Publication: Evaluation of hyperbilirubinemia in acute inflammation of appendix: A prospective study of 45 cases
Date
2006
Authors
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Journal ISSN
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Publisher
Kathmandu University
Abstract
Background: Hyperbilirubinemia is the result of imbalance between production and excretion of bilirubin by the
liver. It may be because of hepatocellular, cholestatic or haemolytic diseases. Liver receives blood mainly through
portal venous system, which receives blood from abdominal organs. Portal blood carries nutrients and other
substances absorbed from gut including bacteria and its product (toxins). In small percentage, even in normal
healthy people, bacteria are found in portal blood. It is commonly cleared by detoxification and immunological
action of reticuloendothelial (RES) system of liver that act as first line defence in clearing toxic substances, bacteria
and it's products. But when bacterial load overwhelms the Kuffer cell function, may cause dysfunction or damage to
the hepatocytes (liver parenchyma). It reflects, rise in serum bilirubin (SB) alone or in combination with liver
enzymes depending upon the type, severity and site of lesion. Recently, another substance known as Cytokines e.g.
IL-6, Tumour necrosis factor (TNF), have also been labelled to be responsible for depressed excretory function of
liver and may lead to increase in SB level without rise in liver enzymes.
Aim: To evaluate hyperbilirubinemia associated in acute inflammation of appendix (acute appendicitis and its
complication).
Material and methods: This is a prospective study conducted at NGMC Teaching hospital Nepalgunj, Nepal during
Oct.2004-Oct.2005. 45 Consecutive cases of acute appendicitis admitted in surgical unit III, were recruited for this
study. Clinically suspected cases were subjected to investigations to confirm the diagnosis. Investigations included
total leucocytes count, differential leucocytes count, urine analysis and ultrasound. These cases were also subjected
to routine liver function tests. Subsequently these cases were operated and clinical diagnosis was confirmed per–
operatively and post operatively by histopathological examination of the specimen. Their clinical and investigative
data were compiled and analyzed and following observations were obtained. Routine liver function test results were
compared with laboratory reference values given in Table- 1, 2 and 3.
Inclusion Criteria: Case with acute appendicitis and its complication with test negative for HBSAg and no past
history of jaundice. Exclusion Criteria: Case with acute appendicitis and its complication with test positive for
HBSAg and /or past history of jaundice.
Results: Total number cases were 45. Of 45, 25 were males and 20 were females. Their age ranged from 11years to
60 years. The average was 27.2 years. Duration of symptoms ranged from 5 hours to maximum 9 days. Among 45
cases diagnosed as acute appendicitis clinically (preoperatively), per operatively, 36 cases had inflamed appendix, 3
cases had gangrene, 5 cases had perforation with peritonitis (4 localized and 1 generalized peritonitis) and only a
single case was noted to be of normal appendix (Table 4). Liver function tests (LFT) analysis revealed following
results, Among 45 cases, SB was raised in 39cases where as 6 cases had normal SB level. The raised SB ranged
from 1.2 mg/dL to 8.4 mg/dL. The average level of SB was 2.38 mg/dL. All the cases had indirect fraction of SB
above 15%. (Table 4). The rise in SB was without concomitant much rise in liver enzymes.
Conclusion: Following conclusion can be drawn from the present study. Firstly, There was Hyperbilirubinemia in
86.6% of the patients of acute inflammation of appendix (i.e. acute appendicitis and its complications). Secondly,
Raised SB ranged from 1.2mg/dL - 8.4 mg/dL. Thirdly, The rise in SB was mixed in type (both indirect and direct).
Finally, The hyperbiliubinemia was intra hepatic cholestatic in type due either to abnormality in permeability of
hepatocyte or ductular membrane enzyme inhibition as the liver enzymes were not much elevated.
Key words: Acute Inflammation of Appendix, Acute appendicitis, Hyperbilirubinemia, Serum bilirubin
Description
Khan S
Department of Surgery, Nepalgunj Medical College, Teaching Hospital, Nepalgunj, Nepal