Diagnostic accuracy of hyperbilirubinemia in preoperative diagnosis of acute perforated appendix

Brinda Kolanjiappan, Himanshu Raj, Chandrasekaran Ramaraj


Background: Delayed diagnosis of perforated appendicitis is a life threating condition. All these cases warrant expeditious surgical intervention. Hyperbilirubinemia can play a vital role in early diagnosis of perforated appendix and thereby reduce mortality, morbidity and prolonged hospital stay. The aim of this study is to compare the levels of bilirubin in simple appendicitis and perforated appendicitis.

Methods: This was a single center retrospective study of 100 patients who attended Surgery OPD with right iliac fossa pain during the period between July 2017 and June 2018.

Results: During the period of study, 100 patients were selected of which 18 (18%) subjects were diagnosed having perforated appendix and 82 (82%) cases were having non-perforated appendix. The mean serum bilirubin levels were 1.65±0.83 among subjects diagnosed having perforated appendix whereas it was 0.82±0.36 among subjects having non-perforated appendix. Further raised levels of bilirubin levels in blood were detected among 20 cases, of which 17 cases were diagnosed having perforated appendix. Out of total 20 cases in whom hyperbilirubinemia was observed, only 3 cases were having non-perforated appendix. Of total 80 cases in which normal Bilirubin levels in blood were detected, only 1 case had perforated appendix.

Conclusions: Preoperative serum bilirubin levels are promising tool with high diagnostic accuracy in preoperative diagnosis of acute perforated appendix when used together with clinical correlation. 


Acute perforated appendix, Hyperbilirubinemia, Unwanted appendisectomies

Full Text:



Muller S, Falch C, Axt S, Wilhelm P, Hein D, Königsrainer A, Kirschniak A. Diagnostic accuracy of hyperbilirubinaemia in anticipating appendicitis and its severity. Emerg Med J. 2015;32(9):698-702.

Sand M, Bechara FG, Holland-Letz T, Sand D, Mehnert G, Mann B. Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis. The American journal of surgery. 2009;198(2):193-8.

Syed R. Evaluation of hyperbilirubinemia in acute appendicitis. International Journal of Contemporary Medical Research 2018;5(10):J13-J16.

Hong YR, Chung CW, Kim JW, Kwon CI, Ahn DH, Kwon SW, et al. Hyperbilirubinemia is a significant indicator for the severity of acute appendicitis. J Korean Soc Coloproctol. 2012;28(5):247.

Noh H, Chang SJ, Han A. The diagnostic values of preoperative laboratory markers in children with complicated appendicitis. J Korean Surg Soc. 2012;83(4):237-41.

Panagiotopoulou IG, Parashar D, Lin R, Antonowicz S, Wells AD, Bajwa FM, et al. The diagnostic value of white cell count, C-reactive protein and bilirubin in acute appendicitis and its complications. The Annals of the Royal College of Surgeons of England. 2013;95(3):215-21.

Acharya A, Markar SR, Ni M, Hanna GB. Biomarkers of acute appendicitis: systematic review and cost–benefit trade-off analysis. Surgical endoscopy. 2017;31(3):1022-31.

Chambers AC, Bismohun SL, Davies H, White P, Patil AV. Predictive value of abnormally raised serum bilirubin in acute appendicitis: a cohort study. Int J Surg. 2015;13:207-10.

Natesan S, Lee J, Volkamer H, Thoureen T. Evidence-based medicine approach to abdominal pain. Emerg Med Clin North Am. 2016;34(2):165-90.

IAPSM's Text Book of Community Medicine. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine; 2019.

Detels R, Beaglehole R, Lansang MA, Gulliford M. Oxford textbook of public health. Oxford University Press; 2011.

Forthofer RN, Lee ES. Introduction to biostatistics: a guide to design, analysis and discovery. Elsevier; 2014.

Prystowsky JB, Pugh CM, Nagle AP. Appendicitis. Current problems in surgery. 2005;42(10):694-742.

Paterson HM, Qadan M, De Luca SM, Nixon SJ, Paterson-Brown S. Changing trends in surgery for acute appendicitis. British J Surg: Incorporating European J Surg Swiss Surg. 2008;95(3):363-8.

Ghimire P, Thapa P, Yogi N. Role of serum bilirubin as a marker of acute gangrenous appendicitis. Nepal J Med Sci. 2012;1(2):89-92.

D’Souza N, Karim D, Sunthareswaran R. Bilirubin; a diagnostic marker for appendicitis. Int J Surg. 2013;11(10):1114-7.

Burcharth J, Pommergaard H, Rosenberg J, Gögenur I. Hyperbilirubinemia as a predictor for appendiceal perforation: a systematic review. Scandinavian J Surg. 2013;102(2):55-60.

Hong YR, Chung C-W, Kim JW, Kwon CI, Ahn DH, Kwon SW, et al. Hyperbilirubinemia is a significant indicator for the severity of acute appendicitis. J Korean Soc Coloproctol. 2012;28(5):247-52.

Michael S. Diagnostic value of hyperbilirubinemia as predictive factor for appendiceal perforation in acute appendicitis. Am J Surg. 2009;2:193-8.

McGowan DR, Sims HM, Zia K, Uheba M, Shaikh IA. The value of biochemical markers in predicting a perforation in acute appendicitis. ANZ J Surg. 2013;83(1-2):79-83.

Estrada JJ, Petrosyan M, Barnhart J, Tao M, Sohn H, Towfigh S, et al. Hyperbilirubinemia in appendicitis: a new predictor of perforation. J Gastrointes Surgery. 2007;11(6):714-8.

Khan S. The diagnostic value of hyperbilirubinemia and total leucocyte count in the evaluation of acute appendicitis. JCDR. 2009;3:1647-52.

Atahan K, Üreyen O, Aslan E, Deniz M, Çökmez A, Gür S, et al. Preoperative diagnostic role of hyperbilirubinemia as a marker of appendix perforation. JIMR. 2011;39:609-18.

Emmanuel A, Murchan P, Wilson I, Balfe P. The value of hyperbilirubinaemia in the diagnosis of acute appendicitis. Ann Royal College of Surgeons of England. 2011;93(3):213.

Giordano S, Pääkkönen M, Salminen P, Grönroos JM. Elevated serum bilirubin in assessing the likelihood of perforation in acute appendicitis: a diagnostic meta-analysis. Int J Surg. 2013;11(9):795-800.