Traces of Inflammation in Acute Appendicitis, Cholecystitis, and Diverticulitis: The Role of Biomarkers in Diagnosis

Year 2025, Volume: 4 Issue: 1, 27 - 33, 27.03.2025

Serap Ulusoy , Furkan Savaş

Abstract

Introductıon: Acute appendicitis, acute cholecystitis, and acute diverticulitis are among the most common causes of acute abdominal pain, requiring early diagnosis and rapid treatment. Although imaging modalities such as ultrasonography and computed tomography play a crucial role in diagnosis, access to these methods may be limited in certain situations. Inflammatory biomarkers, including C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and delta neutrophil index (DNI), have been suggested as potential tools for differential diagnosis. This study aims to evaluate the diagnostic value of these biomarkers.
Methods: This retrospective study included 171 patients diagnosed with acute appendicitis (n=62), acute diverticulitis (n=56), and acute cholecystitis (n=53). White blood cell (WBC), neutrophil, lymphocyte, and eosinophil counts, as well as NLR, DNI, and CRP levels, were compared. Statistical analyses and ROC analysis were performed to assess the diagnostic performance of these biomarkers.
Results: CRP and lymphocyte levels were found to be significantly higher in the acute diverticulitis group (p < 0.05). Although DNI, NLR, WBC, and neutrophil levels were elevated in all three groups, no statistically significant difference was observed between them (p > 0.05). ROC analysis demonstrated that DNI has a moderate diagnostic potential for all three diseases, but none of the biomarkers provided high specificity.
Conclusion: Inflammatory biomarkers alone are not sufficient as a diagnostic tool for differentiating acute appendicitis, acute cholecystitis, and acute diverticulitis. However, CRP may be useful in assessing disease severity in patients with diverticulitis. Particularly in settings where access to imaging modalities is limited or unavailable, biomarkers such as CRP, DNI, and NLR may serve as supportive tools for diagnosis. Nevertheless, large-scale, multicenter studies are required to better define the role of inflammatory response and biomarkers in differential diagnosis and prognosis.

Keywords

Acute Appendicitis, Acute Cholecystitis, Acute Diverticulitis, C-Reactive Protein (CRP), Neutrophil-to-Lymphocyte Ratio (NLR), Delta Neutrophil Index (DNI)

References

• 1. Yew KS, George MK, Allred HB. Acute abdominal pain in adults: evaluation and diagnosis. Am Fam Physician. 2023;107(6):585–96.
• 2. Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2017;12:29.
• 3. Sartelli M, Barie P, Agnoletti V, et al. Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery. World J Emerg Surg. 2024;19(1):22.
• 4. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2017;390(10104):1736–42.
• 5. Adachi T, Eguchi S, Muto Y. Pathophysiology and pathology of acute cholecystitis: a secondary publication of the Japanese version from 1992. J Hepatobiliary Pancreat Sci. 2022;29(2):212–6.
• 6. Piscopo N, Ellul P. Diverticular disease: a review on pathophysiology and recent evidence. Ulster Med J. 2020;89(2):83–8.
• 7. Bonomo RA, Chow AW, Edwards MS, et al. 2024 Clinical practice guideline update by the Infectious Diseases Society of America on complicated intra-abdominal infections: risk assessment, diagnostic imaging, and microbiological evaluation in adults, children, and pregnant people. Clin Infect Dis. 2024;79(3):81–7.
• 8. Sproston NR, Ashworth JJ. Role of C-reactive protein at sites of inflammation and infection. Front Immunol. 2018;9:754.
• 9. Huang Z, Fu Z, Huang W, Huang K. Prognostic value of neutrophil-to-lymphocyte ratio in sepsis: a meta-analysis. Am J Emerg Med. 2020;38(3):641–7.
• 10. Park JH, Byeon HJ, Lee KH, et al. Delta neutrophil index (DNI) as a novel diagnostic and prognostic marker of infection: a systematic review and meta-analysis. Inflamm Res. 2017;66(10):863–70.
• 11. Laméris W, van Randen A, van Gulik TM, et al. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum. 2010;53(6):896–904.
• 12. Strate SM, Syed A. Acute colonic diverticulitis. Ann Intern Med. 2018;168(9):65–74.
• 13. Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15:1–42.
• 14. Tan JP, Barazanchi AW, Singh PP, Hill AG, Maccormick AD. Predictors of acute diverticulitis severity: a systematic review. Int J Surg. 2016;26:43–52.
• 15. Tursi A, Papa A, Danese S. The pathophysiology and medical management of diverticulosis and diverticular disease of the colon. Aliment Pharmacol Ther. 2015;42(6):664–84.
• 16. Vijfschagt ND, de Boer MR, Berger MY, Burger H, Holtman GA. Accuracy of diagnostic tests for acute diverticulitis that are feasible in primary care: a systematic review and meta-analysis. Fam Pract. 2024;41(1):1–8.
• 17. Zahorec R. Neutrophil-to-lymphocyte ratio, past, present and future perspectives. Bratisl Lek Listy. 2021;122(7):474–88.
• 18. Liu X, Shen Y, Wang H, Ge Q, Fei A, Pan S. Prognostic significance of neutrophil‐to‐lymphocyte ratio in patients with sepsis: a prospective observational study. Mediators Inflamm. 2016;2016:8191254.
• 19. Rajalingam VR, Mustafa A, Ayeni A, et al. The role of neutrophil-lymphocyte-ratio (NLR) and platelet-lymphocyte-ratio (PLR) as a biomarker for distinguishing between complicated and uncomplicated appendicitis. Cureus. 2022;14(1):e21446.
• 20. Ahn C, Kim W, Lim TH, et al. The delta neutrophil index (DNI) as a prognostic marker for mortality in adults with sepsis: a systematic review andmeta-analysis. Sci Rep. 2018;8(1):6621.
• 21. Jeong HM, Bang CS, Lee JJ, Baik GH. Delta neutrophil index for the prediction of prognosis in acute gastrointestinal diseases; diagnostic test accuracy meta-analysis. J Clin Med. 2020;9(4):1133.
• 22. Kang HS, Cha YS, Park KH, Hwang SO. Delta neutrophil index as a promising prognostic marker of emergent surgical intervention for acute diverticulitis in the emergency department. PLoS One. 2017;12(11):e0187629.
• 23. Prystowsky JB, Pugh CM, Nagle AP. Current problems in surgery: appendicitis. Curr Probl Surg. 2005;42:688–742.
• 24. Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41–54.
• 25. Msolli MA, Beltaief K, Bouida W, et al. Value of early change of serum C reactive protein combined to modified Alvarado score in the diagnosis of acute appendicitis. BMC Emerg Med. 2018;18:1–6.