell E, Hamdan M, Platt T. Normal inflammatory markers in appendicitis:
evidence from two independent cohort studies. JRSM Short Rep. 2011; 2(5): 43. doi:
1258/shorts.2011.010114. PMID: 21637404, PMCID: PMC3105453.
Socea B, Carâp A, Rac-Albu M, Constantin V. The value of serum bilirubin level and of white blood cell
count as severity markers for acute appendicitis. Chirurgia (Bucur). 2013; 108(6): 829-34. PMID:
Nomura S, Watanabe M, Komine O, Shioya T, Toyoda T, Bou H, et al. Serum total bilirubin elevation is a
predictor of the clinicopathological severity of acute appendicitis. Surg Today. 2014; 44(6): 1104-8. doi:
1007/s00595-013-0659-5. PMID: 23880964.
Giordano S, Pääkkönen M, Salminen P, Grönroos JM. Elevated serum bilirubin in assessing the likelihood
of perforation in acute appendicitis: a diagnostic meta-analysis. Int J Surg. 2013; 11(9): 795-800. doi:
1016/j.ijsu.2013.05.029. PMID: 23732757.
Estrada JJ, Petrosyan M, Barnhart J, Tao M, Sohn H, Towfigh S, et al. Hyperbilirubinemia in appendicitis:
a new predictor of perforation. J Gastrointest Surg. 2007; 11(6): 714-8. doi: 10.1007/s11605-007-0156-5.
PMID: 17436050.
Sand M, Bechara FG, Holland-Letz T, Sand D, Mehnert G, Mann B. Diagnostic value of
hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis. Am J Surg.
; 198(2): 193-8. doi: 10.1016/j.amjsurg.2008.08.026. PMID: 19306980.
Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Engl J Med. 2003;
(3): 236-42. doi: 10.1056/NEJMcp013351. PMID: 12529465.
Keskek M, Tez M, Yoldas O, Acar A, Akgul O, Gocmen E, et al. Receiver operating characteristic analysis
of leukocyte counts in operations for suspected appendicitis. Am J Emerg Med. 2008; 26(7): 769-72. doi:
1016/j.ajem.2007.10.036. PMID: 18774040.
Póvoa P. C-reactive protein: a valuable marker of sepsis. Intensive Care Med. 2002; 28(3): 235-43. doi:
1007/s00134-002-1209-6. PMID: 11904651.
Grönroos JM, Grönroos P. Leucocyte count and C‐reactive protein in the diagnosis of acute appendicitis.
Br J Surg. 1999; 86(4): 501-4. doi: 10.1046/j.1365-2168.1999.01063.x. PMID: 10215824.
Käser SA, Fankhauser G, Willi N, Maurer CA. C-reactive protein is superior to bilirubin for anticipation of
perforation in acute appendicitis. Scand J Gastroenterol. 2010; 45(7-8): 885-92. doi:
3109/00365521003728572. PMID: 20334601.
Brienza N, Dalfino L, Cinnella G, Diele C, Bruno F, Fiore T. Jaundice in critical illness: promoting factors
of a concealed reality. Intensive Care Med. 2006; 32(2): 267-74. doi: 10.1007/s00134-005-0023-3. PMID:
Khan S. Elevated serum bilirubin in acute appendicitis: a new diagnostic tool. Kathmandu Univ Med J.
; 6(2): 161-5. PMID: 18769079.
Atahan K, Üreyen O, Aslan E, Deniz M, Çökmez A, Gür S, et al. Preoperative diagnostic role of
hyperbilirubinaemia as a marker of appendix perforation. J Int Med Res. 2011; 39(2): 609-18. doi:
1177/147323001103900230. PMID: 21672366.
Emmanuel A, Murchan P, Wilson I, Balfe P. The value of hyperbilirubinaemia in the diagnosis of acute
appendicitis. Ann R Coll Surg Engl. 2011; 93(3): 213-7. doi: 10.1308/147870811X566402. PMID:
, PMCID: PMC3291137.
Ortega-Deballon P, Ruiz de Adana-Belbel JC, Hernández-Matías A, García-Septiem J, Moreno-Azcoita M.
Usefulness of laboratory data in the management of right iliac fossa pain in adults. Dis Colon Rectum.
; 51(7): 1093-9. doi: 10.1007/s10350-008-9265-9. PMID: 18484138, PMCID: PMC2887665.
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. 2009; 91(2): 113-5. doi: 10.1308/003588409X359330.
PMID: 19102827, PMCID: PMC2749345.
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