The predictive value of neutrophil-to-lymphocyte ratio to diagnose acute appendicitis and grade its severity
Keywords:Acute appendicitis, Children, Diagnosis, Neutrophil/lymphocyte ratio, Severity
Background: Acute appendicitis (AA) is one of the most common acute abdominal emergencies in the pediatric population, occurring commonly between the ages of 7-15 years. The diagnosis mostly depends upon typical presentation and clinical findings. Laboratory investigations and imaging techniques aid the diagnosis. Neutrophil to lymphocyte ratio (NLR) is a valuable indicator of diagnosis in questionable cases.
Methods: This is a retrospective study consisting of 260 pediatric patients who underwent appendicectomy. The study was conducted at the Department of Pediatric Surgery, Maternity and Children’s Hospital Dammam, Saudi Arabia. The duration of the study was May 2018 to March 2021. The clinical features and initial preoperative total leukocyte count (TLC), with neutrophil and lymphocyte values, were collected. The neutrophil to lymphocyte ratio (NLR) was preoperatively calculated by dividing the values obtained. The patients were categorized in group 1 as non-appendicitis and group 2 as appendicitis. On the basis of histopathological findings, group 2 was further divided into catarrhal, phlegmonous, and gangrenous/perforated as groups A, B, and C respectively. The value of NLR was compared between the groups.
Results: The children with acute appendicitis had a higher NLR than healthy children. Acute appendicitis was ruled out at 2 cut-off-value of NLR with 94% sensitivity and 100% specificity. An NLR of 3.5 was an accurate marker for acute appendicitis. Significant differences in NLR values were also observed in the severity of appendicitis. Phlegmonous appendicitis had 78% sensitivity and 82% specificity at a cut-off value of 6.0 while NLR of > 8.0 was the cut-off point for gangreneous/perforated appendicitis with 80 % sensitivity and 87% specificity.
Conclusion: The NLR is a reliable biomarker to exclude, diagnose, and grade the severity of acute appendicitis. It is a valuable indicator of atypically presented cases or cases lacking adequate clinical findings. The yield of the test is increased in conjunction with other laboratory parameters.
Tuncer AA, Cavus S, Balcioglu A, Silay S, Demiralp, Calkan E, Altin MA, Eryilmaz E, Karaisaoglu AO, Bukulmez A, Dogan, Embleton DB, Cetinkursun S. Can mean platelet volume, Neutrophil-to-Lymphocyte, Lymphocyte-to-Monocyte, Platelet-to-Lymphocyte ratios be favorable predictors for the differential diagnosis of appendicitis? JPMA: 2019; 69(5):647-654.
Dedi, Rochadia P, Gunadia. Accuracy of neutrophil lymphocyte ratio for diagnosis of acute appendicitis in children: A diagnostic study. Ann Med Surg (Lond): 2019 Dec; 48: 35–38.
George H, Patrick MJ. Aschcraft’s Pediatric surgery 5th edition. Sunders Elseiver 2010. Appendicitis.973-980.
Yilmaz BK, Acar YA. Investigation of the Diagnostic Value of Neutrophil to Lymphocyte Ratio in Pediatric Appendicitis Cases. Iran J Pediatr: 2017; 27(3): e9593.
Yazici M, Ozkisacik S, Oztan MO, Gürsoy H. Neutrophil/lymphocyte Ratio in the Diagnosis of Childhood Appendicitis. Turk J Pediatr: 2010; 52(4):400-3.
Kapetanovic SB, Avdagic N, Zaciragic A, Hasic S, Babic N, Hadzimuratovic A. Could the neutrophil-to-lymphocyte ratio serve as a marker in the diagnosis and prediction of acute appendicitis complications in children? Arch Med Sci, DOI: https://doi.org/10.5114/aoms. 2019.87697.
CelikB, Nalcacioglu , Ozcatal M, Altuner Y. Torun. Role of Neutrophil-To-Lymphocyte Ratio and Platelet-To-Lymphocyte Ratio in Identifying Complicated Appendicitis in the Pediatric Emergency Department. Ulus Travma acil Cerrahi Derg: 2019; 25(3): 222-228.
YalçınO, Aygün A, Ertürk EY. Assessment of New Biomarkers Used in the Diagnosis of Acute Appendicitis in Children. Ulutas Med J: 2019; 5(2): 149-154.
Stanković N, Stanojević I, Đorđević D, Kostić Z, Udovičić I, Miličković M, Savić D, Grujić B, Đuričić S, Šurbatović M. Neutrophil-to-lymphocyte ratio in pediatric acute appendicitis. Vojnosanit Pregl: 2018; 75(1): 46-55.
Paramita DA, Fikri E, Lubis Z. Role of Red Blood Cell Distribution Width (RDW) and Neutrophil Lymphocyte Ratio (NLR) in Diagnosis of Appendicitis in Paediatric Patients in H. Adam Malik Medan Central General Hospital. IJMSCI: 2018; 5(03): 3591-3595.
Virmani S, Prabhu PS, Sundeep PT, Kumar V. Role of Laboratory Markers in Predicting Severity of Acute Appendicitis. Afr J Paediatr Surg: 2018; 15(1):1-4.
Khan U, Kitar M, Krichen I, Maazoun K, Althobaiti RA, Khalif M, Adwani M. To Determine Validity of Ultrasound in Predicting Acute Appendicitis Among Children Keeping Histopathology as Gold Standard. Ann Med Surg (London): 2019 Feb; 38: 22–27.
Yazici M, Ozkisacik S, Oztan MO, Gürsoy H. Neutrophil/lymphocyte ratio in the diagnosis of childhood appendicitis. Turk J Pediatr. 2010; 52:400–3.
Yardmc S, Ugurlu MO, Coskun M, Attaallah W, Yegen SC. Neutrophil-Lymphocyte ratio and mean platelet volume can be a predictor for severity of acute appendicitis. Ulus Travma Acil Cerrahi Derg. 2016; 22:163-8.
Morrow SE, Newman KD. Current management of appendicitis. Semin Pediatr Surg 2007; 16: 34-40.
Singh M, Kadian YS, Rattan KN, Jangra B. Complicated appendicitis: Analysis of risk factors in children. Afr J Paeditr Surg 2014; 11:109-13.
Ishizuka M, Shimizu T, Kubota K. Neutrophil-to-lymphocyte ratio has a close association with gangrenous appendicitis in patient undergoing appendectomy. Int Surg 2012; 97:299-304.
Bialas M, Taran K, Gryszkiewicz M, Modzelewski B. Evaluation of neutrophil-lymphocyte ratio usefulness in the diagnosis of appendicitis. Wiad Lek 2006; 59: 601-6.
Kostakis ID, Maria A, Katerina K, Gardikis S, Kyriaki CG, Theodora G, Vaos G. Hematological Diagnostic Markers of Acute Appendicitis in Children. Hellenic Journal of Surgery 2018; 90(03), 127-136.
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