Neutrophil to lymphocyte ratio in diagnosis of complicated Sri Lanka Journal of Child Health, 2017; 46: 59-65

Neutrophil to lymphocyte ratio in diagnosis of complicated and non-

complicated appendicitis
*Mervan Bekdas1, Hulya Ozturk1, Sevil Bilir Goksugur1, Fatih Demircioglu1, Metin Tahaoglu1

Sri Lanka Journal of Child Health, 2017; 46: 59-65

Abstract significantly higher than the non-complicated group

Introduction: Acute appendicitis is one of the most (65.8% vs. 34.3%, p=0.035 and 67.1% vs. 32.9%,
common surgical problems of childhood. Late or p=0.046, respectively). In diagnosis of complicated
misdiagnosis may increase the morbidity and acute appendicitis, the cut off value for N/L was
mortality of this condition. determined as 7.2 (p=0.017) (Sensitivity 83.6%,
specificity 69.6%).
Objective: To test the utility of some laboratory
methods, especially Neutrophil/Lymphocyte (N/L) Conclusions: In our study the most appropriate cut
ratio in rapid diagnosis of simple and complicated off value of N/L in differentiating complicated
acute appendicitis acute appendicitis from non-complicated
appendicitis was 7.2. In our study, WBC>12x103
Method: The records of 498 cases hospitalized in and CRP>15 mg/dl values were important
paediatric surgery departments in Turkey between parameters distinguishing complicated appendicitis
the years 2008 and 2014 with the suspicion or pre- from non-complicated one.
diagnosis of acute appendicitis were retrospectively
evaluated. Among these, 279 were diagnosed as DOI: http://dx.doi.org/10.4038/sljch.v46i1.8238
non-complicated appendicitis while 73 were
diagnosed as complicated appendicitis. The (Key words: Neutrophil to lymphocyte ratio,
remaining 146 cases without the appendectomy complicated appendicitis, non-complicated
requirement comprised the control group. Clinical, appendicitis, child)
haematologic and radiologic data of all cases were
investigated. Introduction
Abdominal pain is a common symptom of
Results: Among the patients who had childhood. The important point that doctors should
appendectomy, 214 (60.8%) were male. The mean judge promptly in children admitted with this
age of the patients was 9.8 ± 3.5 years. The mean symptom is differentiation of acute appendicitis.
C-reactive protein (CRP) (46.6±54.1 vs. 17.3±17.1, Acute appendicitis is a common surgical problems
p=0.048), white blood cell count (WBC) (18.2±4.8 in childhood1,2. Appendectomy is one of the most
vs. 10.3±4.6, p<0.001), polymorphonuclear commonly performed operations with an incidence
leucocyte (14.5±4 vs. 7.3±4.6, p<0.001) and N/L of about 10% lifelong3. In childhood, it is mostly
(8.4±6 vs. 4.4±3.8, p=0.024) values of the patients reported in 2nd decade4. The reduction in fibres and
who had appendectomy were significantly higher. increase in refined carbohydrates in diet is regarded
In diagnosis of acute appendicitis, the cut off value as a risk factor for acute appendicitis5.
for N/L was determined as 5 (p=0.003) (Sensitivity
72.7%, specificity 67.8%). Among complicated In appendicitis diagnosis, history and physical
acute appendicitis cases, N/L value was examination findings are important. Abdominal
significantly higher (10.9±7.2 vs. 6.7±3.3, p=0.04), pain starting around umbilicus, nausea and anorexia
and the number of patients with WBC greater than are the classical admission symptoms. The most
12x103 and CRP value greater than 15 mg/dl were valuable finding in physical examination is
_________________________________________ tenderness of right lower quadrant. However, only
1
Department of Pediatrics, Abant Izzet Baysal 60% of acute appendicitis cases present with typical
University Faculty of Medicine, Bolu, Turkey symptoms6. Especially symptoms in early periods
*Correspondence: vanbek@gmail.com may cause misdiagnosis of the clinical picture with
(Received on 16 May 2016: Accepted after revision other diseases7. Although with the history and
on 17 June 2016) physical examination the disease is commonly
The authors declare that there are no conflicts of diagnosed, in some cases laboratory tests such as C-
interest reactive protein (CRP), erythrocyte sedimentation
Personal funding was used in formulating the article. rate (ESR), white blood cell count (WBC)8,9 and
Open Access Article published under the Creative IL-6 ve IL-1010 and imaging techniques such as
ultrasonography or computed tomography11 may be
Commons Attribution CC-BY License. required. With the increase in number of tests, the

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Neutrophil to lymphocyte ratio in diagnosis of complicated Sri Lanka Journal of Child Health, 2017; 46: 59-65

cost is also increasing. For this reason, more simple (haemoglobin, thrombocyte count, mean platelet
and trustworthy parameters like Neutrophil volume (MPV), white blood cell (WBC),
/Lymphocyte (N/L) ratio are necessary12. polymorphonuclear (PNL), lymphocyte count, CRP
and abdominal ultrasonography) of included
The main reason for this high interest in the topic is patients were investigated. The ultrasonographic
the aim of decreasing morbidity and mortality of evaluations of patients were performed by the
the disease. In early periods of the disease, with radiologists of the medical centres. Regarding the
hurried diagnosis of the clinician, there are negative complete blood counts, neutrophil/lymphocyte
appendectomies and with late decision, perforations ratios were calculated. The data were analyzed with
may take place6. These clinical pictures are the Statistical Package for Social Sciences (SPSS,
generally reported in atypical cases that comprise Inc., Chicago, IL) for Windows 15.0 statistical
31.7% of acute appendicitis cases13. In this study, programme. The data were expressed as mean
our aim is to test the utility of some laboratory ±standard deviation. In statistical evaluations,
methods and especially N/L ratio in rapid diagnosis student-t, chi-square (χ2) tests and ROC curve
of simple and complicated acute appendicitis and analyses were performed. The p value of <0.05 was
by this way in reducing the diagnostic delays and considered as statistically significant.
negative appendectomy rates in childhood period.
Results
Method Totally 567 patients, who were admitted to the
After the approval of local ethics committee, the paediatric emergency, and paediatric outpatient
study was started. The records of patients who were departments of 2 hospitals in Turkey and
hospitalised in the paediatric surgery departments hospitalized with the pre-diagnosis of acute
of Abant İzzet Baysal University Medical Faculty appendicitis in paediatric surgery departments in
and Bolu Izzet Baysal Obstetrics and Paediatrics the study period were investigated; and 498 of those
Hospital in Turkey between years 2008 and 2014 patients with the comprehensive data in their
with the symptom of acute abdominal pain were records were included in the study. Among those
retrospectively evaluated. Among these patients, patients, 320 (64.2%) were children while 178
those who were diagnosed with urinary system (35.7%) were adolescents. Conventional
infection, respiratory tract infection, Familial appendectomy was performed in 352 (70.6%) of
Mediterranean Fever and acute gastroenteritis those patients with the diagnosis of acute
which may also cause the same symptoms were appendicitis. Among the patients who had
excluded. The patients included in the study were appendectomy, 214 (60.8%) were male while 138
divided into 2 groups as patients with non-specific (39.2%) were female. The mean age of the patients
abdominal pain (n=146) and patients operated for was 9.8±3.5 years (7 months-17 years).The features
acute appendicitis (n=352). The patients operated of patients with abdominal pain are summarized in
with conventional method with the diagnosis of Table-1.
acute appendicitis were also divided into 2 groups
as non-complicated (n=279) or complicated (n=73) In patients who had appendectomy, male gender
regarding the presence of phlegmon, abscess or (p=0.038), nausea (p=0.001), vomiting (p=0.002),
perforation cases. The patients with non-specific anorexia (p<0.001) and constipation (p<0.001)
abdominal pain were diagnosed with mesenteric symptoms were significantly more common. In
lymphadenitis, ovarian cyst, peptic ulcer or laboratory evaluation of patients who had
cholelithiasis after the follow-up of 12-24 hours and appendectomy, CRP (p=0.048), WBC (p<0.001),
performed tests. Patients with histologically proven PNL (p<0.001) and N/L (p=0.024) values were
negative appendectomy were not included in this determined to be significantly higher.
study.
The characteristics of patients with complicated and
The clinical (location and duration of the abdominal non-complicated acute appendicitis are shown in
pain, nausea, vomiting, fever, anorexia, diarrhoea, Table 2.
constipation, and dysuria) and laboratory data

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Neutrophil to lymphocyte ratio in diagnosis of complicated Sri Lanka Journal of Child Health, 2017; 46: 59-65

Table-1: The characteristics of all patients admitted with abdominal pain

Characteristic Acute appendicitis Other causes of abdominal p
(n=352) pain (n=146)
Age (years) 9.8±3.5 10.2±3.1 0.81
Gender (n)
Male 214 (60.8%) 74 (50.7%) 0.038
Female 138 (39.2%) 72 (49.3%)
Type of abdominal pain (n)
Localized 196 (55.6%) 79 (54.1%) 0.74
Generalized 156 (44.3%) 67 (45.9%)
Time of abdominal pain (hrs) 65.4±33.5 69.2±21.2 0.45
Nausea (n) 278 (78.9%) 95 (65.1%) 0.001
Vomiting (n) 252 (71.5%) 84 (57.5%) 0.002
Anorexia (n) 326 (92.6%) 106 (72.5%) <0.001
Fever (n) 96 (27.3%) 58 (39.7%) 0.006
Diarrhoea (n) 11 (03.1%) 03 (02.1%) 0.51
Constipation (n) 212 (60.2%) 63 (43.2%) <0.001
Dysuria (n) 24 (06.8%) 18 (12.3%) 0.077
Haemoglobin (g/dl) 13±1.5 12.3±1.7 0.78
Platelet count (/μl) 307±79 293±80 0.57
MPV(fl) 7.9±0.8 8.5±1.3 0.092
C-reactive protein (mg/dl) 46.6±54.1 17.3±17.1 0.048
White cell count (x103 /μl) 18.2±4.8 10.3±4.6 <0.001
Neutrophil (x103 /μl) 14.5±4 7.3±4.6 <0.001
Lymphocyte (x103 /μl) 2.1±0.8 2.6±2.9 0.81
N/L 8.4±6 4.4±3.8 0.024

Table 2: The characteristics of patients with complicated and non-complicated acute appendicitis
Characteristic Non-complicated Complicated appendicitis p
appendicitis (n=279) (n=73)
Age (years) 11±3.8 11.8±4.2 0.91
Gender (n)
Male 173 (62.1%) 41 (56.1%)\ 0.36
Female 106 (37.9%) 32 (43.9%)
Type of abdominal pain (n)
Localized 158 (56.6%) 51 (69.9%) 0.04
Generalized 121 (43.4%) 22 (30.1%)
Time of abdominal pain (hrs) 61.8±28.2 68.3±32.2 0.24
Haemoglobin (g/dl) 13.1±1.7 12.8±1.1 0.54
Platelet count (/μl) 313±87 297±66 0.62
MPV(fl) 8.1±1.1 7.5±0.7 0.13
C-reactive protein (mg/dl) Overall 39±27.1 50.5±64.3 0.59
<15mg/dl 128 (45.9%) 24 (32.9%)
15mg/dl or > 151 (54.1%) 49 (67.1%) 0.046
White cell count (x103/μl) 17.6±4.5 19.4±5.2 0.34
White cell count (/μl)
<12x103/μl 134 (48%) 25 (34.2%) 0.046
12x103/μl or > 145 (52%) 48 (65.8%)
Neutrophil (x103/μl) 14.2±4.2 15.3±3.1 0.49
Lymphocyte (x103 l) 2.3±0.8 1.7±0.6 0.052
N/L 6.7±3.3 10.9±7.2 0.04

In diagnosis of acute appendicitis, the cut off value diagnosed with complicated acute appendicitis.
for N/L was determined as 5 (p=0.003) (95% CI Among those cases, 41 (56.1%) were male while 32
(0.6-0.94)). For that cut off value sensitivity was (43.8%) were female. The mean age of the patients
72.7%, and specificity was 67.8%. Seventy three was 11.5±3.5 years. Localized abdominal pain was
(20.7%) of the appendectomy performed cases were significantly more common in complicated acute

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Neutrophil to lymphocyte ratio in diagnosis of complicated Sri Lanka Journal of Child Health, 2017; 46: 59-65

appendicitis cases (69.9% vs. 30.1%, p=0.04). In appendicitis while Gronroos19 suggested just the
those cases, N/L ratio was significantly higher opposite.
(10.9±7.2 vs. 6.7±3.3, p=0.04). When compared
with the simple appendicitis group there was not a In 10-20% of people, appendix may be located
significant difference in complicated appendicitis atypically20,21. Despite the evolutions in diagnostic
group regarding CRP values; but in complicated methods in recent years, the perforation rate of 19%
group the number of patients with CRP value and mis-diagnosis rate of 10% in acute appendicitis
greater than 15 mg/dl were significantly higher in children still could not be improved22. Especially
than the non-complicated group. When compared keeping atypical cases may increase the perforation
with the simple appendicitis group there was no possibility while operating them may cause the
significant difference in the complicated negative appendectomies. On the other hand, Saraç
appendicitis group regarding WBC and CRP et al23 defined the most common cause of
values; but in complicated group the number of perforated appendicitis as not distinguishing the
patients with WBC greater than 12x103 /μL and clinical picture by the doctors. Especially in
CRP value greater than 15 mg/dl were significantly children younger than 5 years of age, the causes of
higher than the non-complicated group (65.8% vs. perforation were determined as barely expression of
34.3%, p=0.035 and 67.1% vs. 32.9%, p=0.046, children themselves, and difficulty in performance
respectively). In diagnosis of complicated acute of physical examination24. In that aspect, N/L ratio
appendicitis, the cut off value for N/L was seems to solve these problems. In diagnosis of
determined as 7.2 (p=0.017) (95% CI (0.6-0.94)). acute appendicitis, N/L by itself is a better
For that cut off value sensitivity was 83.6%, and parameter than CRP, WBC and absolute neutrophil
specificity was 69.6%. count25 but different cut-off values were determined
in previous studies. In our study, the best cut-off
Discussion value of N/L that can differentiate the inflamed
To decrease the morbidity and mortality rates appendix from the normal one was determined as 5
caused by acute appendicitis; its prompt and (75.2% sensitivity and 67.8% specificity). This
definite diagnosis is warranted. Performance of obtained value was between the values of 3.5
some different hematological and radiological tests reported by Yazıcı et al12 and Białas et al26 and 6
is not enough every time for the exact diagnosis in reported by Markar et al25.
children. For those cases, simple parameters are
required for prompt and correct diagnosis13. As in Complicated acute appendicitis pictures due to
our study, acute appendicitis is more common in phlegmon, abscess or perforation are still important.
males4,14. The exact cause of this is still not defined. Generally these situations take place due to the
However, there are some studies more commonly delay in interventions with a rate ranging between
reporting acute appendicitis in females15. 21.5%27 and 28%28. In our study, we have
determined that localized abdominal pain in right
The diagnosis of acute appendicitis in childhood is lower quadrant was significantly more common in
mainly suspected by doctors with the admission this condition. In those conditions with more severe
symptoms. Together with the abdominal pain; inflammation, higher CRP and neutrophil counts
nausea-vomiting and anorexia are the most were determined29. Nevertheless, N/L ratio is more
commonly determined admission symptoms16. In valuable in diagnosis of complicated acute
our study, along with those symptoms, constipation appendicitis compared with WBC,26 and moreover
was also determined as significantly higher. In it may reach higher values compared with the non-
complete blood count, a simple test, WBC, absolute complicated appendicitis25,29,30.
neutrophil count and N/L ratio can be obtained and
these parameters were investigated in many other In our study, the most appropriate cut off value of
studies as inflammatory determinants8,9. Low cost is N/L in differentiating complicated acute
the main advantage of these parameters. With the appendicitis from non-complicated one was
augmented inflammation, increase in those determined as 7.2 (83.6% sensitivity, 69.6%
parameters is another advantage. On the other hand, specificity). This obtained value was between the
there are also studies reporting low sensitivity and values of 5.7 reported by Kahramanca et al13 and 8
specificity rates of especially WBC and absolute reported by Ishizuka et al29. In early periods of
neutrophil count in inflammatory conditions17. In acute appendicitis, due to the consumption of PNL
our study, we have determined significantly in marginal pool, PNL increases more than WBC
increased CRP, WBC and N/L ratio in acute which is the reason of increase in N/L ratio in early
appendicitis cases compared with the cases periods. In complicated appendicitis, PNL
admitted with non-specific abdominal pain. production intensifies while lymphocyte count
Dueholm et al18 defined that normal WBC, N/L and decreases in bone marrow and this alteration is an
CRP values excludes the diagnosis of acute
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Neutrophil to lymphocyte ratio in diagnosis of complicated Sri Lanka Journal of Child Health, 2017; 46: 59-65

important cause of increase in N/L ratio in pediatrics in 2011. Choices in

complicated appendicitis31-33. endocrinology, gastroenterology, hemato-
oncology, infectious diseases,
In clinical pictures other than acute appendicitis, otolaryngology, pharmacotherapy and
admitting with similar symptoms; WBC rarely respiratory tract illnesses. Italian Journal
exceeds 12x103 /mm3,26. Erturk et al16 reported that, of Pediatrics 2012; 38:23-7.
in childhood acute appendicitis cases, total https://doi.org/10.1186/1824-7288-38-23
leucocyte count higher than 11.8x103 /μL and CRP PMid: 22682313 PMCid: PMC3431994
values higher than 13.5 mg/dl have high
sensitivities. In our study, we have determined that 6. Ma KW, Chia NH, Yeung HW, Cheung
WBC>12x103 and CRP>15 mg/dl values were MT. If not appendicitis, then what else can
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appendicitis was 7.2. child have appendicitis? Journal of the
American Medical Association 2007;
• In our study, WBC>12x103 and CRP>15 298:438-51.
mg/dl values were important parameters https://doi.org/10.1001/jama.298.4.438
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8. Yang HR, Wang YC, Chung PK, et al.
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