Langenbeck's Archives of Surgery

, Volume 400, Issue 2, pp 221–228 | Cite as

High admission C-reactive protein level and longer in-hospital delay to surgery are associated with increased risk of complicated appendicitis

  • Henna E. SammalkorpiEmail author
  • Ari Leppäniemi
  • Panu Mentula
Original Article



Debate on the effect of in-hospital delay on the risk of perforation in appendicitis persists, and the results from previous studies are controversial. The aims of this study were to present the effect of in-hospital delay on the risk of perforation in appendicitis and to assess the utility of C-reactive protein (CRP) measurement in detecting the patients with complicated appendicitis.


Prospectively collected data of 389 adult patients who underwent surgery for acute appendicitis were analyzed in order to find the most accurate method for recognizing the pre-hospital perforations. The effect of in-hospital delay on the further risk of perforation in patients with not yet perforated acute appendicitis was then analyzed.


Out of 389 patients with appendicitis, 91 patients (23.4 %) had complicated appendicitis, 23 with abscess, and 68 with free perforation. Admission CRP level of 99 mg/l or higher was 90.3 % specific for complicated appendicitis. In patients with admission CRP less than 99 mg/l, the incidence of perforation doubled from 9.5 to 18.9 % when the in-hospital delay increased from less than 6 h to more than 12 h.


Complicated appendicitis can be identified with a high CRP level on admission. Delaying surgery can increase the risk of perforation.


Appendicitis, acute Appendicitis, perforated Abdomen, acute C-reactive protein 


Conflicts of interest


Authors’ contributions

Study conception and design: Leppäniemi and Mentula

Acquisition of data: Sammalkorpi

Analysis and interpretation of data: Mentula and Sammalkorpi

Drafting of manuscript: Sammalkorpi and Mentula

Critical revision of manuscript: Leppäniemi and Mentula


  1. 1.
    Masoomi H et al (2011) Comparison of outcomes of laparoscopic versus open appendectomy in adults: data from the Nationwide Inpatient Sample (NIS), 2006–2008. J Gastrointest Surg 15(12):2226–2231CrossRefPubMedGoogle Scholar
  2. 2.
    Ingraham AM et al (2010) Effect of delay to operation on outcomes in adults with acute appendicitis. Arch Surg 145(9):886–892CrossRefPubMedGoogle Scholar
  3. 3.
    Busch M et al (2011) In-hospital delay increases the risk of perforation in adults with appendicitis. World J Surg 35(7):1626–1633CrossRefPubMedGoogle Scholar
  4. 4.
    Temple CL, Huchcroft SA, Temple WJ (1995) The natural history of appendicitis in adults. A Prospect Stud Annals Surg 221(3):278–281Google Scholar
  5. 5.
    Bickell NA (2006) How time affects the risk of rupture in appendicitis. J Am Coll Surg 202(3):401–406CrossRefPubMedGoogle Scholar
  6. 6.
    Hansson LE, Laurell H, Gunnarsson U (2008) Impact of time in the development of acute appendicitis. Dig Surg 25(5):394CrossRefPubMedGoogle Scholar
  7. 7.
    Ditillo MF, Dziura JD, Rabinovici R (2006) Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 244(5):656–660CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Andersson R et al (1994) Indications for operation in suspected appendicitis and incidence of perforation. BMJ 308(6921):107–110CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Omundsen M, Dennett E (2006) Delay to appendicectomy and associated morbidity: a retrospective review. ANZ J Surg 76(3):153–155CrossRefPubMedGoogle Scholar
  10. 10.
    Abou-Nukta F (2006) Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg 141(5):504–506, discussCrossRefPubMedGoogle Scholar
  11. 11.
    Hornby ST et al (2014) Delay to surgery does not influence the pathological outcome of acute appendicitis. Scand J Surg 103(1):5CrossRefPubMedGoogle Scholar
  12. 12.
    United Kingdom National Surgical Research, C, Bhangu A (2014) Safety of short, in-hospital delays before surgery for acute appendicitis: multicentre cohort study, systematic review, and meta-analysis. Ann Surg 259(5):894–903Google Scholar
  13. 13.
    Farooqui W, Pommergaard HC, Burcharth J, Eriksen JR (2014) The diagnostic value of a panel ofserological markers in acute appendicitis. Scand J Surg 0:1-7Google Scholar
  14. 14.
    Kim HC et al (2011) Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels. Br J Radiol 84(1008):1115–1120CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Shindoh J et al (2011) Diagnostic power of inflammatory markers in predicting severity of appendicitis. Hepato-Gastroenterology 58(112):2003–2006PubMedGoogle Scholar
  16. 16.
    Kaser SA (2010) C-reactive protein is superior to bilirubin for anticipation of perforation in acute appendicitis. Scand J Gastroenterol 45(7–8):885–892CrossRefPubMedGoogle Scholar
  17. 17.
    Gronroos JM, Gronroos P (1999) Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis. Br J Surg 86(4):501–504CrossRefPubMedGoogle Scholar
  18. 18.
    Bröker MEE et al (2012) Discriminating between simple and perforated appendicitis. J Surg Res 176(1):79CrossRefPubMedGoogle Scholar
  19. 19.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–13Google Scholar
  20. 20.
    Alvarado A (1986) A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 15(5):557–564CrossRefPubMedGoogle Scholar
  21. 21.
    Andersson M, Andersson RE (2008) The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg 32(8):1843–1849CrossRefPubMedGoogle Scholar
  22. 22.
    Clyne B, Olshaker JS (1999) The C-reactive protein. J Emerg Med 17(6):1019CrossRefPubMedGoogle Scholar
  23. 23.
    Earley AS et al (2006) An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg 244(4):498PubMedCentralPubMedGoogle Scholar
  24. 24.
    Livingston EH et al (2007) Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 245(6):886–892CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Andersson RE (2007) The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 31(1):86–92CrossRefPubMedGoogle Scholar
  26. 26.
    Rivera-Chavez FA (2004) Innate immunity genes influence the severity of acute appendicitis. Ann Surg 240(2):269–277CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Henna E. Sammalkorpi
    • 1
    Email author
  • Ari Leppäniemi
    • 1
  • Panu Mentula
    • 1
  1. 1.Department of Abdominal SurgeryHelsinki University Central HospitalHelsinkiFinland

Personalised recommendations