The vermiform appendix is considered by most to be a vestigeal organ, its importance in surgery being only due to its propensity for imflammation that in a clinical syndrome called ‘acute appendicitis’. Recently, it has been proposed that an elevated total bilirubin (TB) level could be used as a specific marker for the prediction of perforated appendicitis⁷. The rationale for this proposal is based on the hepatic congestion occurring during bacteria sepsis secondary to Gram negative bacteria. Our purpose of this study is to establish the correlation of total serum bilirubin with the appendiceal perforation in acute appendicitis and to compare the reliability of total bilirubin versus WBC count for suspected perforated appendicitis.

Keywords: Appendicitis, Hyperbilirubinemia.

1. Bickell NA, Aufses AH, Rojas M. Et al. (2006) How time affects the risk of rupture in appendicitis. J Am Coll Surg 202:401-406.
2. Kearney D, Cahill RA, O’Brien E, et al. (2008) Influence of delays on perforation risk in adults with acute appendicitis. Dis Colon Rectum 51:1823-1827.
3. Anderson RE, Hugander AP, Ghazi SH, et al. (1999) Diagnostic value disease history, clinical presentation, and inflammatory parameters of appendicitis. World J Surg 23:133-140.
4. Bergeron E (2006) Clinical judgement remains of great value in the diagnosis of acute appendicitis. Can J Surg 49:96-100.
5. Kin CJ, Chen JD, Tiu CM, et al. (2005) Can ruptured appendicitis be detected preoperatively in the ED? Am J Emerg Med 23:60-66.
6. Wang P and Chaudhary IH. Mechanism of hepatocellular dysfunction during hyper dynamic sepsis. Am J Physiol Regul Integr Comp Physiol 1996: 270:927-38 & 363-61.
7. Estrada JJ, Petrosyan M. Barnhart J. et. Al (2007) Hyperbilirubinemia in appendicitis: A new predictor of perforation. J Gastrointest Surg 11:714-718.
8. Bennion RS. Baron EJ, Thompson JE, et al. (1990) The bacteriology of gangrenous and perforated appendicitis – Revisited. Ann Surg 211:165-171.
9. Vesalius A. De Humani Corporis fabrics Liber V. Basel, Switzerland: Johanes Oporinu; 1543.
10. Bailey and Love’s Short Practice of Surgery: 25^th Christopher J.K. Bulstrode, Norman S. Williams, P. RonanO’Connell (Ed); (2008), Ch. 67: The vermiform appendix; p. 1204-17.
11. Friffiths EA et al. Bifid vermiform appendix, Curr Surg 2006 May – Jun; 63(3); 176-8
12. Uriev L et al. Triple-barrelled type of appendical triplication: Ann Diagn Pathol: 2006 June; 10(3): 160-1.
13. Basta M. Morton N E, Mulvilli J J et al. Inheritance of acute appendicitis: familial aggregation and evidence of polygenic transmission. Am J Hum Gent 1990; 46:377-82.
14. Koepsell T D: Factors affecting perforation in acute appendicitis; Surg Gynaecol Obs; 153:508, 1981.
15. Jackson RH; Parents, family doctors and acute appendicitis in childhood; Br Med J; 2:227, 1963.
16. Anderson A. Berghdahl L: acute appendicitis in patients over sixty. Am J Surg. 44:445, 1978.
17. Owen BJ and Harmit HF: Appendicitis in elderly. Ann Surg. 187:392, 1978.
18. Peltokallio P. Tykka H: Evolution of the age distribution and mortality of acute appendicitis. Arch Surg. 116:153, 1981.
19. Short (1920): Quoted by Burkitt DP: Etiology of appendicitis, Br J Surg. 58:695, 1971.
20. Burkitt DP: Etiology of appendicitis, Br J Surg. 58:695, 1971.
21. D Adamis, E Roma Giannikou, K Karamolegou et al: Fibre intake and childhood appendicitis. Int J of Food Sci and Nutr. Vol 51, Issue 3, May 2000.
22. Pieper R, Kager L et al: Acute appendicitis, a clinical study of 1018 cases of emergency appendectomy. Act Chir Scand. 148:39-63, 1982.
23. Shepherd J: Surgery of the acute abdomen: 1^st edition, p.401-501, 1960.
24. Holt P, Legionnaire’s disease and abscess: Treatment of Appendix, Br Med J. 2:103, 1981.
25. Tobe T: Inapparent virus infection as a trigger of appendicitis, The Lancet 1: 1343, 1965.
26. Arnbjornsson E: Varying frequency of acute appendicitis in different phases of menstrual cycles, Surg Gynaecol Obs. 155:709, 1982.
27. Tracey M, Fletcher HS. Apppendicitis in pregnancy. Am J Surg, 2000; 66:555-9.
28. Wangansteen OH, Bowers WF et al: Significance of the obstructive factor in the genesis of acute appendicitis, an experimental study. Arch Surg. 34: 496, 1937.
29. Shield R: the absorption of secretion of electrolytes and fluid by obstructed bowel; Br J Surg. 52:74, 1965.
30. Storer EH: Appendix from: Principles of Surgery, Edited by Schwartz S. 1, 5^th Edition; Br J Surg. 52:74, 1995.
31. Almond et al: Unpublished data, Department of surgical pathology, Washington University School of Medicine, 1956 (from Ackerman’s surgical pathology: 5^th edition p. 489, 1981).
32. Horton LW: Etiology of appendicitis: Br Med J 2: 1672, 1977.
33. Condon RE: Appendicitis in: Textbook of Surgery; 13^th Edition, 967-983, 1986.
34. Leigh DA Simons K, Norman E: Bacterial flora of the appendix fossa in appendicitis and post operative infection. J Clin Patho, 27: 997, 1974.
35. Duzgun AP, Munevver Moran, Seluk Uzun et al: Unusual findings in appedicectomy specimens: Evaluation of 2458 cases and review of literature.
36. Adebamowo CA, Akang EE, Lodipo JK: Schistosomiasis of the appendix, Br J Surg 1991; 78: 1219-21.
37. Johnson JR: Etiology of appendicitis. Br Med J 1:305, 1978.
38. Azzie G, Salloum A. Beasley S. Et al. The complication rate and outcomes of laparoscopic appndicectomy in children with perforated appendicitis. Paediatric Endosurgery Innovative technique 2004; 8 (10): 19 – 23.
39. Amyand C. Of an inguinal rupture, with a pin in the appendix cacci, incrusted with stone, and some observation on wounds in the guts. Philos Trans R Soc Lond 1736: 39: 329 – 342.
40. Tsoulfas G, Howe JR. Amyand’s hernia: Appendicitis in an incarcerated hernia. Surg Rounds 2004: 27:515 – 517.
41. Tait L. Surgical treatment of typhlitis. Birmingham Med Rev 1890; 27:26-34.
42. Fitz RH. Perforating inflammation of the vermiform appendix; with special reference to its early diagnosis and treatment. Am J Med Sci 1886; 92:321 – 346.
43. McBurney CM. Experience with early operative interference in cases of disease of the vermiform appendix. N Y Med J 1889; 50:676 – 684.
44. Treves F. A series of cases of relapsing typhilitis treated by operation, BMJ 1893; 835 – 837.
45. Addiss DG, Shaffer N. Fowler BS. Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132:910 – 925 (PubMed: 2239906).
46. Cannova JV, Krummen DM, Nicholson O. Pneumoperitoneum in association with perforated appendicitis. Am Surg 1995; 61: 324-325.
47. Sand M, Bechara FG, Holland-Letz T et al: Diagnositc value of hyperbilirubina-emia as a predictive factor for appendiceal perforation in acute appendicitis, Am J Surg 2009; 198: 193-198.
48. Korner H. Sondenna K. Soreide JA, et al: Incidence of acute non perforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 1997; 21:313 – 317.
49. Chipponi J. Appendicities. In: Favniez PL, Houssin D, eds. Pathologie Chirurugicale: Chirurigie Digestive et Thoracique. Paris: Masson, 1991: 253-260.
50. Hale DA. Molloy M. Pearl R. Schutt DC, Jaques DP. Appendectomy. A contemporary appraisal. Ann Surg 1997; 225: 252-261.
51. Oberlin P. Valette M. Malafosse M. Pneumoperitonie et peritonite appendiculaire. Gastroenterol Clin Biol 1981; 5: 287-289.
52. Newman B, Nussbaum A. Kirkpatrick JA jun. Colodny A. Appendiceal perforation, pneumoperitoneum, and Hirschsprung’s disease. J Pediatr Surg 1988; 23: 854-856.
53. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg med 1986; 15:557-564 (PubMed: 3963537).
54. Saidi RF, Ghasemi M. Role of Alvarado score in diagnosis and treatment of suspected acute appendicitis. Am J Emerg Med 2000; 18:230-231 (PubMed:107509411).
55. Baril N, Wren S. Radin R et al. The role of anticoagulation in pylephlebitis. Am J Surg 1996; 172:449-452 (PubMed: 89425242).
56. Elangovan S. Clinical and laboratory findings in acute appendicitis in the elderly. J Am Board Fam Pract. 1996; 9:75-8.
57. Salamat Khan: The diagnostic value of hyperbilirubinaemia and total leucocyte count in the evaluation of acute appendicitis. Journal of Clinical and Diagnostic Research (serial online) 2009 August (cited: 2009 August 7); 3:1647-1652.
58. Atahan K. Ureyen O, Aslan E et al: Preoperative diagnostic role of hyperbilirubinaemia as a marker of appendix perforation. The J Intern Med Research 2011; 39: 609-618.
59. Marcelo A. Beltran, Pedro E. Mendez et al: Is hyperbilirubinaemia in appendicitis a better predictor of perforation than C-reactive protein? – prospective study; Indian J Surg (September- October 2009) 71:265-272.
60. Andrew Emmanuel1,2 Peter Murchan2, Ian Wilson, Paul Balfel: The value of hyperbilirubinaemia in the diagnosis of acute appendicitis; Ann R Coll Surg Engl 2011; 93: 213-217.
61. Swasso RD, Hanna EA, Moore DL. Leukocytic and neutrophilic counts in the acute appendicitis. Am J surj 1970; 120:563-6.
62. Coleman C, Thomson J, Bennion R, Schmit P. White Blood Cell count is a poor predictor of severity of disease in diagnosis of appendicitis. Am Surg 1998; 64 (10): 983-5.
63. Doraiswamy NV. Leucocyte counts in the diagnosis and prognosis of acute appendicitis in children. Br J Surg 1979; 66:782.
64. Vermeulen B, Morabia A. Unger PP. Influence of white cell count on surgical decision making in patients with abdominal pain in the right lower quadrant. Eur J Surg 1995; 161:483-6.
65. Schwartz’s principles of surgery; F. Charles Brunicardi, MD, FAS (Ed); 9^th ed; Mc Graw Hill; 2010; Ch. 30: The Appendix; p 1073-90.
66. Tillet W, Francis T. Serological reactions in pneumonia with non-protein somatic fraction of pneumococcus. 1930; 52:561.
67. Gurleyik E, Gurleyik G. Unalmiser S. Accuracy of serum of C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon’s clinical impression. Dis Colon Rectum 1995 Dec: 38 (12):1270-4.
68. Gronroos M and Gronroos P. leucocyte count and C- reactive protein in the diagnosis of acute appendicitis. BJS 1999; 86: 501-4.
69. Shakhatresh HS. The accuracy of C-reactive protein in the diagnosis of acute appendicitis compared with that of clinical diagnosis. Med Arh 2000; 54(2):109-10.
70. Asfar S. Safar H, Khoursheed M. Dasthi H, Al-Bader A. Would measurement of Creative protein reduce the rate of negative exploration for acute appendicitis? J R Coll Surg Edinb Feb 2000; 45:21-4.
71. Ducholm S. Bagi P. Bud M. Laboratory aid in the diagnosis of acute appendicitis. A blinded, prospective trial concerning diagnostic value of leukocyte count neutrophil differential count, and C- reactive protein. Dis colon rectum 1989 Oct; 32(10):855-9.
72. Oosterhuis WP, Zwinderman AH, Teeuwen M, van Andel G. Oldenziel H, Kerkhoff JF et al. C reactive protein in the diagnosis of acute appendicitis. Eur J Surg 1993 Feb; 1599(2):115-9.
73. Eriksson S, Olander B, Pira U, Granstorm L. White blood cell count, leucocyte elastase activity, and serum concentrations of interleukin-6 and C-reactive protein after open appendicectomy. Eur J Surg 1997; 163:123-7.
74. Thimsen DA, Tong GK, Gruen DA, Tong GK, Gruenburg JC. Prospective evaluation of C- reactive protein in patients suspected to have acute appendicitis. Am Surg 1989 Jul; 55(7):466-8.
75. Al-Saigh AH. C-reactive protein in the differentital diagnosis of the acute abdomen especially acute appendicitis. J R Coll Surg Edinb 1992 Aug; 37(4):238-40.
76. Davies AH. Bernau F. Salisbury A, souter RG. C –reactive protein in right iliac fossa pain. JR Coll Surg Ednib 1991 Aug; 36(4):242-4.
77. Marchand A. Van Lente F. Galen RS. The assessment of laboratory tests in the diagnosis of acute appendicitis. Am J Clin Pathol 1983 Sep; 80(3):369-74.
78. Mikaelsson C, Arnbjornsson F. The value of C – reactive protein (CRP) determinations in patients with suspected acute appendicitis. Ann Gynaecol. 1984; 73(5):281-4.
79. Brooks DW, Killen DA, Roentgenorgraphic findings in acute appendicitis. Surgery. 1965; 57:377.
80. Jona JZ, Belin RP, Selke AC. Barium enema as a diagnostic aid in children with right lower quadrant pain J A M A 1981; 245; 505-648.
81. Stephanic R Wilson; Gastrointestinal system in; diagnostic ultrasound Carol M Rumack M.D. Stephanic R Wilson. J William Chorboneau M.D (ed) 3^rd edition Mosby 2005 VOl I.
82. Clive A Barrtan ;GIT Large bowel; Diagnostic Radiology A Textbook of Medical Imaging ;R.G Granger, D.J. Allison (Ed) 3^rd edition; Mosby; VOL II SEC IV 1042 chapter 50.
83. Lee HJ, Jeong YK, Hwang JC, Ham SY, Yang SO. Graded compression sonography with adjuvant use of a posterior manual compression technique in the sonographic diagnosis of acute appendicitis. AJR AM J Roentgenol. 2002; 178:863-8.
84. Patriquin HB, Garcier JM, Lafortune M et al. Appendicitis in children and young adults. Doppler sonographic – pathologic correlation. AJR Am J Roentgenol 1996; 166:629-33.
85. Nesterenko IuA, Grinberg AA, Shapovaliants SG, Mikhailusov SV, Drozdov GE, Maksimova VV. Ultrasound diagnosis of acute appendicitis; Khirurgiia (Mosk). 1994 Jul; (7):26-9.
86. West WM, Brady-West DC, McDonald AH, Hanchard B, Fearon-Boothe, Ultrsound and white blood cell counts in suspected acute appendicitis. West Indian Med J 2006 Mar; 55(2):100-2.
87. Uebel P. Weissis H. Trimborn CP, FiedlerL. Bersch W; Ultrasound diagnosis of acute appendicitis-possibilities and limits of the method-results of prospective and retrospective clinical studies; Ultraschall Med. 1996 Jun;17(3):100-5.
88. Shirazi, A.S., M. Sametzadeh, R. Kamankesh and F. Rahim, 2010. Accuracy of sonography in diagnosis of acute appendicitis running. Pak J Biol Sciences, 13:190-3.
89. CDR David S. Wade, MC, USN; Stephen E. Morrow, MD; Zubin N. Balsara, MD: Thomas K Burkhard, MD; Walter B. Goff, DO; Accuracy of Ultrasound in the Diagnosis of Acute Appendicitis Compared with the Surgeon’s Clinical Impression; Arch Surg. 1993; 128(9):1039-46.
90. A. Worrell, L. F. Drolshagen, T. C. Kelly, D. W. Hunton, G.R. Durmon and AC Fleischer; Graded compression ultrasound in the diagnosis of appendicitis. A comparison of diagnostic criteria. Journal of Ultrasound in Medicine 1990; 9(3):145-50.
91. HS Fung. S Lau, JCW Siu, CM Chan, SCH Chan; Audit of Ultrasonography for Diagnosis of Acute Appendicitis Retrospective Study; J HK Coll Radiol. 2008; 11: 108-11.
92. Shryl-Chryl Chen, MD, Kai-Mo Chen, MD, Shih-Ming Wang MD. Abdominal Sonography screening of clinically diagnosed or suspected appendicitis before surgery. World Journal of Surgery 1998; 22:419-51.
93. Incesu L. Coskun A, Seleuk M.B et al. MR imaging and sonographic correlation. AJR Am J Roentegenol 1997; 168: 669-74.
94. Kipper SL, Rypins EB, Evans DG et al. Neutrophil-specific 99m Tc-labeled anti-CD15 monoclonal antibody imaging for diagnosis of equivocal appendicitis. J Nucl Med 2000; 41:449-55.
95. Paterson-Brown S. Thompson JN, et al. Which patients with suspected apeendicitis should undergo laparoscopy? Br Med J 1988; 296-363.
96. Kalan M., Rich AJ., Talbot D., Cunliffe WJ.; Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R. Coll. Surg. Engl 1994; 76:418-9.
97. Sabiston Text Book of Surgery. The biological basis of modern surgical practice. 19^th, T M Townsend et al. Ch. 51: The Appendix: p. 1279-93, 2012.
98. Harrisons Text book of Internal Medicine (Vol. II). D. Longo. S. Faucci, Danis L Kasper, et al. Eds published by Mac Graw Hill, Medical Publishing Division. 18^th International edition, Ch. 303: The hyperbilirubinaemias; p.2531-37:2012.
99. Khan S. Evaluation of hyperbilirubinaemia in acute inflammation of appendix: A prospective study of 45 cases; Kathamandu Univ Med J (2006), Vol. 4, No. 3, Issue 15, 281-289.
100. Joaquin J. Estrada et al. Hyperibilirubinaemia in Appendicitis: A New Predictor of Perforation. Journal of Gastrointestinal Surgery (2007) 11:714-718.
101. Khan MN. Davie E, Irshad K: The role of white cell count and C-reactive protein in the diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2004; 16: 17-19.
102. Hoffman J. Rasmussen OO; Aids in the diagnosis of acute appendicitis. Br. J Surg 1989; 76: 774-779.
103. Zoller WG, Kellner H. Schwerk WB; Value of ultrasound in diagnosis of acute appendicitis; Bildgeburg, 1996 Jun; 63(2): 78-82

Dr Dharbind Kumar Jha

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