A prospective study of preoperative neutrophil to lymphocyte ratio, platelet to lymphocyte ratio and sonological findings in predicting severe cholecystitis


  • Swathi Santharaj Department of General Surgery, KIMS Hospital & Research Centre, Bangalore, Karnataka, India
  • Preethan Kamagere Nagappa Department of Surgical Gastroenterology, KIMS Hospital & Research Centre, Bangalore, Karnataka, India




Cholecystitis, Laparoscopic cholecystectomy, Prognosis, Severity, Ultrasonography, Neutrophil-lymphocyte ratio, Platelet-lymphocyte ratio, Predict, Cut off value


Background: The aims and objectives of the study was to assess the utility of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and ultrasound findings to predict severe cholecystitis and to identify an NLR, PLR cut off value that discriminates between simple and severe cholecystitis.

Methods: A prospective observational time bound study was conducted with sample size of 100 patients from December 2019 to January 2021. Severe cholecystitis was defined as cholecystitis complicated by secondary changes like haemorrhage, gangrene, emphysema, abscess, perforation, carcinoma. NLR, PLR values were calculated from absolute neutrophil count and absolute lymphocyte count. All patients underwent ultrasound abdomen by the same radiologist and findings were grouped into three categories, luminal, mural and pericholecystic changes. Intraoperative findings, Histopathological examinations were also taken into account. Data was analysed using Statistical package for social sciences (SPSS) Software Version 22. Receiver operating characteristic curve analysis was employed to identify optimal NLR, PLR cut off values and to predict combined accuracy of NLR, PLR and Ultrasound findings to predict severe cholecystitis.

Results: In our study, 23% patients had severe cholecystitis. The mean age of patients was 46 years. 65% were females. Presence of calculi and presence of multiple calculi was higher in patients with severe cholecystitis (p value 0.25) calculated using Chi square test. Ultrasound findings of luminal, mural and pericholecystic changes were also found to be higher in severe cholecystitis (p<0.001). Mann whitney test showed mean NLR, PLR higher in severe cholecystitis. A Cut off NLR of 3.75 had a sensitivity of 100%, specificity of 77.92%. Length of hospital stay in patients with severe cholecystitis was longer.

Conclusions: NLR of 3.75 is a cut off value to predict severe cholecystitis and prolonged length of hospital stay. Combined Predictive Accuracy of NLR, PLR, Ultrasound findings was 91%. Ultrasonography is a reliable, specific diagnostic tool.



Lee SK, Lee SC, Park JW, Kim SJ. The utility of the preoperative neutrophil-to-lymphocyte ratio in predicting severe cholecystitis: a retrospective cohort study. BMC surgery. 2014;14(1):1-7.

Charalel RA, Jeffrey RB, Shin LK. Complicated cholecystitis: the complementary roles of sonography and computed tomography. Ultrasound quarterly. 2011;27(3):161-70.

Hareen TK, Bhaskaran A, Jaswanthi AR. Neutrophil to lymphocyte ratio in diagnosing acute cholecystitis: a retrospective cohort study in a tertiary rural hospital. International Surgery Journal. 2016;4(1):372-6.

Wang S, Zhang Z, Fang F, Gao X, Sun W, Liu H. The neutrophil/lymphocyte ratio is an independent prognostic indicator in patients with bone metastasis. Oncology letters. 2011;2(4):735-40.

Dixit VK, Prakash AN, Gupta AN, Pandey M, Gautam A, Kumar M, Shukla VK. Xanthogranulomatous cholecystitis. Digestive Dis Sci. 1998;43(5):940-2.

Lee SW, Yang SS, Chang CS, Yeh HJ. Impact of the Tokyo guidelines on the management of patients with acute calculous cholecystitis. J Gastroenterol Hepatol. 2009;24(12):1857-61.

Sureka B, Rastogi A, Mukund A, Thapar S, Bhadoria AS, Chattopadhyay TK. Gangrenous cholecystitis: Analysis of imaging findings in histopathologically confirmed cases. Indian J Radiol Imaging. 2018;28(01):49-54.

Wilson AK, Kozol RA, Salwen WA, Manov LJ, Tennenberg SD. Gangrenous cholecystitis in an urban VA hospital. J Surgical Res. 1994;56(5):402-4.

Thapa P, Adhikari KM, Sharma A. Correlation between the severity and outcome of acute calculous cholecystits according to Tokyo Guidelines. Journal of Nepalgunj Medical College. 2019;17(1):34-7.

Wang AJ, Wang TE, Lin CC, Lin SC, Shih SC. Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis. World J Gastroenterol: WJG. 2003;9(12):2821.

Sood BP, Kalra N, Gupta S, Sidhu R, Gulati M, Khandelwal N, Suri S. Role of sonography in the diagnosis of gallbladder perforation. Journal of clinical ultrasound. 2002;30(5):270-4.

Wang S, Zhang Z, Fang F, Gao X, Sun W, Liu H. The neutrophil/lymphocyte ratio is an independent prognostic indicator in patients with bone metastasis. Oncology letters. 2011;2(4):735-40.

Chiang SF, Hung HY, Tang R, Changchien CR, Chen JS, You YT et al. Can neutrophil-to-lymphocyte ratio predict the survival of colorectal cancer patients who have received curative surgery electively?. Int J Colorectal Dis. 2012;27(10):1347-57.

Malietzis G, Giacometti M, Askari A, Nachiappan S, Kennedy RH, Faiz OD et al. A preoperative neutrophil to lymphocyte ratio of 3 predicts disease-free survival after curative elective colorectal cancer surgery. Annals of surgery. 2014;260(2):287-92.

Jeong JH, Lim SM, Yun JY, Rhee GW, Lim JY, Cho JY et al. Comparison of two inflammation-based prognostic scores in patients with unresectable advanced gastric cancer. Oncology. 2012;83(5):292-9.

Keizman D, Ish-Shalom M, Huang P, Eisenberger MA, Pili R, Hammers H et al. The association of pre-treatment neutrophil to lymphocyte ratio with response rate, progression free survival and overall survival of patients treated with sunitinib for metastatic renal cell carcinoma. Euro J Cancer. 2012;48(2):202-8.






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