The Utility of Neutrophil to Lymphocyte Ratio as a Predictor of Intervention in Acute Diverticulitis

Abstract

Background: Neutrophil to lymphocyte ratio (NLR) is a novel biomarker that has been recently studied in diverticulitis. The primary aim of this study was to assess the accuracy of NLR in predicting which patients had complicated diverticulitis and which patients required a radiological or surgical intervention. The accuracy of NLR was compared to C-reactive protein (CRP), white blood cell (WBC) count, neutrophil count and white cell to lymphocyte ratio (WLR). Methods: Details of all patients admitted with acute diverticulitis over an 18-month period were collected prospectively. Median CRP, WBC, neutrophil count, WLR and NLR values at initial presentation were compared using the Mann-Whitney U test. The diagnostic accuracy of each test was assessed using receiver operating characteristic curve analysis. Optimal cut-off points were determined for each biomarker using Youden's Index (J). Results: CRP, WBC, neutrophil count, WLR and NLR had variable accuracy in predicting complicated diverticulitis. NLR had the greatest accuracy of the 5 biomarkers in predicting the need for intervention with an area under the curve of 0.79 (p < 0.0001). The optimal cut-off point for NLR was 5.34 (J = 0.45). Conclusion: NLR was more accurate than CRP, WBC, neutrophil count and WLR in predicting the need for intervention. This cost-neutral, readily available biomarker can easily be calculated from the complete blood count and is a useful adjunct to CT.

Associations of novel inflammatory markers with long‐term outcomes and recurrence of diverticulitis

“…Perhaps the differences between the results are related to the higher intervention rates in that study (20.8%) compared to ours (7.5%). 15 It should be noted that we decided to choose a novel cutoff for NLR and PLR instead of using previous studies' cutoffs due to the large cohort and the possibility to establish new cutoff values that may be more significant than cutoff values used for small cohorts.…”

Recent advances in understanding and managing diverticulitis

“…Actually, the possible recognition of clinical or biochemical parameters that could be used to identify patients who progress from uncomplicated to complicated AD and to monitor the potential development of complications requiring immediate surgical intervention are matters of debate. Procalcitonin 113 and neutrophil count and white cell to lymphocyte ratio 114 have been proposed as accurate markers to differentiate complicated from uncomplicated diverticulitis, and higher levels of calprotectin, an inflammatory colonic mucosal marker, tend to be associated with more severe AD 25 . Clinical predictors of early recurrences up to 6 months after a first episode of AD appear to be high C-reactive protein (CRP) levels 115 , the presence of systemic inflammatory response syndrome, high pain score, and regular steroid or immunomodulator use 116 .…”

Delta neutrophil index as a promising prognostic marker of emergent surgical intervention for acute diverticulitis in the emergency department

“…In this study, the predictive power of the DNI with regards to the need for emergent surgical intervention in patients with acute diverticulitis was significantly higher than that of serum CRP levels, and WBC and neutrophil counts, which are commonly used markers for predicting inflammation and infection in the ED. The diagnostic power of the DNI in predicting the need for emergent surgical intervention in patients with acute diverticulitis was also significantly higher than that of the NLR, which was recently reported as being useful for predicting of surgical intervention in acute diverticulitis [ 13 ]. Even though CT-based imaging severity criteria, including the Hinchey classification and its successive modifications, have been shown to assist in the prediction of the clinical course of diverticulitis [ 23 , 25 , 26 ], the predictive value of the combination of initial DNI and CT was significantly higher than its of only CT and the predictive value of combination of initial DNI and CT was most powerful diagnostic modality.…”

“…A recent prospective study evaluated the role of the NLR in the setting of acute diverticulitis. They concluded that the NLR was more accurate than CRP levels, and WBC and neutrophil counts in predicting the need for a surgical intervention, which indicates complicated diverticulitis [ 13 ]. The principle of the NLR is that neutrophil levels elevate as part of the inflammatory cascade, whereas lymphocytes are decreased during sepsis.…”

“…However, findings of CT alone may not predict the need for emergent surgical intervention in all patients with acute diverticulitis in the ED. Serum inflammation markers, such as C-reactive protein (CRP) levels, white blood cell (WBC) count, and neutrophil-to-lymphocyte ratios (NLR), may help to differentiate severity of acute diverticulitis and predict the need for surgical intervention in clinical practice [ 9 , 11 – 13 ].…”