Evaluation of Hyperbilirubinemia as a New Diagnostic Marker for Acute Appendicitis and its Role in the Prediction of Appendicular Perforation

Abstract

INTRODUCTION: The most common cause of acute abdomen is Appendicitis. The diagnosis of acute appendicitis is based on clinical history and physical examination. It is difficult to diagnose in cases of retrocaecal or retro ileal appendix. Appendicectomy is the most commonly performed abdominal surgery. 15-30% of appendicectomy specimen found to be normal. In order to decrease the number of unnecessary appendicectomy, significance of labarotory investigations like White Blood Cells, CReactive Protein, etc have been emphasised. Ultrasonagram abdomen has been widely accepted as the diagnostic tool for appendicitis. Many number of scoring system were developed to arrive the diagnosis. These scoring systems are based on clinical features, laboratory investigations. Some examples are Alvarado, Modified alvarado, Ripasa. Still there is no definitive laboratory marker for acute appendicitis and appendicular perforations. Studies show that serum bilirubin is raised in acute appendicitis and appendicular perforations. But the siginificance of which is not stressed. On bacterial invasion of the appendix, there is transmigration of bacteria and release of proinflammatory cytokines like TNF α,.IL6. The cytokines reach the liver through the superior mesentric vein and may lead to inflammation, abscess and liver dysfunction. OBJECTIVES: The objectives of the study were- 1. To study the relationship between hyperbilirubinemia and acute appendicitis; and to evaluate its credibility as a diagnostic marker for acute appendicitis. 2. To evaluate whether elevated bilirubin levels have a predictive potential for the diagnosis of Appendicular perforation. MATERIALS AND METHODS: The study was conducted in the Department of General Surgery, Govt. Stanley Medical College, Chennai during the period of November 2013 to November 2014. Study design - A prospective non randomised study. Source - The present study was conducted in the Department of Surgery, Govt. Stanley Medical College, Chennai Study period - One year from November 2013 to November 2014. Source of data - Patients admitted with clinical diagnosis of acute appendicitis or appendicular perforation under the Department of Surgery, Govt.stanley medical college,chennai during the study period. Sample size - A total of 100 patients with clinical diagnosis of acute appendicitis or appendicular perforation were studied. Selection criteria: Inclusion criteria - • All patients diagnosed as acute appendicitis clinically on admission. • All patients diagnosed as appendicular perforation clinically on admission. • For both these groups, only patients with histopathological report suggestive of acute appendicitis or appendicular perforation were included. Exclusion criteria - • All patients documented to have a past history ofo Jaundice or Liver disease. o Chronic alcoholism (that is intake of alcohol of > 40 g/day for Men and > 20 g/day in Women for 10 years).71 o Hemolytic disease. o Acquired or congenital biliary disease. • All patients with positive HBsAg. • All patients with cholelithiasis. • All patients with cancer of hepato-biliary system. RESULTS: A total of 100 patients with clinical diagnosis of acute appendicitis or appendicular perforation admitted in the Department of General surgery, Govt.stanley medical college,chennai were studied. As per the study, the age group 11-20years is most commonly affected (44%) followed by age group 21-30 (32%). The youngest patients of this study were of 8 years old while the oldest patient was a 70 year lady. CONCLUSION The present study suggests- Serum bilirubin levels appears to be a promising new laboratory marker for diagnosing acute appendicitis, however diagnosis of appendicitis remains essentially still - clinical. Its level come out to be a credible aid in diagnosis of acute appendicitis and would be helpful investigation in decision making. Patients with clinical signs and symptoms of appendicitis and with hyperbilirubinemia higher than the normal range should be identified as having a higher probability of Appendicular perforation suggesting, serum bilirubin levels have a predictive potential for the diagnosis of Appendicular perforation.