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A study to determine the value of pre operative hyperbilirubinemia as a predictor of complicated appendicitis

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. Diagnosis of appendicitis is based on history, examination, laboratory values and imaging. In some cases, the signs and symptoms are variable and a diagnosis can be difficult to make. Delay in diagnosis of acute appendicitis leads to perforation and peritonitis and increased mortality. Incidence of perforation ranges 5090% in various series.


INTRODUCTION
Acute appendicitis is the commonest cause of 'acute surgical abdomen'. 1,2 Appendicectomy is the most frequently performed urgent abdominal operation and is often the first major procedure performed by a surgeon in training. Diagnosis of appendicitis is based on history, examination, laboratory values and imaging. In some cases, the signs and symptoms are variable and a diagnosis can be difficult to make. Delay in diagnosis of acute appendicitis leads to perforation and peritonitis and increased mortality. Incidence of perforation ranges 50-90% in various series. 3,4 To supplement clinical diagnosis and to reduce the frequency of unnecessary appendicectomy, the importance of laboratory investigations like white blood cell (WBC) counts and C-reactive protein (CRP) values has been stressed. 5 The use of ultrasonography (USG) as a diagnostic tool for appendicitis has been widely known and studied. 6 Scores combining clinical features and laboratory investigations have also been developed and are good enough to reach the diagnosis. Available scoring Importance of raised total bilirubin has not been stressed in acute appendicitis and appendicular perforation. Bacterial invasion in appendix leads to transmigration of bacteria and release of pro-inflammatory cytokines such as TNF-alpha, IL-6 and cytokines which in turn reach the liver via the portal system and may produce inflammation, abscess or dysfunction of liver either directly or indirectly by altering the hepatic blood flow. 9,10 Present study was conducted to assess relationship between hyperbilirubinemia and acute appendicitis and to find out whether elevated bilirubin levels have a predictive potential for diagnosis of gangrene/ suppuration/perforation in acute appendicitis.

METHODS
The study was conducted in Department of General Surgery, Sree Gokulam Medical College and Research Foundation, Venjaramoodu, Trivandrum. This was a prospective observational study of 100 consecutive cases.
All patients who were diagnosed to have appendicitis and admitted in surgery department and who underwent appendicectomy were included in the study. Appendicectomy performed incidentally, patients with appendicular lump, history of alcoholic liver disease, hemolytic or liver diseases associated with hyperbilirubinemia, history of viral hepatitis, Gilbert's disease, Dubin Johnson syndrome were excluded. Data was collected by interview with the participant with help of structured proforma, clinical examination, blood routine examination, Alvarado score, ultrasound abdomen, histopathology examination, pre and postoperative values of total bilirubin, direct bilirubin and indirect bilirubin. 7 The upper limit of normal value in our laboratory for total bilirubin was 1.4 mg/dl (direct-0.3 mg/dl, indirect-1.1 mg/dl). The data was uploaded in Microsoft excel sheet and analyzed using ROC curve and Kappa test. The study had a sample size of 100 patients and the study duration was 18 months from November 2013 to May 2015.

RESULTS
In our study 57 (57%) were males and 43 (43%) were females. Out of the 100 cases 44 were complicated (Table  1). In our study acute appendicitis were classified as complicated as uncomplicated. Complications included perforated appendix, gangrenous appendix and appendicitis with suppuration. 62 cases had elevated bilirubin preoperatively in which 35 cases were having complications like gangrene, suppuration and perforation.
Out of the 62 cases that had elevated bilirubin pre operatively 31 (50%), the bilirubin level came down to normal limits after 72 hours of appendicectomy (Table 2).   In our study CRP was positive in 81 cases (>0.6 mg/l). In hundred cases Alvarado score had a mean of 6.5, maximum being 10 and minimum being 2. On histopathology, 56 were acute appendicitis, 13 were perforated appendicitis, 11 were gangrenous appendicitis, 20 were suppurative appendicitis. From the study of sensitivity and specificity of pre-operative total bilirubin values in predicting perforated appendicitis, it was found that preoperative total bilirubin value of 1.55 mg/dl had the best sensitivity and specificity (   From the study of sensitivity and specificity of preoperative total bilirubin values in predicting gangrenous appendicitis, it was found that preoperative total bilirubin value of 1.80 mg/dl had the best sensitivity and specificity (  From the study of sensitivity and specificity of preoperative total bilirubin values in predicting suppurative appendicitis, it was found that preoperative total bilirubin value of 1.45 mg/dl had the best sensitivity and specificity (Table 6). It was done using a ROC curve.    Taking preoperative total bilirubin value as 1.45 mg/dl as cut off in predicting gangrenous appendicitis the sensitivity was 55, specificity was 91.1 with an accuracy of 81.6. Thus, inclusion of total bilirubin estimation in routine preoperative laboratory investigations of acute appendicitis can help in predicting the complications.