Sanju, Unnikrishnan (2019) A Comparative study of Diagnostic Value of Hyperbilirubinemia in Predicting Appendicitis and Its Complications. Masters thesis, Madurai Medical College, Madurai.
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Abstract
INTRODUCTION: The most common cause of acute abdomen is Appendicitis. The diagnosis of acute appendicitis is based on clinical history and physical examination. It is difficult to diagnose in cases of retrocaecal or retro ileal appendix. Appendicectomy is the most commonly performed abdominal surgery. 15-30% of appendicectomy specimen found to be normal. In order to decrease the number of unnecessary appendicectomy, significance of labarotory investigations like White Blood Cells, CReactive Protein, etc have been emphasised. Ultrasonagram abdomen has been widely accepted as the diagnostic tool for appendicitis. Many number of scoring system were developed to arrive the diagnosis. These scoring systems are based on clinical features, laboratory investigations. Some examples are Alvarado, Modified alvarado, Ripasa. Still there is no definitive laboratory marker for acute appendicitis and appendicular perforations. Studies show that serum bilirubin is raised in acute appendicitis and appendicular perforations.But the siginificance of which is not stressed.On bacterial invasion of the appendix, there is transmigration of bacteria and release of proinflammatory cytokines like TNF α,.IL6. The cytokines reach the liver through the superior mesentric vein and may lead to inflammation, abscess and liver dysfunction. In view of the above context, the present study was undertaken to assess the relationship between HYPERBILIRUBINEMIA and acute appendicitis and to evaluate its credibility as a diagnostic marker for acute appendicitis and also, to see whether elevated bilirubin levels have a predictive potential for the diagnosis of appendicular perforation. OBJECTIVES: 1. To study the relationship between hyperbilirubinemia and acute appendicitis; and to evaluate its credibility as a diagnostic marker for acute appendicitis. 2. To evaluate whether elevated bilirubin levels have a predictive potential for the diagnosis of Appendicular perforation. MATERIALS AND METHODS: The study was conducted in the Department of General Surgery, Govt.Rajaji Hospital and Medical College, Madurai during the period of August 2017 to August 2018. Study Design: A prospective non randomised study. Source: The present study was conducted in the Department of Surgery, Govt.Rajaji Hospital and Medical College, Madurai Study period One year from August 2017 to August 2018. Source of Data: Patients admitted with clinical diagnosis of acute appendicitis or appendicular perforation under the Department of Surgery, Govt.Rajaji Hospital and Medical College, Madurai during the study period. Sample Size: A total of 100 patients with clinical diagnosis of acute appendicitis or appendicular perforation were studied. Selection Criteria: Inclusion Criteria: All patients diagnosed as acute appendicitis clinically on admission. All patients diagnosed as appendicular perforation clinically on admission. For both these groups, only patients with histopathological report suggestive of acute appendicitis or appendicular perforation were included. Exclusion Criteria: All patients documented to have a past history ofo Jaundice or Liver disease, o Chronic alcoholism (that is intake of alcohol of > 40 g/day for Men and > 20 g/day in Women for 10 years), o Hemolytic disease, o Acquired or congenital biliary disease. All patients with positive HBsAg. All patients with cholelithiasis. All patients with cancer of hepato-biliary system. RESULTS: A total of 100 patients with clinical diagnosis of acute appendicitis or appendicular perforation admitted in the Department of General surgery, Govt.Rajaji Hospital and medical college,Madurai were studied. As per the study, the age group 11-20years is most commonly affected (44%) followed by age group 21-30 (32%). The youngest patients of this study were of 8 years old while the oldest patient was a 70 year lady. SUMMARY: Acute appendicitis is the most common cause of “acute abdomen” in young adults. Diagnosis of Appendicitis still remains a dilemma in spite of the advances in various laboratory and radiological investigations. Importance of hyperbilirubinemia or elevated Serum Bilirubin and its association in acute appendicitis has been postulated recently. It is hypothesized that an association exists between hyperbilirubinemia and acute appendicitis and its complications. The present study was undertaken to assess relationship between hyperbilirubinemia and acute appendicitis and to evaluate its credibility as a diagnostic marker for acute appendicitis and also, to see whether elevated bilirubin level shave a predictive potential for the diagnosis of Appendicular perforation. The present study was conducted in the Department of Surgery, GRH & MMC, Madurai during the period of August 2017 to August 2018. A total of 100 patients with clinical diagnosis of acute appendicitis or Appendicular perforation were studied. The serum bilirubin and LFTs were carried out in all the patients. In this study, males (56%) out numbered females (44%) and overall the mean age was 23.1±11.99 years. Mean total bilirubin was noted as 1.5 ±0.8mg/dL (range, 0.7 – 2.3 mg/dL) while direct bilirubin was1.0±0.7mg/dL(0.2-1.7mg/dL). The mean SGOT and SGPT were 27.9±12.2U/L (range, 15.7- 40.1U/L)and 25.9±11.0U/L (range, 14.935.9U/L). The mean ALP values were 80.8±21.6 U/L (range, 59.2-102.4U/L). Normal bilirubin values were seen in 26% patients while,74% hadraisedbilirubinlevels (Hyperbilirubinemia). Of 81 patients with acute appendicitis, 71.6% had raised bilirubin levels, while 28.4% had normal levels. 19 patients were diagnosed as Appendicular perforation, 16 patients (84.21%) had raised bilirubin levels, while there maining 03 patients(15.79%)hadnormallevels. Thetotal leukocyte count was less than 11,000/mm3 in 65% patients while, 35% patients had counts above 11,000/mm3. Of the100 patients, 91% were diagnosed as acute appendicitis clinically while 9% were diagnosed with Appendicular perforation. On Ultrasonography, 82% patients were diagnosed with acute appendicitis or appendicular perforation while 18% had normal findings. Post-operatively 81% were confirmed as acute appendicitis while19% were diagnosed with Appendicular perforation. The mean bilirubin levels in patients diagnosed with acute appendicitis was1.4±0.65mg/dL (range,0.75–2.05mg/dL) while in patients diagnosed with Appendicular perforation was1.9±1.16 mg/dL (range, 0.74–3.06mg/dL). The Direct bilirubin and Indirect bilirubin in patients diagnosed with acute appendicitis was 0.9±0.57mg/dL and 0.5±0.21 respectively. The Direct bilirubin and Indirect bilirubin in patients diagnosed with Appendicular perforation was 1.2±1.06mg/dL and 0.70±0.33mg/dL respectively. 58 patients (71.6%) of the total patients diagnosed with acute appendicitis (n=81) were found to have elevated bilirubin levels while 23 patients (28.4%) had normal bilirubin levels. Similarly, 16 patients (84.21%) of the total patients diagnosed with Appendicular perforation (n=19) were found to have elevated bilirubin levels while 03 patients (15.79%) had normal bilirubin levels. The Sensitivity and Specificity of serum bilirubin as a marker in predicting acute appendicitis and Appendicular perforation was 71.6% and 15.79% respectively. Similarly the Positive predicative value and Negative predicative value for the same was 78.38% and 11.54% respectively with odds ratio 0.472. Serum bilirubin levels appears to be a promising new laboratory marker for diagnosing acute appendicitis, however diagnosis of appendicitisis essentially still-clinical. Patients with clinical signs and symptoms of appendicitis and with hyperbilirubinemia double the normal range (Raisein Direct Bilirubin beings till higher) should be identified as having a higher probability of Appendicular perforation suggesting, serum bilirubin levels have a predictive potential for the diagnosis of Appendicular perforation. CONCLUSION: The present study suggests: Serum bilirubin levels appears to be a promising new laboratory marker for diagnosing acute appendicitis, however diagnosis of appendicitis remains essentially still - clinical. Its level come out to be a credible aid in diagnosis of acute appendicitis and would be helpful investigation in decision making. Patients with clinical signs and symptoms of appendicitis and with hyperbilirubinemia higher than the normal range should be identified as having a higher probability of Appendicular perforation suggesting, serum bilirubin levels have a predictive potential for the diagnosis of Appendicular perforation.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | Diagnostic Value, Hyperbilirubinemia, Predicting Appendicitis, Complications. |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Subramani R |
| Date Deposited: | 03 Sep 2019 23:16 |
| Last Modified: | 06 Sep 2019 07:46 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/11431 |
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