Can normal inflammatory markers rule out acute appendicitis? The reliability of biochemical investigations in diagnosis

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Kim, Jason JY
Dobson, Benjamin H
Ng, Cedric LH
Thong, Da Wei
Arthur, Thomas
Parker, David
Anwari, Tahmina
Archer, Leigh
Auld, Michael
Bagguley, Dominic
Bhatt, Jubin
Bierton, Christopher
Bormann, Sarah
Bradshaw, Kimberley
Callahan, Rosie
Capati, Gian
Cattanach, Daniel
Chai, Debbie
Cozier, Matthew
Daza, Fermina
Della Martina, Olivia
Dickfos, Marina
Duncan, Catriona
Edward, Laura
Elstner, Kristen
Franceschini, Luke
Fuller, Emma
Gavey, Roderick
Goldman, Hariette
Gole, Hobia
Harrison, Elizabeth
Honore, Matthew
Hughes, Ian
Hwang, Yang
Jacob, Matthew
Jain, Anshini
Jones, Stephanie
Kothapalli, Anita
Kwok, Michael
Lavarack, Bruce
Lee, Lisa
Liu, David
Lonie, James
Low, Nicholas
Machin, David
Maddern, Guy
McFarlane, Julia
Metcalfe, Dinusha
Moar, Xavier
Morden, Brendon
Nabi, Hajir
Neo, Eu Nice
Kin, Daniel Ng Ying
O'Brien, Eavan
O'Donohue, Peter
Paget, Sarah
Potent, Keith
Puhalla, Harald
Ramachandran, Roshan
Rosley, Muhammad
Schachtel, Michael
Schmidt, Amy
Sharpe, Kendall
Shivananda, Arjun
Stupart, Douglas
Ta'I, Shayan
Theophilus, Mary
Toonsen, Phill
Udovicich, Cristian
Van Der Nest, Bianca
Walch, Anna
Walker, Daniel
Wong, Enoch
Wong, Zee Hame
Zubair, Omar
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2019
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Abstract

Background: Acute appendicitis is a common general surgical condition where diagnosis is predominantly clinical, with the aid of adjunct investigations. This study reviews the relationship between normal and elevated biochemical inflammatory markers, duration of symptoms and proven appendicitis. Methods: A multicentre prospective observational study was performed across 27 centres and included a total of 949 patients with clinical suspicion of appendicitis, who had both white cell count (WCC) and C‐reactive protein (CRP) recorded and underwent appendicectomy. Results: A total of 90.4% of patients with raised WCC and CRP had appendicitis with a positive predictive value (PPV) of 0.9 and negative predictive value (NPV) of 0.4. Sensitivity and specificity of elevated WCC (sensitivity 66.5%, specificity 66.0%) and elevated CRP (sensitivity 77.3%, specificity 52.0%) lie within ranges identified by previous studies. A total of 39.8% of patients with normal CRP and WCC had appendicitis. Sensitivity and PPV for patients with elevated inflammatory markers were high until 48 h of symptoms (sensitivity 94%, PPV 0.87). NPV was elevated after 24 h (NPV 0.65 in patients with 24–48 h of symptoms, and 0.61 after 48 h), whilst those with symptoms less than 24 h had a lower NPV of 0.52. Conclusion: Whilst elevated inflammatory markers are a helpful aid in the diagnosis of appendicitis, they should not be relied on by themselves. Nor can normal inflammatory markers be used to exclude appendicitis, even in those with prolonged duration of symptoms. The diagnosis of appendicitis should be guided by a combination of clinical judgement with the assistance of inflammatory markers.

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ANZ Journal of Surgery

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This publication has been entered into Griffith Research Online as an Advanced Online Version.

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Clinical sciences

Science & Technology

Life Sciences & Biomedicine

Surgery

appendicitis

C-reactive protein

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Kim, et al., Can normal inflammatory markers rule out acute appendicitis? The reliability of biochemical investigations in diagnosis, ANZ Journal of Surgery, 2019

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