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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1252-1255

Accuracy of change in leukocytic count in relation to clinical pictures and histopathology in diagnosis of acute appendicitis


Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission16-Oct-2018
Date of Decision06-Dec-2018
Date of Acceptance15-Dec-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Mohamed I Hamza
Kafr Elzaiat, Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_329_18

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  Abstract 


Objective
To evaluate the accuracy of change in leukocytes count in comparison with clinical pictures and histopathology in diagnosis of acute appendicitis.
Background
The diagnosis of acute appendicitis is primarily clinical and should be made on clinical symptoms and signs. However, some patients have equivocal physical findings and may be admitted for a period of observation. We suggest that these patients could also have serial total white cell counts taken as an aid for diagnosis.
Patients and methods
The study is a prospective randomized clinical trial. This study was conducted on patients presenting to the General Surgery Department in Menoufia University Hospitals and Al Minshawy General Hospital in Tanta during the period from March 2017 to March 2018. This study included 68 patients with acute lower abdominal pain suspecting acute appendicitis divided into two groups: A (34 patients) and B (34 patients). Patients in group A had normal leukocytes count and patients in group B had a high leukocyte count. All specimens of appendectomies were sent for histopathological examination.
Results
The leukocytes count has a sensitivity of 58%, specificity of 85%, accuracy of 63%, and negative appendectomy rate of 19%.
Conclusion
It was found that if the total leukocytes count and neutrophils were highly elevated and correlated with the clinical picture, the diagnostic accuracy of acute appendicitis was more increased.

Keywords: abdominal pain, appendectomy, appendicitis, leukocytes count, normal appendix


How to cite this article:
Hamza MI, Farghaly AE, Mohamed AF. Accuracy of change in leukocytic count in relation to clinical pictures and histopathology in diagnosis of acute appendicitis. Menoufia Med J 2019;32:1252-5

How to cite this URL:
Hamza MI, Farghaly AE, Mohamed AF. Accuracy of change in leukocytic count in relation to clinical pictures and histopathology in diagnosis of acute appendicitis. Menoufia Med J [serial online] 2019 [cited 2020 Jun 6];32:1252-5. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1252/274258




  Introduction Top


Acute appendicitis is sufficiently common that appendectomy has been the most frequently performed urgent operation [1].

The combination of the clinical scoring system and advanced imaging has been deeply influential in clinical practice [2].

Appendicitis is the most common acute abdominal surgical emergency. In western countries, 16% of the population undergo appendectomy. Appendicitis is most prevalent in the second and third decades of life, after which the risk declines with age. As the appendix of the infant is wide mouthed and well drained and as in the elderly the lumen is almost obliterated and the wall contains little lymphoid tissue, appendicitis in the two extremes of life is relatively low. Acute ischemia damage the mucosa and lead to bacterial infection [3]. Appendicitis is a common and urgent surgical illness. Significant diagnostic delay is often encountered, as the clinical picture has manifestations that tend to overlap with other conditions. Thus, no single symptom and sign or diagnostic test accurately makes the diagnosis of appendiceal inflammation in all cases. The surgeon's goal is to evaluate patients referred for suspected appendicitis with the aim of the approaching 100% sensitivity for the diagnosis in a time-, cost-, and consultation-efficient manner and to minimize the negative appendectomy rate without increasing the incidence of perforation [4].

An accurate clinical diagnosis of acute appendicitis is more difficult in children as they may not be able to communicate their complaints adequately, and findings at physical examination may be nonspecific [5].

Older patients with abdominal pain can be difficult to evaluate in the emergency department. Older patients are more likely to have serious pathology, and their vital signs and examination do not always reflect the severity of their underlying illness [6].

Ultrasonography in patients suspected of having appendicitis can significantly lower the negative appendectomy rate [7].

Appendectomy is the mainstay of treatment for acute appendicitis. However, diagnosing acute appendicitis remains a challenge. Misdiagnosis is not uncommon, and not infrequently surgery for appendicitis is performed to find a normal appendix [8].

The aim of this study was to evaluate the accuracy of change in leukocytes count in comparison with clinical pictures and histopathology in the diagnosis of suspected acute appendicitis.


  Patients and Methods Top


The study was conducted on patients presenting to the General Surgery Department in Menoufia University Hospitals and Al Minshawy General Hospital in Tanta during the period from March 2017 to March 2018, with lower abdominal pain suspected of acute appendicitis. Local ethics committee's approval and written consent were obtained. The study is a prospective randomized clinical trial. Patients included in the study represented 68 patients divided into two groups: A (34 patients) and B (34 patients). The patients were chosen by closed envelope method. Patients in group A had normal leukocytes count and patients in group B had high leukocytes count. Included patients presented with lower abdominal pain suspected of acute appendicitis, with age between 1 and 60 years. The study excluded pregnant, infant, and elderly patients (above 60 years). All patients were subjected to physical examination: throughout history, there have been described numerous clinical signs associated with acute appendicitis that facilitates the diagnosis; however, they lack adequate sensitivity and specificity. Blood analysis: no analytical marker has a sensitivity and specificity adequate to confirm the diagnosis. Blood samples were collected and submitted to laboratories of Menoufia University Hospitals and Al Minshawy General Hospital in Tanta. Leukocytes count more than 4 to 10 × 109/L was taken as cutoff value. The moderate increase of leukocytes with left shift is the most common finding. Leukocytes count was calculated by auto analyzer (SYSMEX, model SF-3000, SYSMEX AMERICA, Illinois state, America). Other markers of acute inflammation such as C-reactive protein (CRP) or procalcitonin may be useful. It is recommended to perform a pregnancy test in the differential diagnosis in all women of childbearing age. Risk scales: these scales combine different parameters trying to get a more accurate diagnosis. Among the most widely used scale is Alvarado (Annex 1). Several studies have demonstrated a high sensitivity but low specificity. The latest Appendicitis Inflammatory Response score (Annex 2) has greater precision than the scale of Alvarado. In ultrasound, the data that best relate to acute appendicitis is an image of cecal appendix more than 6 mm. All cases were done by open appendectomy technique. The patient is placed on the operating table in supine position. All cases were performed under general anesthesia. Examination under anesthesia was done to detect any appendicular masses. Gridiron incision was done for all patients, while opening of the layers of the anterior abdominal wall, opening of the peritoneum, delivery of the cecum, and identification of the appendix by following the convergence of the tenia to the base of the appendix. Once identification the appendix, mobilize it by dividing the mesoappendix taking care to ligate the appendiceal artery securely. The appendix was divided at the base, leaving an appendicular stump which was managed by simple secure ligation. The peritoneal cavity was irrigated and the wound closed in layers. Collected specimen was sent to the pathologist laboratories of Menoufia University Hospitals and Al Minshawy General Hospital in Tanta. Histopathological examination was done of the collected specimens of patients undergoing surgical intervention, and so the patients will be classified into four groups: negative (not appendicitis), catarrhal appendicitis, suppurative appendicitis, and complicated appendicitis.

Statistical analysis

The results had been collected, evaluated, calculated, tabulated, and statistically analyzed by using a computer statistical package (IBM SPSS statistics for Windows, version 21.0; IBM Corp., Armonk, New York, USA). Descriptive statistics were used in the form of number and percentage. χ2 test was used to find the association of Total leukocytes count (TLC) (high, normal) with the pathological status of appendix at 5% level of significance.


  Results Top


The patients represented 38 females and 30 males. All cases were diagnosed clinically as acute appendicitis. In addition to routine laboratory tests, all patients are subjected to total leukocytes count and postoperative histopathological examination.

Total leukocytes count was within normal average 10.000 cells/mm 3 in 34 patients and it was above normal average in 34 patients [Table 1].
Table 1: Histopathological result in relation to TLC

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The clinical items used in the diagnosis were gathered for all 55 patients. Tenderness was present in all cases (100%), followed by Rebound tenderness in 85.5%. The least frequent symptom was the pyrexia, which was present only in 71% of all cases [Table 2].
Table 2: TLC in relation to clinical pictures and histopathological results

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Histopathological examination was done in all cases to confirm the diagnosis, and the appendicitis was positive in 55 patients and negative in 13 patients [Table 3], [Figure 1] and [Figure 2].
Table 3: The results of histopathological examination in patients (68 patients)

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Figure 1: A case of acute suppurative appendicitis.

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Figure 2: Histopathology of a case of acute suppurative appendicitis.

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  Discussion Top


In spite of the radical advances in medical technology, appendicitis still poses a diagnostic challenge. The main aim of the clinician is to reach an accurate diagnosis in the fastest and most economical way possible, without subjecting the patient to unnecessary surgery or investigations [7]. The incidence of appendiceal perforation has been reported to be between 3 and 19%. Removal of noninflamed appendix also causes complications [9]. Despite intensive research and discussion, the diagnosis of acute appendicitis is still difficult and remains perhaps the most common problem in clinical surgery. A delayed diagnosis of appendicitis may lead to perforation and peritonitis. The accuracy of diagnosis of acute appendicitis has improved only marginally in recent decades. The diagnosis of acute appendicitis is correctly made by clinical appraisal in 43–88% of patients undergoing appendectomy [10]. Diagnosis of acute appendicitis is made by considering the typical history along with physical and laboratory findings. The accepted rate of negative exploration is between 10 and 30% of all appendectomies. Laparoscopy, ultrasonography, and computed tomography have all been shown to improve the diagnostic accuracy. However, none of these methods have proven superiority [11]. Preoperative laboratory tests often aid the surgeon in decision making in patients with appendicitis. Measuring body inflammatory agents such as CRP, and white cell count may reduce unnecessary operations by up to 30–40%. However, these techniques are not universally available. The total white cell count is often used in the diagnosis of right iliac fossa pain. The total white cell count alone is not diagnostic because it has low sensitivity, although this can be improved by combining the total leukocytes count with the differential neutrophil count [12]. In this study, the upper limit of normal total white cell count was taken as 10 × 103/mm 3 in accordance with local reference values. Erikssoon et al. [13] found that the sensitivity of the total white cell count in acute appendicitis has been between 55 and 90%, and the specificity between 41 and 85%. These correlate well with the values from this study (58 and 85%, respectively). Bolion et al. [14] reported that serial white cell count remained high in patients with acute appendicitis, but fall in those with nonspecific abdominal pain. Conversely, Raferty [15] concluded that serial counts are of no value even in equivocal cases. However, reduction in the total white cell count in the second tests in patients with acute appendicitis may be owing to the perforation of the appendix, which is a well-recognized phenomenon. Neutrophil are the body's primary defense against bacterial infection and physiological stress. An increased need for neutrophil, as with an acute bacterial infection, will cause an increase in both the total number of mature neutrophils and the less mature bands to respond to the infection. The term shift to the left is often used when determining if a patient has an inflammatory process such as acute appendicitis or cholecystitis. This term is a holdover from the days in which laboratory reports were written by hand. The bands, the less mature neutrophil forms, were written first on the left hand side of the laboratory report. Today, the term shift to the left means that the bands have increased, indicating an infection in progress [16]. Although less favorable results of repeated measurements also have been reported, combining the measurement of white blood cells and CRP may bring sensitivity near 100%, but specificity declines to approximately 50%. Therefore, a negative CRP and the leukocyte test result may be more informative than a positive one [17]. Ng and Lai [18] reported that if the combination of elevated CRP, leukocytosis, and elevated neutrophil ratio was used, satisfactory specificity and positive predictive value was achieved in diagnosing acute appendicitis.


  Conclusion Top


Acute appendicitis is one of the most common problems requiring emergency surgery. It has been estimated that the accuracy of the clinical diagnosis of acute appendicitis is only between 75 and 90%. Thus, accurate diagnosis of acute appendicitis is still difficult. The present study included evaluation of the role of leukocytes count in the diagnosis of acute appendicitis. It was found that if total leukocytes count and neutrophils were highly elevated and correlated with the clinical picture, the diagnostic accuracy of acute appendicitis was more increased in contrast to depending on a single item.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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O'Connell PR. The vermiform appendix. In: Williams NS, Bulstrode CJ, O'Connell PR, eds. Baily and love's. Short practice of surgery. 25th ed. London: Arnold; 2008. 67. 1206.  Back to cited text no. 1
    
2.
McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007; 25:489–493.  Back to cited text no. 2
    
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Emil Laberge JM, Mikhail P, Baicon L. Appendicitis in children. A ten year up date of therapeutic recommendation. J Ped Surg 2003; 38:236–242.  Back to cited text no. 5
    
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Puig S, Hormann M, Rebhandl W. Us as a primary diagnostic tool in relation to negative appendectomy: six years experience. Radiology 2003; 226:101–104.  Back to cited text no. 7
    
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Flum DR, Morris A. Has misdiagnose of appendicitis decreased over time? A population-based analysis. JAMA 2001; 28b: 1748–1753.  Back to cited text no. 8
    
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Krooks S. Obstruction of the small intestine due to adhesions and bands. Acta Chir Scand 1997; 95:1.  Back to cited text no. 9
    
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Anderson R, Hugander A, Thulin A. Diagnostic accuracy and perforation rate in appendicitis association with age and sex of the patient and with appendectomy rate. Eur J Surg 1992; 158:37–158.  Back to cited text no. 10
    
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Gupta H, Dupuy DE. Advances in imaging of the acute abdomen. Surg Clin North Am 1997; 77:1245–1263.  Back to cited text no. 11
    
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Lau W, Ho Y, Yeung C. Leucocyte count and neutrophil percentage in appendectomy for suspected appendicitis. Aust NZJ Surg 2002; 59:395.  Back to cited text no. 12
    
13.
Erikssoon S, Granstrom L, Bark S. Laboratory tests in patients with suspected acute appendicitis. Acta Chri Scand 1996; 155:117–155.  Back to cited text no. 13
    
14.
Bolion JP, Craven ER, Croft RJ. An assessment of the value of the white cell count in the management of suspected acute appendicitis. Br J Surgery 1997; 62:906.  Back to cited text no. 14
    
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Raferty A. The value of the leucocyte count in the diagnosis of acute appendicitis. Br J Surg 1998; 63:143.  Back to cited text no. 15
    
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Dacie JV, Lewis SM. Practical hematology 4th ed. Churchill, London: The primary defense against bacterial infection; 1990. 57.  Back to cited text no. 16
    
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Gronroos J, Forsstrom J, Irjala K. Phospholipase A2, C-reactive protein and white blood cell count in the diagnosis of acute appendicitis. Clin Chem 2000; 40:9–1757.  Back to cited text no. 17
    
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Ng KC, Lai SW. Clinical analysis of the related factor in acute appendicitis. Yale J Biol Med 2002; 75:41–45.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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