Study of serum bilirubin as a diagnostic method to predict acute perforated appendicitis

Background: Acute appendicitis is the commonest cause of ‘acute surgical abdomen’. Appendicectomy is the most frequently performed urgent abdominal operation and is often the first major procedure performed by a surgeon in training. The aim of the study was to whether hyperbilirubinemia might be used as a diagnostic tool to predict perforated appendicitis.Methods: This study comprised patients who presented with the condition of appendicitis and abnormal liver function tests on admission and had a laparoscopic or open appendectomy. The age information, duration of symptoms, temperature, white blood cell counts, bilirubin levels, and histology data were gathered. Peritoneal fluid was cultured and examined for sensitivity.Results: The average bilirubin level of all participating patients was 0.92 mg/dl (range, 0.1-4.3 mg/dl). The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (0.7 mg/dl and 0.4 mg/dl, p<0.001). Hyperbilirubinaemia was reported to have a specificity of 89% and a positive predictive value of 90.02% for acute appendicitis. Patients with appendiceal perforation, however, had a mean bilirubin level of 1.7 mg/dl and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 73%.Conclusions: Patients with hyperbilirubinemia with appendicitis condition should be screened for a greater risk of appendiceal perforation than those with normal bilirubin levels.

Appendiceal Intraluminal Gas: A CT Marker for Gangrenous Appendicitis

Introduction. This manuscript aims to investigate the amount of intraluminal gas in acute, nonperforated appendicitis identified on computed tomography (CT) in diagnosing gangrenous appendicitis. Methods. This is a retrospective observational, case-control study with consecutive data collected at a tertiary institution over a two-year period, of patients with CT-diagnosed acute appendicitis who subsequently went on for surgery within 48 hours. Patients who were less than 16 years old, who had an interval between CT and surgery of more than 48 hours, or with CT evidence of appendiceal perforation were excluded. Images were independently assessed by 3 radiologists for intraluminal gas, and the results were then correlated with reference standards obtained from surgical and histopathology reports for the diagnosis of nongangrenous versus gangrenous appendicitis. The sensitivity, specificity, and predictive values of CT intraluminal gas in gangrenous appendicitis were calculated. Results. Our study identified 93 patients with nonperforated acute appendicitis who underwent surgery within the stated timeframe. Intraluminal gas in the appendix was identified in 26 patients (28%), of which 54% had macroscopic and/or microscopic evidence of gangrenous appendicitis. This is in contrast to the subgroup of patients who did not have intraluminal gas (72%), of which only 33% had gangrenous appendicitis. The specificity of intraluminal gas for gangrenous appendicitis is 79%, with a negative predictive value of 86% and likelihood ratio of 1.85. Conclusion. In cases of established acute appendicitis, the presence of intraluminal gas is a moderately specific sign for gangrenous complication. This is worth reporting as it can help prognosticate and triage patients accordingly, for a timelier surgical management and a better outcome.

TP10.2.10A Prospective Analysis of Imaging Modalities in Appendicitis during the COVID-19 Pandemic

Aims Acute appendicitis is a common general surgical emergency, occurring in 90-100 per 100,000 patients per year. Clinical practice in the UK involves either a clinical or ultrasound (US) diagnosis, with computed tomography (CT) reserved for cases of suspected complicated appendicitis. Due to the COVID-19 pandemic management pathways were altered, this study sought to capture that. Methods This prospective study included adult patients with suspected appendicitis at a single UK centre from March-June 2020. The primary outcome measures were rates of US and CT imaging. Secondary outcomes included subsequent operative and histological findings. Results Seventy-five patients were included. A clinical diagnosis of appendicitis was made in 11 (15%). Thirty-five (47%) patients had CT, 22 (29%) had an US and 7 (9%) had both. The appendix was visualised in only 10 patients and a radiological diagnosis of appendicitis was made in 6 cases. Appendicitis was confirmed on histology in 67% of subsequently operated cases. CT evidence of appendicitis correlated with operative appendicitis in 93% (28/30) of cases. There were two cases of appendiceal malignancy not demonstrated on CT. Correlation of complicated appendicitis between CT and operative findings was poor; one third (10/28) of patients had appendiceal perforation not identified on CT. Conclusions The use of CT for diagnosing appendicitis was markedly increased during the first wave of the pandemic. The appendix was visualised infrequently on ultrasound, but when seen correlated well with histological findings. CT was superior at detecting appendicitis but failed to differentiate well between complicated and uncomplicated disease.

EP.FRI.241 Negative appendicectomy rate and role of biomarkers in predicting the severity of acute appendicitis

Aim Acute appendicitis is the most common general surgical emergency. A recent consensus study has proposed a 10% negative appendicectomy rate. We aimed to determine the negative appendicectomy rate in our centre whilst evaluating the role of biomarkers in predicting the severity of appendicitis. Methods A single-centre retrospective analysis of consecutive laparoscopic appendicectomies from 2019-2020 was performed. Patients were categorised by severity using AAST grading system. Kruskal-Wallis test was used to compare biomarkers levels (WCC, CRP, bilirubin, neutrophil:lymphocyte ratio (NLR) and platelet:lymphocyte ratio (PLR)). T-test, ROC curve and Fisher’s exact test were used to differentiate between perforated and non-perforated appendicitis and negative appendicectomy rate. WCC ≥11, CRP ≥50, bilirubin ≥21, NLR ≥6.4 and PLR ≥153 were the cut-off values. Negative appendicitis was defined as normal appendix at histopathological analysis. Results 224 patients were included; mean age 33.7 years, 57.1% were male. 17 patients (7.6%) had negative appendicectomy. CRP, NLR, bilirubin and PLR increase with AAST score (P &lt; 0.001). WCC ≥11 (p &lt; 0.001) and NLR ≥6.4 (p = 0.007) predicted acute appendicitis. WCC (p = 0.018), CRP (p &lt; 0.001), bilirubin (p &lt; 0.001), NLR (p &lt; 0.001), PLR (p = 0.002) were predictive for appendiceal perforation. Conclusion 7.6% negative appendicectomy rate in our centre is below the recommended standard of 10% and lower than other centres. In our centre, raised WCC and NLR were predictive of acute appendicitis. WCC, CRP, bilirubin, NLR and PLR may be used to distinguish between perforated and non-perforated appendicitis. Our results add to the conflicting body of evidence relating to biomarkers and the severity of appendicitis.

Enterocutaneous fistula resulting from the drainage of a contained appendiceal perforation secondary to a partially obstructing low-grade appendiceal mucinous neoplasm

We report a case of an enterocutaneous fistula resulting from drainage of a contained appendiceal perforation secondary to an obstructing appendiceal mucinous neoplasm. A 66-year-old otherwise healthy female patient proceeded to laparoscopic appendicectomy with resection of the fistula tract. Histopathology demonstrated a mid-appendiceal mucinous neoplasm, with a benign enterocutaneous fistula tract communicating with the distal, non-malignant portion of the appendix. We provide an overview of the literature and highlight the need to consider appendiceal mucinous neoplasm as a differential in the management of spontaneous right iliac fossa collections and fistulae.

DIAGNOSTIC VALUE OF HYPERBILIRUBINEMIA IN ACUTE APPENDICITIS AND APPENDICULAR PERFORATION

Introduction: Misdiagnosis or delayed diagnosis of acute appendicitis may result in perforation and will increase the mortality and morbidity of patients. Serum Bilirubin may be an aid in the diagnosis of appendiceal perforation. Methods: A study was conducted in the Department of Surgery, Assam Medical College, from November 2019 to November 2020. A total of 50 patients with clinical diagnosis of acute appendicitis or appendicular perforation were studied. The serum bilirubin estimation was carried out in all the patients. Result:Serum Bilirubin was elevated in the patients with both acute appendicitis and appendicular perforation. Conclusion: Serum Bilirubin has a predictive potential for the diagnosis of acute appendicitis and appendicular perforation. Patients who present with clinical signs and symptoms of appendicitis and a raised bilirubin level should be identied as having a higher probability of appendicular perforation.

Perforated Carcinoid Tumor of the Appendix: Need for Guidelines for Management With Respect to Prognostic Factors

Carcinoid tumors, one of the most common malignant lesions involving the appendix, are typically found incidentally during routine appendectomies. While up to 20% of acute appendicitis cases present with perforation, the incidence of perforation among patients with undiagnosed carcinoid tumors of the appendix is unknown. In addition, there is no consensus on the management of carcinoid tumors in the perforated appendix or its impact on prognosis. We present a case of a 42-year-old woman presented with perforated appendicitis. Final pathology demonstrated the presence of a 1.1 cm, well-differentiated grade 1 neuroendocrine tumor at the tip of the appendix extending into the subserosa, without evidence for lymphovascular invasion. Given the depth of tumor invasion and the relatively young age of the patient, the decision was made to perform an interval completion right hemicolectomy for lymph node sampling. Only a few cases have been reported in the available literature, and it remains unclear whether appendiceal perforation represents an independent negative prognostic factor for patient survival. Additional data from cohort studies are needed to determine the true incidence, prognosis, and optimal management of newly diagnosed carcinoid tumors in the perforated appendix. Furthermore, clear consensus guidelines are needed to identify the subgroup of patients who would benefit from interval or primary right hemicolectomy.

ROLE OF HYPERBILIRUBINEMIA, ELEVATED CREACTIVE PROTEIN AND LEUCOCYTE COUNT AS A PREDICTIVE FACTOR FOR APPENDICEAL PERFORATION IN ACUTE APPENDICITIS

Background: Appendiceal perforation in patients with acute appendicitis may cause a variety of potentially life-threatening complications. Escherichia coli endotoxin has been shown to impact physiological bile flow in vivo. This had led to the theory that hyperbilirubinemia and elevated CRP in patients with appendicitis may have a predictive potential for the preoperative diagnosis of appendiceal perforation. Objectives: The aim of this retrospective study was to investigate the diagnostic value of hyperbilirubinemia and elevated CRP as a preoperative laboratory marker for appendiceal perforation in patients with acute appendicitis. Thus a new marker for appendiceal perforation would be welcomed. Thus, the need for the study is to conclude whether the Serum Bilirubin or CRP can be considered as a new laboratory marker to aid in the diagnosis of Appendicular Perforation. Materials and methods: All patients admitted with clinical diagnosis of "Acute Appendicitis" or "Appendicular Perforation" and undergoing surgery in General Surgery Dept in Tertiary Care Teaching Hospital were taken as Subjects for this study. The primary data for this study were the blood investigations of the patients. 200 patients with concerned consent and meeting the inclusion criteria were included in the study. The necessary clinical and lab details were obtained in a prewritten format. The intraoperative findings were noted and documented precisely. Upon completion of data collection the preoperative bilirubin levels of the perforated and uncomplicated groups wereOther clinical and lab parameters obtained during the study were compared between the two groups. All parameters were subjected to statistical analysis and evaluated critically. Results: A total of 200 patients participated in the study. Of the 200 patients studied 132 patients were males and 68 patients were females. The youngest patient was 13 years old and the oldest 64 years. Among all the patients operated with a diagnosis of Acute Appendicitis 92 were found to have a perforated appendix, and 108 were found to have a non-perforated appendix. It was observed that among 92 patients with perforated appendix 86 patients showed a raised CRP levels and 58 patients had a raised Bilirubin levels. However in case of non-perforated cases it was found that among the 108 cases 82 patients had a raised CRP levels and 36 patients showed raised bilirubin levels. Conclusion: Hence Logistic Regression technique revealed that the C- reactive protein and Hyperbilirubinemia can be used to predict the appendicular perforation preoperatively and that their roles are comparable and that there is no definitive advantage of one over the other for the same.