International Surgery Journal

Rathnam U et al. Int Surg J. 2019 Jul;6(7):2386-2389

[Link] pISSN 2349-3305 | eISSN 2349-2902

DOI: [Link]
Original Research Article

C-reactive protein as a diagnostic tool in acute appendicitis

Usharani Rathnam*, Srivignesh Kumar K., Lakkanna Suggaiah

Department of General Surgery, ESIC Medical College, Rajajinagar, Bengaluru, Karnataka, India

Received: 08 June 2019

Revised: 23 June 2019
Accepted: 24 June 2019

*Correspondence:
Dr. Usharani Rathnam,
E-mail: drushagiri@[Link]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal
pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical
symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner lining
of the abdominal wall and sepsis. The main objective is to compare C-reactive levels in diagnosis of acute
appendicitis.
Methods: In this study patients coming to General Surgery Department of ESIC Medical college, Rajajinagar,
Bengaluru, from January 2017 to December 2017, who are diagnosed clinically as to have acute appendicitis form the
source of study.
Results: In the present study, maximum number of cases belongs to 21-30 year age group (22 cases) and male female
ratio is 1.07:1. Most common site of pain being right iliac fossa (52 cases), vomiting as presenting complaint was seen
in 51 cases, fever as a presenting complaint was present in 31 cases, Mc-Burneys point tenderness noted in 49 cases,
rebound tenderness noted in 46 cases. In present series 53 patients had elevated serum CRP level (>2.5 mg/dl) which
is 89% of total study group. In these patients only one patient had high serum CRP level in spite of normal appendix.
Conclusions: An elevated serum CRP level supports the surgeon’s diagnosis and hence avoids chances of error in
diagnosis, due to atypical presentations. Similarly a normal preoperative serum CRP level in patients with suspected
acute appendicitis is most likely to be associated with a normal appendix on histo-pathological examination.

Keywords: C-reactive protein, Acute appendicitis, Abdominal pain

INTRODUCTION tissue from a viral infection, parasites, gallstone, or

tumors may also cause the blockage. This blockage leads
Appendicitis is inflammation of the appendix.1 Symptoms to increased pressures in the appendix, decreased blood
commonly include right lower abdominal pain, nausea, flow to the tissues of the appendix, and bacterial growth
vomiting, and decreased appetite. However, inside the appendix causing inflammation. The
approximately 40% of people do not have these typical combination of inflammation, reduced blood flow to the
symptoms. Severe complications of a ruptured appendix appendix and distention of the appendix causes tissue
include widespread, painful inflammation of the inner injury and tissue death. If this process is left untreated,
lining of the abdominal wall and sepsis.2 the appendix may burst, releasing bacteria into the
abdominal cavity, leading to increased complications.
Appendicitis is caused by a blockage of the hollow
portion of the appendix. This is most commonly due to The diagnosis of appendicitis is largely based on the
a calcified "stone" made of feces. Inflamed lymphoid person's signs and symptoms. In cases where the

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diagnosis is unclear, close observation, medical imaging, developed, including ultrasound, computed tomographic
and laboratory tests can be helpful. The two most scan with intravenous contrast or immunological
common imaging tests used are an ultrasound and markers, magnetic resonance imaging, radiological
computed tomography (CT scan). CT scan has been contrasted techniques, and many different laboratory tests
shown to be more accurate than ultrasound in detecting including C-reactive protein (CRP).
acute appendicitis. However, ultrasound may be preferred
as the first imaging test in children and pregnant women The role of CRP levels in patients with appendicitis has
because of the risks associated with radiation exposure been extensively studied in adults. Some studies have
from CT scans.3 addressed the predictive value of CRP at different cutoff
levels in adults determined by ROC curve analysis and
The standard treatment for acute appendicitis is surgical have found that CRP levels were useful for the diagnosis
removal of the appendix. This may be done by an open of appendicitis during the first 3 days after the onset of
incision in the abdomen (laparotomy) or through a few symptoms.
smaller incisions with the help of cameras (laparoscopy).
Surgery decreases the risk of side effects or death The main objective is to compare C-reactive levels in
associated with rupture of the appendix. Antibiotics may diagnosis of acute appendicitis.
be equally effective in certain cases of non-ruptured
appendicitis. It is one of the most common and significant METHODS
causes of severe abdominal pain that comes on quickly.
In 2015 about 11.6 million cases of appendicitis occurred In this study patients coming to General Surgery
which resulted in about 50,100 deaths. In the United Department of ESIC Medical college, Rajajinagar,
States, appendicitis is the most common cause of sudden Bengaluru, from January 2017 to December 2017, who
abdominal pain requiring surgery. Each year in the are diagnosed clinically as to have acute appendicitis
United States, more than 300,000 people with form the source of study.
appendicitis have their appendix surgically
removed. Reginald Fitz is credited with being the first Inclusion criteria
person to describe the condition in 1886.
All the patients who will be admitted to ESIC Medical
Few studies have addressed the predictive value of C- College, Rajajinagar, Bengaluru, during the study period
reactive protein at different cutoff values in appendicitis. with diagnosis of acute appendicitis and posted for
We have determined the cutoff values for C-reactive surgery are included in the study.
protein levels at different periods during clinical
evolution of appendicitis and established their use to Exclusion criteria
support the diagnosis of appendicitis.
Patients with past history of jaundice, signs and
The analysis of C-reactive protein levels demonstrated a symptoms of liver disease, chronic alcoholism are
high sensitivity to differentiate patients with and without excluded as CRP is exclusively produced in liver.
appendicitis. C-reactive protein levels can be used to Females taking oral contraceptive pill or pregnant are
support the clinical diagnosis of appendicitis, and excluded as CRP is elevated in these individuals.
depending on time from onset of symptoms to diagnosis,
they also can be used to differentiate patients with and Data analysis
without appendicitis.
Preoperative blood test results for the corresponding
The classic clinical picture of appendicitis has been patients from the histological database were obtained
widely known for more than 110 years, and described using our hospital computer system. The median CRP
mainly in adults. Some atypical symptoms that could lead levels for each of the NA, AA and PA groups were
to errors in the diagnosis of appendicitis have also been obtained using excel® (Microsoft, Redmond, WA, US).
described in young adults and children.4 All statistical analysis was performed using stata® v11
(StataCorp, College Station, TX, US) and prism® 5
The problem with an erroneous diagnosis of appendicitis (GraphPad Software, La Jolla, CA, US). Results were
is that the removal of a normal appendix or, on the compared using the Mann–Whitney U test. A p-value of
contrary, the delay in treatment of appendicitis associated <0.05 was considered statistically significant.
to its major complications, such as phlegmon, abscess or
peritonitis, has ethical, economical and legal The diagnostic value of CRP was predicted with
implications.5 sensitivity, specificity, positive predictive value (PPV)
and negative predictive value (NPV) for the above groups
To avoid these problems and to improve the early and either for each individual test or when combined.
accurate diagnosis of appendicitis, technological Sensitivity, specificity, PPVs and NPVs varied when
approaches to diagnose appendicitis have been different cut-off values were examined (sensitivity

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 Rathnam U et al. Int Surg J. 2019 Jul;6(7):2386-2389

analysis). The cut-off value finally chosen to compare DISCUSSION

sensitivity, specificity, PPV and NPV for each variable
when looked at individually corresponded to the highest In the present study, maximum number of cases belongs
combined value for sensitivity and specificity, which to 21-30 year age group (22 cases) and male female ratio
resulted in a value either higher than normal or within the is 1.07:1. CRP levels were higher in patients with
upper range of normal for each of the corresponding appendicitis compared with patients without appendicitis;
markers. CRP levels were significantly higher in patients
diagnosed between 13 and 24 hours from the onset of
RESULTS symptoms compared with patients with symptoms for
less than 12 hours. CRP reaches its peak approximately at
In the present study maximum number of cases belongs 40 hours; consequently, the higher value encountered at
to 21-30 year age group (22 cases) and male female ratio 24 hours represents the rising of the CRP concentration.
is 1.07:1. CRP levels increase with complications of appendicitis.6
It has been reported that a CRP value higher than 100
Table 1: Age and sex wise distribution of cases (n=58). mg/L was strongly related to appendiceal necrosis, and a
CRP value higher than 170 mg/L was a strong predictor
Age group Male Female Total for the presence of infection.7
11-20 08 07 15 In our study, the most common site of pain being right
21-30 12 10 22 iliac fossa (52 cases), vomiting as presenting complaint
31-40 06 05 11 was seen in 51 cases, fever as a presenting complaint was
41-50 04 06 10 present in 31 cases, Mc-Burneys point tenderness noted
Total 30 28 58 in 49 cases, rebound tenderness noted in 46 cases.
According to a study by Ghimire et al, a cross sectional
Table 2: Distribution of cases based on sign and study was done with consecutive patients diagnosed with
symptoms. acute appendicitis that underwent appendectomy over six
month’s period. Pre-operative findings and
Sign and symptoms Number of cases histopathology report were compared and analyzed with
the level of C-reactive protein. A total of 54 patients were
Abdominal pain enrolled in this study. 94.40% were proved as acute
Right iliac fossa 52 appendicitis in histopathology. The level of C-reactive
Umbilical 06 protein was significantly raised among highly inflamed
Vomiting 51 appendix. C-reactive protein showed 84.31% sensitivity,
Fever 31 66.66% specificity, 97.72% positive predictive value and
Diarrhoea 26 20% negative predictive value in diagnosing acute
McBurney tenderness 49 appendicitis. So author concluded that, raised level of C-
Rebound tenderness 46 reactive protein is an aid for diagnosing acute
Shifting tenderness 21 appendicitis.8

Table 3: Correlation between C-reactive protein level In present series, 53 patients had elevated serum CRP
and appendicitis. level (>2.5 mg/dl) which is 89% of total study group. In
these patients only one patient had high serum CRP level
CRP test in spite of normal appendix. A study was done to assess
CRP the utility of these markers in patients presenting with
True False
level acute lower abdominal pain. WCC and CRP were
Positive Negative Positive Negative
measured prospectively in 98 patients presenting with
Elevated 52 - 1 - lower abdominal pain, and the results were correlated
Normal - 6 - 1 with each patient's outcome. No patients with WCC and
CRP both in the normal range had acute appendicitis.
The most common site of pain being right iliac fossa (52 Raised WCC and CRP were poor positive predictors of
cases), vomiting as presenting complaint was seen in 51 appendicitis, both alone and in combination, and
cases, fever as a presenting complaint was present in 31 correlated poorly with the development of complications.
cases, Mc-Burneys point tenderness noted in 49 cases, This result may have important clinical and economic
rebound tenderness noted in 46 cases. implications. We suggest that patients experiencing lower
abdominal pain, with normal WCC and CRP values, are
In present series 53 patients had elevated serum CRP unlikely to have acute appendicitis and can be safely sent
level (>2.5 mg/dl) which is 89% of total study group. In home.9
these patients only one patient had high serum CRP level
in spite of normal appendix. In a prospective, double blind study, blood for the
measurement of serum C-reactive protein was collected

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 Rathnam U et al. Int Surg J. 2019 Jul;6(7):2386-2389

pre-operatively from 192 children before going to the 2. Hobler K. Acute and suppurative appendicitis:
operating theatre for appendectomy. The histopathology disease duration and its implications for quality
was grouped into positive (acute appendicitis) and improvement. Permanente Medical Journal.
negative (normal appendix) and this was correlated with 1998;2(2):71-4.
CRP values. CRP was normal in 14 out of 33 negative 3. Paulson EK, Kalady MF, Pappas TN. Clinical
explorations (normal appendix on histopathology). The practice. Suspected appendicitis. N Engl J Med.
specificity and sensitivity of serum CRP was 42% and 2003;348(3):236–42.
91% respectively. The predictive value of a positive 4. Beltrán SM, Tapia TF, Cruces BK, Rojas J, Araya
(raised CRP) and negative (normal CRP) test is 88% and ET, Barraza M, et al. Sintomatología atípica en
48% respectively. They concluded that neither raised nor pacientes con apendicitis: estudio prospectivo. Rev
normal CRP value is helpful in the diagnosis of acute Chil Cir. 2005;57:417-23.
appendicitis. CRP is not a good tool for helping the 5. Beltrán MA, Villar MR, Tapia TF. Score
surgeon makes the diagnosis of appendicitis and it should diagnóstico de apendicitis: Estudio prospectivo,
not be measured in suspected appendicitis.10 doble ciego, no aleatorio. Rev Chil Cir.
2004;56:550-7.
CONCLUSION 6. Ohmann C, Franke C, Yang Q, Margulies M, Chan
M, van Elk PJ, et al. Clinical benefit of a diagnostic
An elevated serum CRP level supports the surgeon’s score for appendicitis. Arch Surg. 1999;134:993-6.
diagnosis and hence avoids chances of error in diagnosis, 7. Zimmerman MA, Selzman CH, Cothren C,
due to atypical presentations. Similarly a normal Sorensen AC, Raeburn CD, Harken AH. Diagnostic
preoperative serum CRP level in patients with suspected implications of C-reactive protein. Arch Surg.
acute appendicitis is most likely to be associated with a 2003;138:220-4.
normal appendix on histo-pathological examination. 8. Ghimire R, Sharma A, Bohara S. Role of C-reactive
Therefore normal serum CRP level after 12 hours of protein in acute appendicitis. Kathmandu Univ Med
onset of symptoms should be used as a basis for the J (KUMJ). 2016;14(54):130-3.
decision to defer surgery to reduce the rate of negative 9. Anshuman S, George B, Simon PB .White cell
appendicectomies, and also to reduce burden on patient count and C-reactive protein measurement in
as well as on health system. patients with possible appendicitis. Ann R Coll Surg
Engl. 2009;91(2):113–5.
Funding: No funding sources 10. Amalesh M, Shankar M, Shankar R. CRP in acute
Conflict of interest: None declared appendicitis: is it a necessary investigation? Int J
Ethical approval: The study was approved by the Surg. 2004;2(2):88-9.
Institutional Ethics Committee

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