Grey Zone Appendicitis: Role of Blood Test Biomarkers to Detect Early Appendicitis and to Decrease the Incidence of Negative Appendectomy
Grey Zone Appendicitis: Role of Blood Test Biomarkers to Detect Early Appendicitis and to Decrease the Incidence of Negative Appendectomy
Introduction: many investigations emerged in the last decades and contribute towards a
 diagnosis of unsure appendicitis; they are valuable to the emergency general surgeon.

 Aim: This study aims to assess the role of laboratory markers (bilirubin and phospholipase
 A2) individually or combined with Computed Tomography (CT) for the diagnosis of grey zone
 appendicitis (Alvarado score 5-6).

 Methods: This prospective study included all 310 patients admitted with right iliac fossa
 (RIF) pain who had Alvarado score 5-6 (intermediate risk of appendicitis). All underwent full
 laboratory investigations including serum total bilirubin and phospholipase A2. All are
 underwent CT scan and classified into group A with normal CT but with persistent right iliac
 fossa pain and group B with proved acute appendicitis by CT. All cases underwent a
 laparoscopic or open appendectomy. Other causes of hyperbilirubine¬mia are excluded among the
 patients.
INTRODUCTION Acute appendicitis is a very common surgical emergency worldwide, with a
 lifetime risk reported to be 7-8%..Accordingly, appendectomy is the most frequently performed
 operation worldwide.

 Many surgical centers attempt to reduce surgical procedures performed during the night, and
 delaying appendectomy for 12-24 h does not seem to increase complications

 Despite thorough research, the diagnosis of acute appendicitis is still difficult and remains
 the most common problem in clinical surgery.

 In addition to clinical examination of the patients with appendicitis, ultrasonography and
 multidetector computed tomography (MDCT) have become the most useful tools with a respective
 sensitivity and specificity of 98.5% and 98.0% in expert centers Routine use of MDCT not only
 increases exposure to radiation but also very expensive and time-consuming. Thus evolving
 methods to diagnose early acute appendicitis without radiological examinations are of
 interest.

 Observing serum bilirubin and phospholipase A2 level came into consideration as it seems to
 elevate in early appendicitis, its determination is fast and can be performed with other
 commonly performed blood tests.

 Bacteria invade the appendix and release tumour necrosis factor-alpha, Interleukien 6, and
 cytokines. These substances reach the liver through superior mesenteric vein and cause
 dysfunction of liver either by direct effect or indirectly through altering the hepatic blood
 flow. So it is important to evaluate the total bilirubin level in the diagnosis of clinically
 suspected cases of appendicitis (6) THE AIM OF THE WORK

 This study aims to evaluate the role of bilirubin and phospholipase A2 in:

 1. Cases of grey zone unsure appendicitis (intermediate risk Alvarado score 5-6).

 2. As a complementary to CT.

 3. Detect early cases of appendicitis.

 4. Decrease the incidence of negative appendicitis.

 5. Decrease complications of missed cases of appendicitis.

 6. Reduce the overnight appendectomy rate with its complications. Patients and methods
 Cases with normal CT but with persistent right iliac fossa tenderness and failed to
 improve under conservative treatment for 48 hrs With antibiotic therapy (Group A)
 underwent laparoscopic appendectomy. Patients proved to be appendicitis by CT underwent
 laparoscopic exploration (Group B). All the appendices removed were sent for
 histological examination and the operated cases divided into positive appendicitis
 (macroscopic or microscopic) and negative appendicitis.

 Group A , patients with normal CT but with persistent right iliac fossa pain. Group B ,
 patients with proved acute appendicitis in CT.
Inclusion Criteria:

 -  Age: more than 14years of both sexes.

 -  Non pregnant female.

 -  Patients taking analgesics. .Patients who diagnosed to have grey zone diagnosis of
 acute appendicitis (Alvarado score 5-6).

 Exclusion Criteria:

 -  Alvarado score >6 or < 5.

 -  Cases of sure acute appendicitis.

 -  Documented Liver disease, biliary disease (congenital or acquired), hemolytic diseases
 and history of alcoholism.

 4) Cases revealed other pathology than appendicitis by CT and laparoscopy.