Leukocyte Count, CRP and Bilirubin Level in Complicated and Non-Complicated Appendicitis: Cross Sectional Study

Research Article

Austin J Surg.2017; 4(3): 1106.

Leukocyte Count, CRP and Bilirubin Level in Complicated and Non-Complicated Appendicitis: Cross Sectional Study

Zejnullahu VA¹, Krasniqi A¹, Isjanovska R³, Bicaj BX¹, Zejnullahu VA¹, Hamza AR¹ and Caloska- Ivanova V²*

¹Department of Abdominal Surgery, University Clinical Centre of Kosova, Kosovo

²Department of Gastroenterohepatology, Ss Cyril and Methodius University of Skopje, Macedonia

³Agency for Quality and Accreditation of Healthcare Organizations in R. Macedonia, Research Fields: Public Health, Health Policies, Health Care Management, Quality and Accreditation, Macedonia

*Corresponding author: Caloska-Ivanov V, Department of Gastroenterology, University Clinical Center of Skopje, Skopje, Republic of Macedonia

Received: August 21, 2017; Accepted: October 24, 2017; Published: October 31, 2017


Background: Undoubtedly, one of the most frequently observed pathology in abdominal surgery is appendicitis, which presents a diagnostic challenge for the majority of general surgeons during their work, regardless of several diagnostic modalities applied.

Aim: The purpose of this study is to evaluate the difference of hyperbilirubinemia, CRP value and leukocyte count in the early diagnosis between the complicated and non- complicated cases of appendicitis.

Materials and Methods: This is a cross sectional study, that was conducted at the University Clinical Center of Prishtina in the Department of Abdominal Surgery in patients admitted with clinical signs of appendiceal inflammation during the period from September 2016 to March 2017. Total number of 91 patients was included in the study. All participants were subjected to the bilirubin level determination, leukocyte count and CRP value determination along with diagnostic, hepatic transaminases and Alvarado score.

Results: The total number of 91 patients with diagnosis of appendicitis acute was involved in this study. The laboratory markers was measured preoperatively for all patients divided in two groups group with complicated appendicitis and group without complication. From the total number of patients 53.8% were male and 45.1% were female. The percentage difference between genders is statistically insignificant p>0.05. In our study we measured the level of WBC, serum bilirubin, CRP and liver enzyme (AST and ALT) between two groups of patients. According to the t- test for WBC, CRP and Bilirubin the difference between two groups are statistical significant (p<0.05).

We didn’t find any difference in the level of AST and ALT between two groups of study. During this study we conclude that predictor model of Alvarado score is useful clinical approach for diagnosis of appendicitis.

Conclusion: Routine measurement of serumbilirubin, CRP, WBC combined with Alvarado Score model in all patients admitted in emergency ward suspected for appendicitis may decrease the rate of complications in acute appendicitis.

Keywords: Acute appendicitis; Serum bilirubin; Ultrasonography; Leukocyte count; Appendectomy


CRP: C - Reactive Protein; WBC: White Blood Cell; MRI: Magnetic Resonance Imaging; CT: Computed Tomography; AIR: Appendicitis Inflammatory Response; PAS: Pediatric Appendicitis Score


The appendix arises from the posteromedial side of the caecum and can be situated in relation to caecum as retrocaecal, pelvic, subcaecal, preileal and in right pericolic area. Summarized findings from Collins in 4,680 appendix postmortal samples, revealed that appendix is placed anteriorly in 50% of cases while 21.4% were with retrocecal localization.

Appendicitis is one of the most common surgical disorders and the cause of emergency surgery on children and in adult ages. Up to 40% of cases occur in the age-group between 10 and 29 years [1]. Common cause of appendicitis is usually obstruction of lumen with nonspecific factors [2,3]. This obstruction occurs from the undigested food, fecaloma, from lymphoid inflammation or even any twist around this organ can be a reason for obstruction.

Escherichia coli and Bacteroides fragilis comprises two organisms which are equally presented in normal appendix as well as in acute and perforated appendicitis [4,5]. Studies in animal models showed that bacteria can interfere with microcirculation on the hepatocyte, thus inducing hepatic damage with impaired acid bile secretion within the hepatobiliary system [6] E. coli affects also the intravascular hemolysis, second mechanisms by which bilirubin levels increases in the blood circulation [7]. Although, it is frequently seen between the second to the fourth decade of life, it can be diagnosed in any given age. Referring to the previous studies appendicitis is more frequent in males compared to females (8.6% vs. 6.7%) [8]. The mortality rate for acute appendicitis with treatment is reported to be less than 1%, high rate of negative appendectomy in children and the constant rate of misdiagnosis up to 15.3% make this condition the diagnostic challenge for the majority of general surgeons during their work [1]. In view of this, it is of crucial importance to decide whether patients need urgent surgery or expectative management may be applied in cases where symptomatology is obscure and further examinations are required. The newest strategy in treatment of uncomplicated acute appendicitis is treatment with antibiotic therapy reserved in early stage of inflammation. From this point of view it is very important to decide whether the conservative approach needs to change in to operative management. Some previous study suggesting for different pattern of treatment between perforated and non-perforated appendicitis [9]. The diagnosis of acute appendicitis and decision when to preformed operation are challenge for any surgeon. Many scoring system are proposed starting from the first score which was presented by Alvarado in 1986 and furthermore modified Alvarado score was presented by Kalan and colleagues [10]. Their score ranged from 0-9 points and include symptoms, signs and laboratory markers. In Sweden, the Appendicitis Inflammatory Response (AIR)-score was presented in 2008 [11]. Adult appendicitis score was presented by Sammalkorpi and colleagues, recently [12]. Concerning the pediatric population two scores are used namely the Pediatric Appendicitis Score (PAS) [13] and the Lintula score [14]. Clinical examination combine with imagery and laboratory markers facilitates the diagnosis and decision for treatment. Early periumbilical pain in appendicitis is conditioned by sympathetic nerve supply and distention of the visceral peritoneum and furthermore, thoracic sensory response because of the parietal peritoneum inflammation, leads to the pain in the right ileocecal region.

Graded compression ultrasound scan for the diagnosis of acute appendicitis, was described for the first time in 1986 by Puylaert [15]. Ultrasound scan alone has a sensitivity of 86%, a specificity of 95% and an accuracy of 92% [16]. Evidence provided by Kaneko and Tsuda showed that ultrasound scan can identify patients who need immediate surgery and enable conservative treatment for mild cases [17]. According to Balthazar and colleagues, computed tomography showed a higher accuracy in the diagnosis of acute appendicitis compared to ultrasound [18]. Another diagnostic modality used in diagnosis of acute appendicitis comprises MRI, which when used as primary diagnostic tool revealed a sensitivity of 96.8% and specificity of 97.4% [19]. The methods such computed tomography and MRI are very expensive and even can delay the diagnosis; especially this method is not available in country with low outcomes.

Laboratory test are very important in diagnostic evaluation of acute appendicitis. Besides the test such is WBC count with differential, serum C Reactive Protein (CRP), and pregnancy test for women of childbearing age, recently several studies focused their attention on the elevated serum bilirubin as a low cost and useful laboratory marker in clinical settings for the diagnosis of the complicated appendicitis. Hyperbilirubinemia was found in 87% of patients with acute appendicitis [20] while in the retrospective study from Sand and colleagues total serum bilirubin was found to be much higher in gangrenous/perforative appendicitis [21]. This paper among many studies is willing to assess whether hyperbilirubinemia together with WBC count and CRP can serve as the primary diagnostic tool in the early diagnosis of appendicitis and to distinguish the complicated from non-complicated acute appendicitis. The operative treatment includes open surgery and laparoscopic appendectomy.

Aim of the Study

The overall aim of this study is to serially compare the laboratory markers between the groups of patients with complicated appendicitis versus the group of patients with non-complicated appendicitis admitted in the emergency ward (Figure 1).