Raised Bilirubin: An Independent Indicator for Perforated or Gangrenous Appendicitis

Acute Appendicitis is still one of the most common surgical emergencies that most general surgeons encounter in their practice. Diagnosis of acute appendicitis is made in almost 80% of cases, clinically and is helped by some laboratory tests. Certain clinical scoring systems such as Alvarado Score and MANTRELS Score have been developed to aid in diagnosis. A delay in diagnosis or delayed presentation leads to perforation and localized or generalized peritonitis leading to increased mortality. Furthermore, the presence of appendicolith has been found to be correlated with complicated appendicitis. Increased bilirubin level (>1.0) has been indicated as marker for predicting appendiceal perforation in various studies. This study aimed to evaluate whether a raised bilirubin level has an independent predictive value for complicated appendix. This was a prospective observational study conducted at Command Hospital, Lucknow, and was further continued at Military Hospital Jaipur and Military Hospital, Jammu, from January 2021 to December 2023. A total of 169 patients were included in the study. After clinical examination, laboratory tests were sent for routine investigations to include total leukocyte count and liver function test. Subsequently, they underwent appendicectomy and intraoperative findings were noted. Data were further analyzed to know the correlation of raised bilirubin with various parameters such as presentation, MANTRELS scoring, presence or absence of appendicolith, intraoperative findings, and pathological findings. In our study, in acute presentation of appendicitis, serum bilirubin was raised (>1 mg/dL) in 94 patients. However, in chronic presentation, it was raised only two patients. This difference was statistically significant with P < 0.001. MANTRELS scoring was compared with bilirubin level and it was found that the patients with higher score had raised bilirubin level with a mean of 7.98 and median was 8. Patients with normal bilirubin level had mean MANTRELS score of 7.01 and median of 7. This difference was significant. Gangrenous appendix, burst or perforated appendix with intraperitoneal pus was found in 39 patients. Out of 39 patients, 38 patients had raised bilirubin level which was statistically significant P < 0.001. In our study, 23 patients had appendicolith, out of which 21 patients had raised bilirubin level which was statistically significant. Thirty-seven patients out of a total of 38 patients with perforated or gangrenous appendix on histopathological examination had raised bilirubin level while only one patient had normal bilirubin level which was statistically significant. A high index of suspicion should be kept for complicated appendicitis in a patient with acute appendicitis with raised bilirubin.