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Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis

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Abstract

Background

No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS).

Aim

To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates.

Methods

Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014–April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR.

Results

Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001).

Conclusion

This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.

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References

  1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132(5):910–925

    Article  CAS  PubMed  Google Scholar 

  2. Rothrock SG, Pagane J (2000) Acute appendicitis in children: emergency department diagnosis and management. Ann Emerg Med 36(1):39–51

    Article  CAS  PubMed  Google Scholar 

  3. Storm-dickerson TL, Horattas MC (2003) What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 185(3):198–201

    Article  PubMed  Google Scholar 

  4. Waxman BP (2015) Treating uncomplicated appendicitis without surgery: will computer tomography scans and antibiotics triumph over clinical acumen and surgical dogma? ANZ J Surg 85(11):800

    Article  PubMed  Google Scholar 

  5. Chong CF, Adi MI, Thien A, Suyoi A, Mackie AJ, Tin AS et al (2010) Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singap Med J 51:22–225

    Google Scholar 

  6. Jang SO, Kim BS, Moon DJ (2008) Application of Alvarado score in patients with suspected appendicitis. Korean J Gastroenterol 52:27–31

    PubMed  Google Scholar 

  7. Bolger JC, Kelly ME, Barry K (2015) Acute appendicitis in the adult population: modelled decision analysis supports a conservative approach. J Gastrointest Surg 19(12):2249–2257

    Article  PubMed  Google Scholar 

  8. Roy H, Burbridge B (2015) To CT or not to CT? The influence of computed tomography on the diagnosis of appendicitis in obese pediatric patients. Can J Surg 58(3):181–187

    Article  PubMed  PubMed Central  Google Scholar 

  9. Wilms IM, De Hoog DE, De Visser DC, Janzing HM (2011) Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev 11:CD008359

    Google Scholar 

  10. Di Saverio S, Sibilio A, Giorgini E et al (2014) The NOTA study (non operative treatment for acute appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg 260(1):109–117

    Article  PubMed  Google Scholar 

  11. Foell D, Bahde R, Senninger N (2015) The non operative treatment for acute appendicitis (NOTA) study: is less surgery better surgery? Ann Surg 265(6):83–84

  12. Rocha LL, Rossi FM, Pessoa CM, Campos FN, Pires CE, Steinman M (2015) Antibiotics alone versus appendectomy to treat uncomplicated acute appendicitis in adults: what do meta-analyses say? World J Emerg Surg 10:51

    Article  PubMed  PubMed Central  Google Scholar 

  13. Vons C, Barry C, Maitre S et al (2011) Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 377(9777):1573–1579

    Article  CAS  PubMed  Google Scholar 

  14. Ehlers AP, Talan DA, Moran GJ, Flum DR, Davidson GH (2016) Evidence for an antibiotics-first strategy for uncomplicated appendicitis in adults: a systematic review and gap analysis. J Am Coll Surg 222(3):309–314

    Article  PubMed  Google Scholar 

  15. Kelly ME, Khan A, Riaz M et al (2015) The utility of neutrophil-to-lymphocyte ratio as a severity predictor of acute appendicitis, length of hospital stay and postoperative complication rates. Dig Surg 32(6):459–463

    Article  PubMed  Google Scholar 

  16. Shimizu T, Ishizuka M, Kubota K (2015) A lower neutrophil to lymphocyte ratio is closely associated with catarrhal appendicitis versus severe appendicitis. Surg Today. doi:10.1007/s00595-015-1125-3

  17. Heinrich PC, Castell JV, Andus T (1990) Interleukin-6 and the acute phase response. Biochem J 265:621–636

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Posul E, Yilmaz B, Aktas G, Kurt M (2015) Does neutrophil-to-lymphocyte ratio predict active ulcerative colitis. Wien Klin Wochenschr. doi:10.1007/s00508-0140683

  19. Kuon Lee S, Chul Lee S, Park JW, Kim SJ (2014) The utility of the pre-operative neutrophil-to-lymphocyte ratio in predicting severe cholecystitis: a retrospective cohort study. BMC Surg 14:100–107

    Article  Google Scholar 

  20. Galizia G, Lieto E, Zamboli A, De Vita F, Castellano P, Romano C, Auricchio A, Cardella F, De Stefano L, Orditura M (2015) Neutrophil to lymphocyte ratio is a strong predictor of tumor recurrence: a propensity score-matched analysis. Surgery 158:112–120

    Article  PubMed  Google Scholar 

  21. Li MX, Lui XM, Zhang XF, Zhang JF, Wang WL, Zhu Y et al (2014) Prognostic role of neutrophil-to-lymphocyte ratio in colorectal cancer: a systematic review and meta-analysis. Int J Cancer 134:2403–2413

    Article  CAS  PubMed  Google Scholar 

  22. Yamanaka T, Matsumoto S, Termukai S, Ishiwata R, Nagai Y, Kukushima M (2007) The baseline ratio of neutrophils to lymphocytes is associated with patient prognosis in advanced gastric cancer. Oncology 73:215–220

    Article  PubMed  Google Scholar 

  23. Sevinç MM, Kınacı E, Çakar E et al (2016) Diagnostic value of basic laboratory parameters for simple and perforated acute appendicitis: an analysis of 3392 cases. Ulus Travma Acil Cerrahi Derg 22(2):155–162

    PubMed  Google Scholar 

  24. Bayhan Z, Zeren S, Kargi E et al (2016) Does neutrophil to lymphocyte ratio predict hospital stay in appendectomy patients? Int Surg. doi:10.9738/INTSURG-D-15-00249.1

  25. Yardımcı S, Uğurlu MÜ, Coşkun M, Attaallah W, Yeğen ŞC (2016) Neutrophil-lymphocyte ratio and mean platelet volume can be a predictor for severity of acute appendicitis. Ulus Travma Acil Cerrahi Derg. 22(2):163–168

    PubMed  Google Scholar 

  26. Kucuk A, Erol MF, Senel S et al (2016) The role of neutrophil lymphocyte ratio to leverage the differential diagnosis of familial Mediterranean fever attack and acute appendicitis. Korean J Intern Med 31(2):386–391

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Yazar FM, Bakacak M, Emre A et al (2015) Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci 31(11):591–596

    Article  PubMed  Google Scholar 

  28. Hansson J, Körner U, Khorram-Manesh A et al (2009) Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 96:473–481

    Article  CAS  PubMed  Google Scholar 

  29. Seetahal SA, Bolorunduro OB, Sookdeo TC et al (2011) Negative appendectomy: a 10-year review of a nationally representative sample. Am J Surg 201(4):433–437

    Article  PubMed  Google Scholar 

  30. Talan DA, Saltzman DJ, Mower WR et al (2016) Antibiotics-first versus surgery for appendicitis: A US pilot randomized controlled trial allowing outpatient antibiotic management. Ann Emerg Med 70:1–11.e9

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Mayo University Hospital, Castlebar, Mayo, Ireland

    A. Khan, M. Riaz, Michael E. Kelly, W. Khan, R. Waldron, K. Barry & I. Z. Khan

  2. Discipline of Surgery, National University of Ireland Galway, Mayo University Hospital, Saolta University Hospital Group, Galway, Ireland

    Michael E. Kelly & K. Barry

Authors
  1. A. Khan
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  2. M. Riaz
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  3. Michael E. Kelly
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  4. W. Khan
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  5. R. Waldron
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  6. K. Barry
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  7. I. Z. Khan
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Correspondence to Michael E. Kelly.

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Khan, A., Riaz, M., Kelly, M.E. et al. Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis. Ir J Med Sci 187, 379–384 (2018). https://doi.org/10.1007/s11845-017-1667-z

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  • DOI: https://doi.org/10.1007/s11845-017-1667-z

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