Role of Total Leukocyte Count in Predicting Intraoperative Severity of Acute Appendicitis

Acute appendicitis is a common surgical emergency characterized by inflammation of the appendix, often necessitating prompt diagnosis and treatment to prevent complications. Understanding the factors that predict the severity of acute appendicitis is crucial for improving patient outcomes and optimizing surgical interventions¹.

 

Previous studies have explored various clinical and laboratory parameters, including total leukocyte count (TLC), as potential indicators for assessing the severity of acute appendicitis².

 

Several clinical risk scores have been developed, the purpose of which is to identify low, intermediate and high risk patients for appendicitis. The most widely used score so far is the Alvarado score. A systemic review and pooled diagnostic accuracy study showed that the score has good sensitivity especially in men but low specificity. Recently, the appendicitis inflammatory response score has been developed, and seems to outperform the Alvarado score in terms of accuracy³.

 

Despite existing research, there remains uncertainty regarding the sensitivity of TLC count alone in predicting the severity of acute appendicitis in relation to intraoperative findings. This study aims to evaluate the sensitivity of TLC count as a predictor of acute appendicitis severity in correlation with intraoperative observations.

This study employs a cross-sectional design to evaluate the sensitivity of total leukocyte count (TLC) alone in predicting the severity of acute appendicitis based on intraoperative findings. A quantitative approach was utilized, involving the collection of numerical data related to TLC and intraoperative observations. The research was conducted in a tertiary care hospital from June 2018 to October 2020, focusing on patients diagnosed with acute appendicitis who underwent surgical intervention. To ensure the accuracy of findings, patients with previous abdominal surgeries or other inflammatory conditions were excluded from the study. Ethical considerations were addressed through approval from the Institutional Review Board and obtaining informed consent from all participants prior to their inclusion.

 

The study’s methodology involved collecting data on TLC levels and intraoperative observations of appendicitis severity. This data was then analyzed to determine the relationship between these two variables, aiming to assess the predictive value of TLC in determining the severity of acute appendicitis using SPSS V 20. By focusing on this specific relationship, the research sought to provide valuable insights into the potential use of TLC as a diagnostic tool for assessing appendicitis severity prior to surgery. This information could potentially aid clinicians in making more informed decisions regarding patient management and surgical planning in cases of acute appendicitis.

The study included 250 patients who had undergone appendectomy. Out of 250 patients 153 were males and 97 were females with the male : female ratio of 1.6:1.  The mean age of the patients was 24.76 (Range 03-58 years). Majority of our patients were between 10-19 years, constituting 25.6% followed by age group 20-29 with 25.2%. 30-39 age group with 18.4%; < 10 age group with 13.2%; 40-49 age group with 11.2% & 6.4% of patients between 50-59 as shown in Table 1.

 

 

In our study 2 patients had gangrenous appendicitis, 146  had inflamed appendicitis, 8 had Perforated appendicitis, 33 had phlegmon and 161 had Suppurative appendicitis. Median TLC rises as the disease becomes more destructive: inflammatory < suppurative < phlegmonous < perforated ≈ gangrenous as shown in Graph 1 and Table 1. In our study p value was 0.007 which was statistically significant between TLC count and Severity of Acute Appendicitis. Variability (IQR and range) also widens in the more severe groups. Very low outliers (≈4–5 ×10³ cells/µL) appear only in the mild inflammatory and suppurative categories, never in perforated or gangrenous disease. In our small sample gangrenous and perforated cases cluster above 14 ×10³ cells/µL.

 

Graph 1: Depicting relationship of TLC and Severity of appendicitis 

 

The diagnostic value of Total Leucocyte Count (TLC) and other inflammatory markers in acute appendicitis has been extensively studied, as evidenced by the reviewed literature^3-5. My findings align with several key observations from these studies, while also highlighting areas of divergence and potential clinical implications.

 

My results demonstrate a significant correlation between TLC levels and the severity of acute appendicitis, with median TLC rising progressively from inflammatory to suppurative, phlegmonous, perforated, and gangrenous stages (p = 0.007). This is consistent with the findings of Mir et al. (2016)³, who reported that TLC had high specificity (83.54%) for acute appendicitis and even higher sensitivity (100%) for perforated appendicitis at a cutoff of 9000/mm³. Similarly, Vig et al. (2021)⁴ identified a TLC cutoff of 17,930 cells/mm³ as predictive of perforated appendicitis, with 84.8% sensitivity and 97.3% specificity. My data also support this trend, as perforated and gangrenous cases clustered above 14 ×10³ cells/µL, reinforcing the utility of TLC in distinguishing severe cases.

 

However, the variability in TLC cutoffs across studies (e.g., 9000/mm³ in Mir et al., 12.95 ×10³ cells/L in Khattab et al. [5], and 17,930 cells/mm³ in Vig et al.) suggests that TLC alone may not be universally reliable. For instance, Chanderbhan et al. (2023)⁶ noted that TLC was elevated in only 46% of histopathologically confirmed appendicitis cases, indicating limited specificity. This discrepancy underscores the need for combining TLC with other markers to improve diagnostic accuracy.

 

My study shares limitations with others, such as retrospective design and single-center data. The variability in TLC cutoffs across populations (e.g., pediatric vs. adult) highlights the need for context-specific thresholds. For example, Vig et al. (2021)⁴ focused on children, whereas Mir et al. (2016)³ included adults, potentially explaining differences in optimal cutoffs.

This study demonstrates that total leukocyte count (TLC) serves as a significant predictor of the severity of acute appendicitis, with higher TLC levels correlating strongly with more advanced intraoperative findings, such as perforation and gangrene. The progressive rise in median TLC across inflammatory, suppurative, phlegmonous, perforated, and gangrenous stages (p = 0.007) supports its utility in preoperative risk stratification. Notably, perforated and gangrenous cases consistently exhibited TLC levels above 14 ×10³ cells/µL, reinforcing its potential as a marker for severe disease.

 

Conflict of interests:       The authors declare no conflict of interest regarding the paper’s publication.

 

Funding:  Nil

 

Written informed consent: Taken

1.      Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990 Nov;132(5):910-25. 

2.      Mir MA, Haq I, Manzoor F. Diagnostic value of total leucocyte count (TLC), C-reactive protein (CRP) and bilirubin in patients with suspected acute appendicitis. Int J Contemp Med Res. 2016;3(5):1249-53.

3.      Kollar D, McCartan DP, Bourke M, Cross KS, Fahey T, Dowdall J. Predicting acute appendicitis? A comparision of the Alvarado score, the appendicitis inflammatory response score and clinical assessment. World J Surg 2015;39:104-09.

4.      Vig A, Rathod KJ, Jadhav AS, Pathak M, Saxena R, Sinha A. Role of laboratory parameters in preoperatively predicting perforated appendicitis. Indian Journal of Surgery. 2022 Feb;84(1):136-40.

5.      Khattab M, Nashed GA, Thapa N, Saber M. Value of total leucocytic count and pelvic-abdominal ultrasound in distinguishing complicated from noncomplicated acute appendicitis. The Egyptian Journal of Surgery. 2023 Oct 1;42(4):1070-5.

6.      Chanderbhan, Garg MK, Sebastian S, Malik P, Saluja SK, Gathwal C. Study of evaluation of role of total leucoycte count (TLC), absolute neutrophil count (ANC), neutrophil lymphocyte ratio (NLR) and ultrasound abdomen in patients with clinical diagnosis of acute appendicitis-a cross sectional study. Pravara Med Rev. March 2023; 15(01): 47-52.