Study of serum bilirubin as a diagnostic method to predict acute perforated appendicitis


  • Valarmathi Marimuthu Department of General Surgery, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
  • Chiddharth Venkateshan Ilamparuthi Department of General Surgery, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India



Hyperbilirubinemia, Appendicitis, Gangrenous appendix, Perforated appendicitis


Background: Acute appendicitis is the commonest cause of ‘acute surgical abdomen’. Appendicectomy is the most frequently performed urgent abdominal operation and is often the first major procedure performed by a surgeon in training. The aim of the study was to whether hyperbilirubinemia might be used as a diagnostic tool to predict perforated appendicitis.

Methods: This study comprised patients who presented with the condition of appendicitis and abnormal liver function tests on admission and had a laparoscopic or open appendectomy. The age information, duration of symptoms, temperature, white blood cell counts, bilirubin levels, and histology data were gathered. Peritoneal fluid was cultured and examined for sensitivity.

Results: The average bilirubin level of all participating patients was 0.92 mg/dl (range, 0.1-4.3 mg/dl). The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (0.7 mg/dl and 0.4 mg/dl, p<0.001). Hyperbilirubinaemia was reported to have a specificity of 89% and a positive predictive value of 90.02% for acute appendicitis. Patients with appendiceal perforation, however, had a mean bilirubin level of 1.7 mg/dl and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 73%.

Conclusions: Patients with hyperbilirubinemia with appendicitis condition should be screened for a greater risk of appendiceal perforation than those with normal bilirubin levels.  


Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910-25.

Williams GR. Presidential Address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg. 1983;197(5):495-506.

Luckmann R, Davis P. The epidemiology of acute appendicitis in California: racial, gender, and seasonal variation. Epidemiology. 1991;2(5):323-30.

Whitehead MW, Hainsworth I, Kingham JG. The causes of obvious jaundice in south west wales: perceptions versus reality. Gut. 2001;48(3):409-13.

Chand N, Sanyal AJ. Sepsis-induced cholestasis. Hepatology. 2007;45(1):230-41.

Sisson RG, Ahlvin RC, Harlow MC. Superficial mucosal ulceration and the pathogenesis of acute appendicitis. Am J Surg. 1971;122(3):378-80.

Bennion RS, Wilson SE, Serota AI, Williams RA. The role of gastrointestinal microflora in the pathogenesis of complications of mesenteric ischemia. Rev Infect Dis. 1984;6(1):132-8.

Bennion RS, Wilson SE, Williams RA. Early portal anaerobic bacteremia in mesenteric ischemia. Arch Surg. 1984;119(2):151-5.

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

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

Atahan K, Üreyen O, Aslan E, Deniz M, Çökmez A, Gür S, et al. Preoperative diagnostic role of hyperbilirubinaemia as a marker of appendix perforation. J Int Med Res. 2011;39(2):609-18.

McGowan DR, Sims HM, Shaikh I, Uheba M. The value of hyperbilirubinaemia in the diagnosis of acute appendicitis. Ann R Coll Surg Engl. 2011;93(6):498.

Emmanuel A, Murchan P, Wilson I, Balfe P. The value of hyperbilirubinaemia in the diagnosis of acute appendicitis. Ann R Coll Surg Engl. 2011;93(3):213-7.






Original Research Articles