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Hyperbilirubinemia as an Indicator of Perforated Acute Appendicitis in Pediatric Population: A Prospective Study
Zenon Pogorelić1,2, Ana Marija Lukšić2, Jakov Mihanović3
1Department of Pediatric Surgery, University Hospital of Split, Split, Croatia.
Insights
Elevated serum bilirubin levels in children may indicate perforated appendicitis. This simple, inexpensive test can aid in early diagnosis, distinguishing between simple and perforated appendicitis in pediatric patients.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Clinical Diagnostics
Background:
- Acute appendicitis is common in children.
- Distinguishing perforated from simple appendicitis is crucial for timely intervention.
- Hyperbilirubinemia is a potential, yet underutilized, diagnostic marker.
Purpose of the Study:
- To investigate the association between hyperbilirubinemia and perforated appendicitis in pediatric patients.
- To determine if serum bilirubin levels can differentiate simple from perforated appendicitis.
- To identify risk factors for perforated appendicitis in children.
Main Methods:
- Prospective cohort study of 284 children diagnosed with acute appendicitis.
- Patients categorized into simple (n=220) and perforated (n=64) appendicitis groups based on operative findings.
- Serum bilirubin levels, inflammatory markers, and clinical data were analyzed preoperatively.
Main Results:
- Median serum bilirubin was significantly higher in perforated appendicitis (27 mcmol/L) vs. simple appendicitis (10 mcmol/L).
- Receiver operating characteristic (ROC) analysis showed a cutoff of 15.5 mcmol/L for total serum bilirubin with 92% sensitivity and 77.3% specificity.
- Multivariable logistic regression identified elevated serum bilirubin, body temperature, and symptom duration as risk factors for perforated appendicitis.
Conclusions:
- Elevated total serum bilirubin is a valuable indicator for perforated appendicitis in children.
- Serum bilirubin is an inexpensive and accessible marker for initial evaluation of acute appendicitis.
- Routine measurement of serum bilirubin is recommended for pediatric appendicitis assessment.
Abstract:
This prospective cohort study aimed to investigate the association of hyperbilirubinemia with perforated appendicitis in the pediatric population. A total of 284 children in whom the diagnosis of acute appendicitis was established were included in this study. The patients were allocated in study groups in regard to operative findings. The first study group included patients who had perforated appendicitis (n = 64; 22.5%) whereas the patients in the second group had simple appendicitis (n = 220; 77.5%). Blood samples for serum bilirubin levels and acute inflammatory markers were taken before the patients underwent surgery. The primary outcome of the study was to investigate whether the level of serum bilirubin should be used to distinguish between simple and perforated appendicitis. The median level of serum bilirubin in children with perforated appendicitis was 27 mcmol/L whereas the patients with simple appendicitis had lower median levels of serum bilirubin (10 μmol/L; p < 0.001). An area under the receiver operating characteristic (ROC) curve for total serum bilirubin was 0.876 (95% confidence interval [CI], 0.820-0.929) in the patients who had a perforated appendicitis. An ROC analysis showed the best sensitivity (92%) and specificity (77.3%) for a cutoff value of 15.5 mcmol/L for total serum bilirubin (p < 0.001). Hyperbilirubinemia at admission was found in 35 patients (54.7%) with complicated appendicitis and in 14 patients (6.4%) with non-perforated appendicitis (p < 0.001). The modeling of collected data by multivariable logistic regression identified serum bilirubin concentration (odss ratio [OR] = 1.12; 95% CI, 1.07-1.18; p < 0.001), serum sodium concentration (OR = 0.64; 95% CI, 0.51-0.81; p < 0.001), body temperature (OR = 2.48; 95% CI, 1.05-0.84; p < 0.001), and duration of symptoms (OR = 1.06; 95% CI, 1.02-1.09; p < 0.001) as risk factors for perforated appendicitis. Elevateds level of total serum bilirubin may be useful as an indicator of perforated appendicitis in children. Levels of bilirubin in serum is an inexpensive, simple, and available laboratory marker and should therefore be recommended in the initial evaluation for acute appendicitis in pediatric patients.
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