Complicated Acute Cholecystitis: The Role of C-Reactive Protein and Neutrophil-Lymphocyte Ratio as Predictive Markers of Severity.

Fahad Mahmood,Mehual Thakkar,Akinfemi Akingboye,Yogeshkumar Malam,Periyathambi Jambulingam

doi:10.7759/cureus.13592

Abstract

ObjectivesThe clinical diagnosis of complicated acute cholecystitis (CAC) remains difficult with several pathological or ultrasonography criteria used to differentiate it from uncomplicated acute cholecystitis (UAC). This study aims to evaluate the use of combined inflammatory markers C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) as surrogate markers to differentiate between UAC and CAC.MethodsWe identified 600 consecutive patients admitted with biliary symptoms during an acute surgical take from our electronic prospectively maintained database over a period of 55 months. Only patients undergoing emergency cholecystectomy performed during the index admission were included. The primary outcome was the finding of CAC versus UAC.ResultsA total of 176 patients underwent emergency laparoscopic cholecystectomy (ELC) during the index admission, including 118 (67%) females with a median age of 51 years (range: 21-97 years). The proportion of UAC (130 [74%]) and CAC (46 [26%]) was determined along with demographic data. Multivariate regression analysis showed that patient’s age (OR=1.047; p=0.003), higher CRP (OR=1.005; p=0.012) and NLR (OR=1.094; p=0.047) were significant independent factors associated with severity of cholecystitis. Receiver operating characteristic (ROC) analysis for CRP showed an AUC (area under the curve) of 0.773 (95% CI: 0.698- 0.849). Using a cut-off value of 55 mg/L for CRP, the sensitivity of CAC was 73.9% and specificity was 73.1% in predicting CAC. The median post-operative length of stay was four days. The conversion rate from laparoscopic cholecystectomy to open surgery was 2% (4/176), and 5% (9/176) patients suffered post-operative complications with no mortality at 30 days.ConclusionCRP, NLR and age were independent factors associated with the severity of acute cholecystitis. NLR and CRP can be used as surrogate markers to predict patients at risk of CAC during emergency admission, which can inform future guidelines. Moreover, ELC for CAC can be safely performed under the supervision of dedicated upper GI surgeons.

Highlights

Each year approximately 1% to 2% of patients with asymptomatic cholelithiasis develop acute cholecystitis [1]
Receiver operating characteristic (ROC) analysis for C-reactive protein (CRP) showed an area under the curve (AUC) of 0.773
We aim to evaluate whether the use of pre-operative CRP and neutrophil-lymphocyte ratio (NLR) as surrogate markers could serve to differentiate between uncomplicated acute cholecystitis (UAC) and CAC

Summary

Introduction

Each year approximately 1% to 2% of patients with asymptomatic cholelithiasis develop acute cholecystitis [1]. Gangrenous cholecystitis (GC), which affects 2-30% of all cases, is a severe form of acute cholecystitis associated with increased morbidity and a reported mortality of 15-50% [2,3,4,5]. This occurs when acute cholecystitis progresses to the advanced stage of inflammation, resulting in perforation secondary to gallbladder wall ischaemia. This ischaemia is a consequence of an impacted cystic duct causing distension of the gallbladder and increased tension on the gallbladder wall, resulting in vascular compromise accompanied by an associated inflammatory reaction [2,3,6,7]. Early emergency cholecystectomy is recommended in suspected cases to reduce the risk of further complications, in complicated acute cholecystitis (CAC)

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