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Complicated appendicitis: value of inflammatory markers based on EAES 2015 guidelines
Maximilian Dölling1,2, Michael Klös3, Jonas Pachmann3
1Faculty of Medicine, University Clinic for General-, Visceral-, Vascular- and Transplantation Surgery, Otto-Von-Guericke-University, Leipziger Str. 44, 39120, Magdeburg, Germany. maximilian.doelling@med.ovgu.de.
Insights
Phlegmonous appendicitis, a form of complicated appendicitis, shows elevated inflammatory markers and increased complication risks. This supports its classification as complicated appendicitis per EAES 2015 guidelines.
Area of Science:
- Gastroenterology
- Surgical Pathology
- Clinical Diagnostics
Background:
- Phlegmonous appendicitis (PHL) clinical presentation raises questions about its classification as complicated acute appendicitis (CAA).
- The European Association for Endoscopic Surgery (EAES) 2015 guidelines classify PHL as CAA, typically requiring surgical intervention.
- This study investigates the clinical relevance of classifying PHL as CAA, focusing on inflammatory markers, surgical outcomes, and hospital stay.
Purpose of the Study:
- To evaluate the clinical significance of classifying phlegmonous appendicitis (PHL) as complicated acute appendicitis (CAA).
- To analyze the role of inflammatory markers, specifically C-reactive protein (CRP) and leucocyte counts, in assessing disease severity.
- To determine the impact of PHL classification on postoperative complications and hospital length of stay.
Main Methods:
- Retrospective single-center study of 559 adult appendectomy patients (2016-2020).
- Intraoperative classification adhered to EAES 2015 guidelines.
- Analysis of preoperative CRP and leucocyte counts in relation to disease severity, complications, and hospital stay.
Main Results:
- Phlegmonous appendicitis (PHL) constituted 30.8% of complicated appendicitis (CAA) cases.
- C-reactive protein (CRP) levels were significantly higher in CAA than uncomplicated appendicitis (UAA) and correlated with disease severity (Median 48.4 vs. 8.8 mg/L).
- PHL demonstrated a 2.3-fold increased risk of postoperative complications and a 21% longer hospital stay, with elevated CRP predicting these outcomes.
Conclusions:
- Phlegmonous appendicitis (PHL) exhibits a distinct clinical profile justifying its classification as complicated appendicitis (CAA).
- Elevated C-reactive protein (CRP) is a key indicator of PHL severity and associated risks.
- Findings support the continued classification of PHL as CAA under EAES 2015 guidelines.
Background:
The clinical course of phlegmonous appendicitis (PHL) appears less severe than other complicated forms, which led to the discussion if PHL should be classified as complicated acute appendicitis (CAA). According to the guidelines of the European Association for Endoscopic Surgery (EAES) from 2015, PHL is classified as a CAA, which requires usually surgery. Therefore, this study aimed to evaluate the relevance of classifying PHL as CAA, with a focus on inflammatory markers, postoperative complications, and hospital length of stay.
Methods:
We conducted a retrospective single-center study including 559 adult patients who underwent appendectomy between 2016 and 2020. Intraoperative classification followed the EAES 2015 guidelines. Preoperative C-reactive protein (CRP) and leucocyte counts were analyzed with respect to disease severity, postoperative complications, and length of hospital stay.
Results:
Complicated appendicitis was diagnosed in 62.5% of patients, with phlegmonous appendicitis accounting for 30.8%. CRP levels were significantly higher in CAA than uncomplicated acute appendicitis (UAA; Median 48.4 vs. 8.8 mg/L; p < 0.001) and increased progressively with disease severity. CRP showed good diagnostic performance in distinguishing CAA from UAA (AUC: 0.76), whereas leucocyte count demonstrated limited diagnostic utility (AUC: 0.57). With suspected appendicitis at a CRP threshold of 52.5 mg/L, at least PHL could be expected (49% sensitivity, 95% specificity, AUC 0.72). The risk of postoperative complications was higher in all CAA subtypes, including PHL (adjusted OR: 2.3; p = 0.015). Elevated preoperative CRP levels were associated with both complications (p < 0.001) and prolonged hospital stay (IRR: 1.21 for PHL; p < 0.001). Leucocyte counts were neither predictive of complications nor hospital duration.
Conclusion:
Phlegmonous appendicitis shows a distinct clinical profile with moderate CRP elevation, a 2.3-fold increased risk of postoperative complications, and a 21% increase in hospital stay. These findings support its classification under EAES 2015 guidelines as complicated appendicitis.
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