A Prospective Study on the Diagnostic Value of Hyperbilirubinemia as a Predictive Factor for Appendicular Perforation in Acute Appendicitis

Abstract

BackgroundAppendicitis is one of the most common surgical emergency in general surgical practices. Early and prompt diagnosis is necessary to avoid life-threatening complications associated with it. The diagnosis is mainly clinically aided by imaging techniques. The physiological obstruction of the bile flow associated with appendicular pathology leads to hyperbilirubinemia, which can be used as a predictive factor of appendicular perforation.MethodThis prospective study was conducted in the department of general surgery in Madras Medical College and Rajiv Gandhi Government Hospital, Chennai, from January 2012 to November 2012. A total of 378 patients with the features of acute appendicitis or appendicular perforation admitted in the emergency surgical ward were included.ResultsOut of 378 of the study population, 18% had appendicular perforation and 82% had acute appendicitis. Out of 67 perforations, 60 patients have hyperbilirubinemia (90%) whereas out of 311 patients with appendicitis, only 89 (29%) of them had elevated bilirubin. Hyperbilirubinemia with a cutoff point of 0.9 mg% for appendicitis patients has a sensitivity of 89.6%, specificity of 71.4%, a positive predictive value of 27%, and a negative predictive value of 96.9%. Hyperbilirubinemia with a cutoff point of >1.3 mg% for appendicular perforation has a sensitivity of 80%, specificity of 89%, a positive predictive value of 93%, and a negative predictive value of 96%.ConclusionsHyperbilirubinemia with bilirubin levels more than 1.3 mg% are highly predictive of appendicular perforation and, hence, aid in prompt diagnosis. This can be combined with a clinical diagnosis and imaging for an accurate and precise diagnosis.

Clinical Implications of Serum Bilirubin and Procalcitonin in the Diagnosis of Acute Appendicitis

“…There is variation in serum bilirubin depending as patient has complicated or non-complicated appendicitis. A bilirubin level of 1.3g was found to be significantly related with a perforated appendix, with a positive predictive value of 93% and a negative predictive value of 96% in as study conducted by Ramasamy et al [11] in India among patients done appendectomy. However, for patient with nonperforated appendix Ramasamy and colleagues observed a serum bilirubin of 0.9 mg with a positive predictive value of 27%, and a negative predictive value of 96.9%.…”

Frequency of Hyperbilirubinemia in Perforated Appendicitis - A Current Update on Diagnostics and Management.

“…However, the insult to hepatocytes due to proliferating bacterial infection causes overwhelm to Kupffer cells directly resulting in release of liver enzymes and bilirubin to blood causing hyperbilrubinemia. 4 Simple appendectomy could be the cure of acute appendicitis if delayed could result in perforation thus increasing morbidity 6 . Current advances in medical research have highlighted a possible role of hyperbilirubinemia in acute appendicitis and appendiceal perforation 6 .…”

“…4 Simple appendectomy could be the cure of acute appendicitis if delayed could result in perforation thus increasing morbidity 6 . Current advances in medical research have highlighted a possible role of hyperbilirubinemia in acute appendicitis and appendiceal perforation 6 . As hyperbilirubinemia is reported in more than 90% of patients in case of perforated appendicitis 5,7 .…”