Value of early change of serum C reactive protein combined to modified Alvarado score in the diagnosis of acute appendicitis

Mohamed Amine Msolli, Kaouther Beltaief, Wahid Bouida, Nahla Jerbi, Mohamed Habib Grissa, Hamdi Boubaker, Riadh Boukef, Semir Nouira, Mohamed Amine Msolli, Kaouther Beltaief, Wahid Bouida, Nahla Jerbi, Mohamed Habib Grissa, Hamdi Boubaker, Riadh Boukef, Semir Nouira

Abstract

Background: The aim of this study is to test the diagnostic value of baseline and early change of C-reactive protein (CRP) concentrations, evaluated separately or in combination with the modified Alvarado score (MAS), in patients with clinically suspected acute appendicitis.

Methods: This is a prospective observational study including all patients presenting to the emergency department with an equivocal diagnosis of acute appendicitis. After inclusion, clinical and demographic data are recorded and blood samples were taken at baseline and 3 h after for serum CRP measurements (3 h CRP). The MAS is also calculated for all patients. The ultimate diagnosis of appendicitis was based on the histologic findings of the excised appendix in operated patients and clinical follow-up in emergency department discharged patients. Diagnostic accuracy of admission CRP, early change of CRP 3 h CRP minus admission CRP, MAS and the combination of these parameters was expressed by sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating characteristics curve.

Results: Five hundred patients were included from January 2010 to December 2013. Overall, 387 patients were operated the negative appendectomy rate was 8,3%. CRP concentrations were higher in patients with acute appendicitis. However, the diagnostic value of admission CRP, delta CRP and MAS was moderate with area under ROC curve respectively equal to 0.63, 0.53 and 0.6. Combining admission CRP and delta CRP values to MAS did not result in a better performance. The area under ROC curve did not exceed 0.7 with the different combinations.

Conclusion: Early change of CRP has a moderate diagnostic value in patients with clinically suspected acute appendicitis. Combining CRP values to MAS did not improve diagnostic accuracy.

Keywords: Acute appendicitis; Alvarado score; C-reactive protein.

Conflict of interest statement

Ethics approval and consent to participate

University Hospital Fattouma Bourguiba Ethics committee approval was received. Informed consent procedures were performed and collected by licensed medical staff. Written informed consent was obtained from each patient.

Consent for publication

The data presented in the manuscript and its supplemental files do not contain any details relevant to any individual patient and thus, no consent for publication was required.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Patients flow chart
Fig. 2
Fig. 2
Area under ROC curve of admission CRP (0.63), delta CRP (0.53), modified Alvarado score (0.6), MAS combined to admission CRP (0.6) and MAS combined to delta CRP (0.59). Delta CRP = admission CRP minus 3 h CRP

References

    1. Sartelli M, Catena F, Ansaloni L, et al. Complicated intra-abdominal infections in Europe: preliminary data from the first three months of the CIAO study. World J Emerg Surg. 2012;7:15. doi: 10.1186/1749-7922-7-15.
    1. Hallan S, Asberg A. The accuracy of C-reactive protein in diagnosing acute appendicitis--a meta-analysis. Scand J Clin Lab Invest. 1997;(5):373–80.
    1. Jones K, Peña AA, Dunn EL, et al. Are negative appendectomies still acceptable? Am J Surg. 2004;(6):748–54.
    1. Bixby SD, Lucey BC, Soto JA, et al. Perforated versus nonperforated acute appendicitis: accuracy of multidetector CT detection. Radiology. 2006;(3):780–6.
    1. Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986;(2):355–60.
    1. Balthazar EJ, Megibow AJ, Siegel SE, et al. Appendicitis: prospective evaluation with high-resolution CT. Radiology. 1991;(1):21–4.
    1. Rao PM, Boland GW. Imaging of acute right lower abdominal quadrant pain. Clin Radiol. 1998;(9):639–49.
    1. Ford RD, Passinault WJ, Morse ME. Diagnostic ultrasound for suspected appendicitis: does the added cost produce a better outcome? Am Surg. 1994;11:895–898.
    1. Sivit CJ. Imaging children with acute right lower quadrant pain. Pediatr Clin N Am. 1997;(3):575–89.
    1. Andersen DK. Maingot’s abdominal operations, 8th edition, Vol. 1 & 2. Ann Surg. 1986;5:607–608.
    1. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;(5):557–64.
    1. Macklin CP, Radcliffe GS, Merei JM, et al. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl. 1997;3:203–205.
    1. Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado score for acute appendicits in adults. Saudi Med J. 2004;9:1229–1231.
    1. Ohmann C, Yang Q, Franke C. Diagnostic scores for acute appendicitis. Abdominal pain study group. Eur. J Surg Acta Chir. 1995;4:273–281.
    1. Ng K-C, Lai S-W. Clinical analysis of the related factors in acute appendicitis. Yale J Biol Med. 2002;1:41–45.
    1. Clyne B, Olshaker JS. The C-reactive protein. J Emerg Med. 1999;6:1019–1025. doi: 10.1016/S0736-4679(99)00135-3.
    1. Pal KM, Khan A. Appendicitis: a continuing challenge. JPMA. 1998;7:189–192.
    1. Rosengren D, Brown AFT, Chu K. Radiological imaging to improve the emergency department diagnosis of acute appendicitis. EMA. 2004;(5–6):410–6.
    1. Groselj-Grenc M, Repše S, Vidmar D, et al. Clinical and laboratory methods in diagnosis of acute appendicitis in children. Croat Med J. 2007;3:353–361.
    1. Lin CY, Wu H-P. Predictive value of C-reactive protein at different cutoff levels in acute appendicitis. Am J Emerg Med. 2005;(4):449–53.
    1. Wu H-P, Chang C-F, Lin C-Y. Predictive inflammatory parameters in the diagnosis of acute appendicitis in children. Acta Paediatr Taiwan. 2003;4:227–231.
    1. Paajanen H, Mansikka A, Laato M, et al. Novel serum inflammatory markers in acute appendicitis. Scand J Clin Lab Invest. 2002;(8):579–84.
    1. Golden SK, Harringa JB, Pickhardt PJ, et al. Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT. Emerg Med J. 2016;(7):458–64.
    1. Shogilev DJ, Duus N, Odom SR, et al. Diagnosing appendicitis: evidence based review of the diagnostic approach in 2014. West J Emerg Med. 2014;(7):859–71.
    1. Kharbanda AB, Cosme Y, Liu K, et al. Discriminative accuracy of novel and traditional biomarkers in children with suspected appendicitis adjusted for duration of abdominal pain. Acad Emerg Med Off J Soc Acad Emerg Med. 2011;(6):567–74.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera