White cell count and C-reactive protein measurement in patients with possible appendicitis

Abstract

Acute appendicitis is a common condition that can lead to peritonitis and, rarely, death.1,2 While traditionally a clinical diagnosis, inflammatory markers are often now used to aid diagnosis.3 The paper published in the Annals by Sengupta et al reviewed 98 patients with lower abdominal pain and concluded that patients with a normal white cell count (WCC) and C-reactive protein (CRP) levels are unlikely to have appendicitis and can be safely sent home. We believe, however, that appendicitis can occur in the presence of normal inflammatory markers. To demonstrate this, we reviewed 200 consecutive cases of appendicitis at our institution. 162 patients had histologically confirmed appendicitis. Appendicitis in the presence of normal CRP, WCC or neutrophil counts occurred in 47, 47 and 36 patients respectively, while appendicitis in the presence of normal CRP, WCC and neutrophil counts occurred in 13 patients. Furthermore, 3 patients with histologically proven gangrenous appendicitis had presented with normal inflammatory markers. We therefore recommend that clinicians be wary of normal inflammatory markers in patients with a high clinical suspicion of appendicitis and that further investigations or treatment should not be delayed where this is the case.