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Table 1

Age, Gender and Number of Patients Included in the Study

Table 2  

Laboratory Examinations

Table 3  

Preoperative Values

Table 4  

Comparison of WBC Count, CRP, and IL-6 (Mann-Whitney U-Test)

Table 5  

Best Cut-off Values, Specifity, Sensitivity, and Areas Under the Curve (AUC) with 95 % Confidence Intervals Estimated for CRP, IL-6 and WBC. Significantly Best Parameters are Shown Bold With Italic p Values in Comparison to WBC

Diagnostic Value of Blood Inflammatory Markers for Detection of Acute Appendicitis in Children

Authors: Ulrich Sack, MD ; Birgit Biereder, MD ; Tino Elouahidi, MD ; Katrin Bauer, MD ; Thomas Keller, MD ; Ralf-Bodo TröbsFaculty and Disclosures


Abstract and Background


Background: Acute appendicitis (AA) is a common surgical problem that is associated with an acute-phase reaction. Previous studies have shown that cytokines and acute-phase proteins are activated and may serve as indicators for the severity of appendicitis. The aim of this study was to compare diagnostic value of different serum inflammatory markers in detection of phlegmonous or perforated appendicitis in children.
Methods: Data were collected prospectively on 211 consecutive children. Laparotomy was performed for suspected AA for 189 patients. Patients were subdivided into groups: nonsurgical abdominal pain, early appendicitis, phlegmonous or gangrenous appendicitis, perforated appendicitis.
White blood cell count (WBC), serum C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor α (TNF-α), acid α1-glycoprotein (α1GP), endotoxin, and erythrocyte sedimentation reaction (ESR) were estimated ad the time of admission. The diagnostic performance was analyzed using receiver operating characteristic (ROC) curves.
Results: WBC count, CRP and IL-6 correlated significantly with the severity of appendiceal inflammation. Identification of children with severe appendicitis was supported by IL-6 or CRP but not WBC. Between IL-6 and CRP, there were no significant differences in diagnostic use.
Conclusion: Laboratory results should be considered to be integrated within the clinical assessment. If used critically, CRP and IL-6 equally provide surgeons with complementary information in discerning the necessity for urgent operation.


It is generally accepted that appendectomy is the therapy of choice in children. Conservative management, as evaluated in some studies of adult patients[1] is not established for children. A delay in diagnosis of acute appendicitis (AA) is associated with increased risk of perforation and further complications. On the other hand in young children, geriatric patients, and in adolescent females, the negative appendectomy rate may be as high as 50 %.[2] Many attempts have been made to determine ways of decreasing the negative laparotomy rate after a clinical suspicion of AA. Under this background it would be very important to differentiate mild early appendicitis from nonspecific abdominal pain. However, despite complete clinical history, physical examination, and the usual laboratory studies clear decision aids for detection of early AA are lacking. Ultrasonography has been used increasingly in the past years with positive results and both high sensitivity and specificity rates.[3] Furthermore, the introduction of diagnostic laparoscopy and laparoscopic appendectomy in clinical pediatric surgical practice opened new horizons. One of the main question is, if laboratory tests are helpful to diagnose even early AA in Childhood. For a long time the main auxiliary test has been the leucocyte count. The diagnostic value of laboratory inflammatory markers has been studied in the past years with different and contradictory results, commonly in a heterogeneous population of adults and children.[4]

The presented study comprises only patients of the pediatric age group and reflects in particular the pathophysiologic characteristics of this age group. It has to be pointed out, that conditions like pelvic inflammatory disease or acute cholecystitis play a diminished role during childhood whereas gastroenteritis, mesenteric lymphadenitis or non-specific terminal ileitis may simulate the symptoms of appendicitis in a significant part of patients with right iliac fossa pain.

The aim of our study is to find an inflammatory marker with predictive value for children who require appendectomy immediately. We intended to answer two main questions: Which laboratory values reflect best severity of appendicitis? Are there specific and sensitive constellations to discriminate between nonspecific right lower fossa abdominal pain and AA?

Table of Contents

  1. Abstract and Background
  2. Methods
  3. Results
  4. Discussion
  5. Conclusion
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