Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 39067

AbstractMaterial and MethodsResultsDiscussionConclusionReferences
Readers' Comments (0) Article in PDF Audio Visual Citation Manager Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : August | Volume : 3 | Issue : 4 | Page : 1647 - 1652

The Diagnostic Value of Hyperbilirubinemia and Total Leucocyte Count in the Evaluation of Acute Appendicitis

KHAN S*

*Department of surgery,NGMC, Teaching hospital,Nepalgunj ,Nepal

Correspondence Address :
Dr. SALAMAT KHAN drsalamatkhan63@yahoo.co.uk

Abstract

Background: Acute appendicitis (AA) is a common abdominal emergency encountered in general surgery. In most of the cases, the diagnosis can be made clinically by assessing the symptoms and physical findings and can be confirmed by laboratory tests and ultrasonography. However, diagnosis is difficult sometimes even after all these tests and in such doubtful cases, either the diagnosis is missed or the patient’s normal appendix is operated on, leading to increase in mortality and morbidity.
Aims: It is to evaluate the importance of total leukocyte count (TLC) and total serum bilirubin (TSB) in the diagnosis of clinically suspected cases of AA.
Settings And Design: This is a prospective study conducted at the Department of Surgery at NGMC, Teaching Hospital, Nepalgunj, Nepal, from December 2004- Jan 2008.
Methods And Material: 122 patients suspected of having appendicitis at clinical evaluation underwent prospective evaluations which included laboratory tests (TLC, LFT, Urine analysis) and ultrasonography (USG) of the abdomen. They were operated on and their diagnosis was confirmed per-operatively and post-operatively by histo-pathological examination. Laboratory results, operative findings and histo-pathological findings were compiled, analyzed and compared with reference values. The TLC and total serum bilirubin (TSB) were considered positive for appendicitis when their values were greater than 1010cell/cmm and > 1.1 mg/dL, respectively.
Results: The ages ranged from 8-73 years with a mean of 29.36 years. Out of 122 patients, 21(17.81%) cases belonged to the early group of cases (reported <24hours after the onset of the symptoms), while 101(82.78%) cases belonged to the delayed group of cases (reported >24 hours after the onset of the symptoms). The histological examination revealed that of the 122 specimens, 118(96.72%) had a positive histology for AA, while 4 (3.22%) had normal histology. TLC was elevated in 93 (76.22%) cases and it was normal in 29 (23.77%) cases. Among the cases that had elevated TLC, only 91(97.84%, CI 14010±254) had a positive histology for AA, while the remaining 2 (2.15%) had normal histology. Among 29 cases that had normal TLC, 27 had positive histology for AA, while the remaining 2 had normal histology. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and overall diagnostic accuracy are 50%, 77%, 97.8%, 7.4% and 76.22%, respectively. TSB was elevated in 95 cases (77.86%, CI 2.06±0.73), while it was within normal limits in 27 (22.13%) cases. Among the cases that had elevated TBS, all had positive histology for AA, while in cases with normal TBS, 23 had a positive histology for AA, while 4 had normal histology. The specificity, sensitivity, PPV, NPV, and overall diagnostic accuracy are 100%, 80%, 100%, 14% and 81.14%, respectively Liver enzyme changes if any, were not helpful in the diagnosis.
Conclusion: Elevated TSB (without severe changes in liver enzymes) was found to be a better laboratory test with 100% specificity, 80% sensitivity and 81.14% overall diagnostic accuracy than TLC with 50% specificity, 77% sensitivity and 76.22% overall diagnostic accuracy in the diagnosis of AA. But the diagnosis can be further improved if positive results of either tests alone or in combination are taken into consideration. This will reduce the missing rate of AA without increasing the rate of negative appendicectomies.

Keywords

Hyperbilirubinaemia, Total Leukocyte Count, Total Serum Bilirubin, Acute Appendicitis

How to cite this article :

KHAN S . THE DIAGNOSTIC VALUE OF HYPERBILIRUBINEMIA AND TOTAL LEUCOCYTE COUNT IN THE EVALUATION OF ACUTE APPENDICITIS . Journal of Clinical and Diagnostic Research [serial online] 2009 August [cited: 2018 Sep 26 ]; 3:1647-1652. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2009&month=August&volume=3&issue=4&page=1647-1652&id=558

Appendicitis is the most common cause of acute abdominal pain that necessitates surgical intervention in the Western world and around Kathmandu valley in Nepal (1), (2). The clinical diagnosis of acute appendicitis is based primarily on symptoms and physical findings. However, this diagnosis is often difficult and up to 50% of the patients hospitalized for possible appendicitis do not actually have this disorder. Authors of large prospective studies reported a 22%-30% removal rate of normal appendices at surgery (3), (4), (5), (6). To reduce the frequency of unnecessary appendectomy, the importance of laboratory findings that include both white blood cell (WBC) counts and C-reactive protein (CRP) values has been stressed (7), (8), (9) and the use of USG as a diagnostic tool for appendicitis has been widely evaluated (10),(11), (12), (13). Various scores combining clinical features and lab investigations have also been developed and are good enough to reach the diagnosis. These are the Alvarado score(14) and the Modified Alvarado score(15). Recently, elevation in serum bilirubin, was reported, but the importance of the raised total has not been stressed(17).
It is well established that when microbes invade the body, leucocytes defend it. This leads to increase in the leucocyte count. Bacterial invasion in the appendix leads to transmigration of bacteria and the release of TNF-alpha, IL6, and cytokines. These reach the liver via Superior mesenteric vein (SMV ) and may produce inflammation, abscess or dysfunction of liver either directly or indirectly by altering the hepatic blood flow(18),(19),(20),(21),(22),(23),(24).

Aim
To evaluate the specificity, sensitivity, PPV, NPV and diagnostic accuracy of TLC and TSB in the diagnosis of acute appendicitis.

Material and Methods

This is a prospective study conducted at Nepalgunj Medical College, Teaching Hospital, Nepalgunj, Nepal, from December 2004 to January 2008. Consecutive patients suspected of having appendicitis at clinical evaluation underwent prospective evaluations which included laboratory tests (TLC, LFT, Urine analysis) and USG of the abdomen. They were operated on and their diagnosis was confirmed per-operatively and post-operatively by histo-pathological examination. Laboratory results, operative findings and histo-pathological findings were compiled, analyzed and compared with the reference values. The TLC and TSB were considered positive for acute appendicitis when their values were greater than 1010cll/cmm and > 1.1 mg/dL, respectively.

Criteria of selection for the cases
Patients with a history of alcohol intake with AST/ALT <2 or no history of alcohol and hepatotoxic drug intake, those who were HBsAg negative or those with no past history of jaundice with acute appendicitis were included in the study, whereas patients with a history of alcohol intake and AST/ALT >2, a history of hepatotoxic drug intake, those which were HBsAg positive and /or those with a past history of jaundice and acute appendicitis were excluded from the study.

Results

A total of 122 patients were included in the present study. Their ages ranged from 8-73 years with a mean age of 29.36 years. The male to female ratio in adults and children were 1.57: 1:: 3.8:1, respectively. The commonest age group was 30 -40 years in adult patients. Out of the 122 cases, 21(17.81%) belonged to the early group of cases (duration of the onset of the symptoms- <24hours), while 101 (82.87%) belong to the delayed group of cases (duration of the onset of symptoms- >24 hours). Among the 21 early cases, 2 reported <12 hours, while the rest of the 19 reported >12 hours for the onset of symptoms (Table/Fig 1), (Table/Fig 2), (Table/Fig 3).

Histological examination reports revealed that out of the 122 appendix specimens, 118 (96.72%) had a positive histology for AA, while the remaining 4(3.22%) had normal histology (Table/Fig 4).

Of the 122 patients, 93 were found to have elevated TLC (76.22%) (18early&75 delayed) and it was normal in 29 (23.77%) (3 early&26 delayed) cases. Among the cases that had elevated TLC, only 91(97.84%, CI 14010±254) had a positive histology for AA and the remaining 2(2.15%) had normal histology. Among 29 cases that had normal TLC, 27 had a positive histology for AA, while the remaining 2 had normal histology. The specificity, sensitivity, PPV, NPV and DA are 50%, 77%, 97.8%, 7.4% and 76.22%, respectively (Table/Fig 5).

Of the 122 patients, 95 were found to have elevated TSB (77.86%, CI 2.06±0.73) (17early &78delayed), while it was within normal limits in 27 (22.13%) cases. Among the cases that had elevated TSB, all had a positive histology for AA, while in cases with normal TBS, 23 had positive histology for AA, while 4 had normal histology. The specificity, sensitivity, PPV, NPV, and DA are 100%, 80%, 100%, 14% and 81.44%, respectively (Table/Fig 6).

Liver enzymes e.g. serum alanine amino trasferase (ALT/SGPT) was normal in 86(70.49%), marginally elevated (<1time) in 26(21.31%), minimally elevated (>1-<2time) in 5(4.09%), moderately elevated (<3times) in 3(2.45%) and severely elevated (>3times) in 2(1.63%) of the cases. Serum aspertate aminotrasferase(AST/SGOT) was normal in 75(61.47%), marginally elevated (<1time) in 37(30.32%), minimally elevated (>1time-<2times) in 8(6.55%), moderately elevated (3times) in 1(0.84%) and no case of severe elevation was observed. Age and sex adjusted ALP was normal in 62(50.81%), slightly elevated (1 time) in 46(37.70%), moderately elevated (< 2 times) in 9(7.37%) and severely elevated (>2 times) in 5(4.09%) of the cases (Table/Fig 7), (Table/Fig 8), (Table/Fig 9).


Discussion

A majority of the cases are reported to the hospital only 24 hours after the onset of symptoms. Histopathological reports of the appendix specimens revealed that 96.27% had a positive histology for AA, whereas TLC and TSB were elevated in 76.22% and 77.86% of the cases, respectively. This indicates that the elevation of both TLC and TSB strictly does not follow the acute inflammation of the appendix.
If TLC alone is taken into consideration to reach the diagnosis in a clinically suspected case of AA, then there is a possibility that about 1.7% results could be false positive (elevation of TLC without inflammation of appendix) and 22.13% results could be false negative (positive histology without elevation of TLC), which means that there are chances that 1.7% normal appendices will be removed, while in 22.13% of the cases, the diagnosis will be missed.
If TSB alone is taken into consideration to reach the diagnosis in a clinically suspected case of AA, there will be no false positive results, but there could be 18.85% false negative results, which means that none of the normal appendices will be removed, but in 18.85% of the cases, the diagnosis will be missed.
On comparing both test results, TSB was found to be a better test than TLC, because the missing percentage of the diagnoses was nearly similar in both tests (22.13% Vs 18.85%), but the percentage of negative appendicectomy with TSB was nil as compared to TLC (1.7%).
If both are elevated, both TLC and TSB are taken into account to reach the diagnosis in clinically suspected cases of AA. The correct diagnosis is usually made only in 55% of the cases. This is because both the tests do not show elevated values at the same time in 45% of the cases. This can cause the real diagnosis to be missed out in too many cases, while if both test results show elevated values which are taken into account either alone or together, the chances of a correct diagnosis is increased to 99.3% and the chances of a missed diagnosis is reduced to <1% at the expense of 1.7% unnecessary appendicectomies (false positive cases). This is much higher than either of the two tests individually and together. Thus, in cases where TLC is normal, TSB can be used as an alternative lab test, or vice –versa, to reach the diagnosis. This may reduce the rate of missed diagnoses without increase in the percentage of negative appendicectomies (7), (25).

Conclusion

Elevated TSB (without severe changes in liver enzymes) is a better laboratory test (with 100% specificity, 80% sensitivity and 81.14% overall diagnostic accuracy) than TLC (with 50% specificity, 77% sensitivity and 76.22% overall diagnostic accuracy) in the diagnosis of AA. But, the diagnostic accuracy is further improved if positive results of either tests alone or in combination are taken into consideration for the diagnosis. This will reduce the rate of missed diagnoses of AA without increasing negative appendicectomies.

References

1.
Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996; 14:653-71.
2.
Chetri RK, Shrestha ML. Comparative study of preoperative with operative diagnosis in acute abdomen. KUMJ 2005; (2) issue 10:107-10.
3.
de Dombal FT, Leaper DJ, Staniland JR, McCann AP, Horrocks JC.Computer-aided diagnosis of acute abdominal pain. BMJ 1972; 2:9-13.
4.
Deutsch A, Shani N, Reiss R. Are some appendectomies unnecessary: and analysis of 319 white appendices. JR Coll Surg Edinb 1983; 28:35-40.
5.
Simmen HP, decurtins M, Rotzer A, Duff C, Brutsch HP, Largiader F.Emergency room patients with abdominal pain unrelated to trauma: prospective analysis in a surgical university hospital. Hepatogastroenterology 1991: 38:279-282.
6.
Rao PM, Rhea JT, Novelline RA. Helical CT of appendicitis and diverticulitis.Radiol Clin North Am 1999; 37:895-910.
7.
Gronroos JM, Gronroos P. Diagnosis of acute appendicitis. Radiology 2001; 219:297-298.
8.
Gronroos JM, Gronroos P. Leucocyte count and C reactive protein in the diagnosis of acute appendicitis. Br J Surg 1999; 86:501-504.
9.
Gronroos JM, Gronroos P. A fertile-aged woman with right lower abdominal pain but unelevated leukocyte count and C-reactive protein: acute appendicitis is very unlikely. Langenbecks Arch Surg 1999; 384:437-440.
10.
Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215:337-348.
11.
Jeffrey RB, Jr, Laing FC, Lewis FR. Acute appendicitis: high-resolution real-time US findings. Radiology 1987; 163:11-14.
12.
Puylaert JBCM, Rutgers PH, Lalisang RI, et al. A prospective study of Ultrasonography in the diagnosis of appendicitis. N Engl J Med 1987; 317:666-669.
13.
Rioux M. Sonographic detection of the normal and abnormal appendix. AJR Am J Roentgenol 1992; 158:773-778.
14.
Alvarado A. .A practical score for early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15: 557-564.
15.
Kalan M, Tabbot O, Cunlife wh et. al. Evaluation of modified Alvrado score in the diagnosis of acute appendicitis. A prostective study. Ann R Cool Surg Engl 1994; 76:418.
16.
Lim HK, Lee WJ, Lee SJ, Namgung S, Lim JH. Focal appendicitis confined to the tip: diagnosis at US. Radiology 1996; 200:799-801.
17.
Khan S. Evaluation of hyperbilirubinemia in acute inflammation of appendix: A prospective study of 45 cases. KUMJ vol.4, No.3, 2006; 15: 281-289.
18.
Beg R B and Garlungton Aw. Translocation of certain endogenous bacteria from the gi tract to mesenteric lymph node and other organ in Gonobiotic mouse model. Infect Immunol 1979; 23: 403-411.
19.
Juric I, Primorac D, Zagar Z, Biocic M, et al. Frequency of portal and systemic bacteremia in acute appendicitis. Pediatr Int 2001 APR; 43(2): 152-6.
20.
Koito Scathen WE, DesprezJD and Holden WD. A bacteriologic study in portal blood in man. Arch Surg 1995; 71: 404-409.
21.
Wang P, Ayala A, Ba ZF, et al. Tumor necrosis factor –alpha produces hepatocellular dysfunction despite of normal cardiac out put and hepatic microcirculation. Am J Physiol Gastrointet Liver Physiol 1993: 265(1): 126-32.
22.
Wang P, Ba ZF, Chaudhary IH. Hepatic extraction of indo-cyanine green is depressed in early sepsis despite increase hepatic blood flow and cardiac out put. Arch Surg Feb 1991; 2:126.
23.
Wang P and Chudhary IH. Mechanism of hepatocellular dysfunction during hyper dynamic sepsis. Am J Physiol Regul Integr Comp Physiol 1996; 270: 927-38 & 363-61.
24.
Whiting JF, Green RM, Rosen AB,et Al. TNF-alpha decreases hepatocyte bile salt uptake and mediated endotoxin-induced cholestasis .Hepatol 1995; 22: 1273.
25.
Gulzar S, Umar S, Dar GM et. al. Acute Appendicitis. Importance of clinical examination in making a confident diagnosis. Pak J Med Sci 2005;21(2):125-32

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2016: 132.37
  • SCOPUS
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • EBSCOhost
  • Embase & EMbiology
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com