Grey Zone Appendicitis: Role of Blood Test Biomarkers to Detect Early Appendicitis and to Decrease the Incidence of Negative Appendectomy
Condition: Appendicitis
MeSH terms: Appendicitis
Study type: Interventional

Summary: 
      Introduction: many investigations emerged in the last decades and contribute towards a
      diagnosis of unsure appendicitis; they are valuable to the emergency general surgeon.

      Aim: This study aims to assess the role of laboratory markers (bilirubin and phospholipase
      A2) individually or combined with Computed Tomography (CT) for the diagnosis of grey zone
      appendicitis (Alvarado score 5-6).

      Methods: This prospective study included all 310 patients admitted with right iliac fossa
      (RIF) pain who had Alvarado score 5-6 (intermediate risk of appendicitis). All underwent full
      laboratory investigations including serum total bilirubin and phospholipase A2. All are
      underwent CT scan and classified into group A with normal CT but with persistent right iliac
      fossa pain and group B with proved acute appendicitis by CT. All cases underwent a
      laparoscopic or open appendectomy. Other causes of hyperbilirubine¬mia are excluded among the
      patients.
    

Detailed description: 
      INTRODUCTION Acute appendicitis is a very common surgical emergency worldwide, with a
      lifetime risk reported to be 7-8%..Accordingly, appendectomy is the most frequently performed
      operation worldwide.

      Many surgical centers attempt to reduce surgical procedures performed during the night, and
      delaying appendectomy for 12-24 h does not seem to increase complications

      Despite thorough research, the diagnosis of acute appendicitis is still difficult and remains
      the most common problem in clinical surgery.

      In addition to clinical examination of the patients with appendicitis, ultrasonography and
      multidetector computed tomography (MDCT) have become the most useful tools with a respective
      sensitivity and specificity of 98.5% and 98.0% in expert centers Routine use of MDCT not only
      increases exposure to radiation but also very expensive and time-consuming. Thus evolving
      methods to diagnose early acute appendicitis without radiological examinations are of
      interest.

      Observing serum bilirubin and phospholipase A2 level came into consideration as it seems to
      elevate in early appendicitis, its determination is fast and can be performed with other
      commonly performed blood tests.

      Bacteria invade the appendix and release tumour necrosis factor-alpha, Interleukien 6, and
      cytokines. These substances reach the liver through superior mesenteric vein and cause
      dysfunction of liver either by direct effect or indirectly through altering the hepatic blood
      flow. So it is important to evaluate the total bilirubin level in the diagnosis of clinically
      suspected cases of appendicitis (6) THE AIM OF THE WORK

      This study aims to evaluate the role of bilirubin and phospholipase A2 in:

        1. Cases of grey zone unsure appendicitis (intermediate risk Alvarado score 5-6).

        2. As a complementary to CT.

        3. Detect early cases of appendicitis.

        4. Decrease the incidence of negative appendicitis.

        5. Decrease complications of missed cases of appendicitis.

        6. Reduce the overnight appendectomy rate with its complications. Patients and methods
           Cases with normal CT but with persistent right iliac fossa tenderness and failed to
           improve under conservative treatment for 48 hrs With antibiotic therapy (Group A)
           underwent laparoscopic appendectomy. Patients proved to be appendicitis by CT underwent
           laparoscopic exploration (Group B). All the appendices removed were sent for
           histological examination and the operated cases divided into positive appendicitis
           (macroscopic or microscopic) and negative appendicitis.

      Group A , patients with normal CT but with persistent right iliac fossa pain. Group B ,
      patients with proved acute appendicitis in CT.
    

Intervention name(s): laparoscopic appendectomy
Intervention type(s): Procedure
Intervention description(s): cases with normal CT underwent laparoscopic appendectomy
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment