Diagnostic Accuracy of White Blood Cell Count, Serum Bilirubin, and C-Reactive Protein for Predicting Perforated Appendicitis: A Cross-Sectional Study
DOI:
https://doi.org/10.52206/jsmc.2026.16.2.1428Abstract
Background: Diagnosing perforated appendicitis remains a significant clinical challenge, particularly in resource-limited settings where access to advanced imaging modalities is restricted. Biochemical markers such as white blood cell (WBC) count, serum bilirubin, and C-reactive protein (CRP) are widely available and may provide a cost-effective means for early identification of complicated appendicitis.
Objective: To evaluate the diagnostic accuracy of WBC count, serum bilirubin, and CRP in identifying perforated appendicitis among patients presenting with suspected acute appendicitis.
Methodology: This descriptive cross-sectional diagnostic accuracy study was conducted at the Department of General Surgery, Liaquat University Hospital, Hyderabad. A total of 200 patients aged 18–40 years with clinical suspicion of acute appendicitis were enrolled. Blood samples were analyzed for WBC count (cells/µL), serum bilirubin (mg/dL), and CRP (mg/L) at presentation. Contrast-enhanced computed tomography (CT) was used as the reference standard. Diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) curve analysis.
Results: Among the 200 patients, 80 (40%) were diagnosed with perforated appendicitis. CRP demonstrated the highest diagnostic accuracy, with sensitivity of 78.75% and specificity of 88.33% (AUC: 0.87; 95% CI: 0.82–0.94). WBC count showed the highest sensitivity (85.00%) but lower specificity (73.33%) (AUC: 0.84; 95% CI: 0.78–0.89). Serum bilirubin demonstrated moderate sensitivity (76.25%) and lower specificity (53.33%) (AUC: 0.73; 95% CI: 0.66–0.81).
Conclusion: CRP, WBC count, and serum bilirubin are useful adjunctive biomarkers for predicting perforated appendicitis, with CRP demonstrating the highest overall diagnostic performance. These readily available and low-cost tests may serve as effective triage tools, particularly in settings where access to CT imaging is limited or delayed.
Keywords: C-reactive protein, Diagnostic accuracy, Perforated appendicitis, ROC curve, Serum bilirubin, WBC count.
References
Zosimas D, Lykoudis PM, Strano G, Burke J, Al-Cerhan E, Shatkar V. Bilirubin is a specific marker for the diagnosis of acute appendicitis. Exp Ther Med. 2021 Oct;22(4):1056. https://doi.org/10.3892/etm.2021.10490
Patmano M, Çetin DA, Gümü? T. Laboratory markers used in the prediction of perforation in acute appendicitis. Ulus Travma Acil Cerrahi Derg. 2022 Jul;28(7):960-966. https://doi.org/10.14744/tjtes.2021.83364
Ghosh M, Mukherjee MP, Chaturvedi V, Mukherjee D. Estimation of serum bilirubin level as a diagnostic marker and its role in predicting appendicular perforation. Asian J Med Sci. 2023;14(6):88-92. https://doi.org/10.3126/ajms.v14i6.52366
Akbulut S, Yagin FH, Cicek IB, Koc C, Colak C, Yilmaz S. Prediction of Perforated and Nonperforated Acute Appendicitis Using Machine Learning-Based Explainable Artificial Intelligence. Diagnostics (Basel). 2023 Mar 19;13(6):1173. https://doi.org/10.3390/diagnostics13061173
Ranjha W, Hassan T, Khan S, Hussain S, Ahmed B, Hussain MS. Diagnostic Accuracy of C-Reactive Protein in Acute Appendicitis. Pak Armed Forces Med J. 2024;74(4):1011-4. https://doi.org/10.51253/pafmj.v74i4.9109
Odion C, Dongo AE, Kpolugbo J, Imoloamen C, Odigie V, Okomayin AA, et al. C-Reactive Protein and White Blood Cell Count as Biomarkers in the Diagnosis of Acute Appendicitis in Adults. J Niger Surg Res Soc. 2024;1(1):18-29. https://nsrs.ng/jnsrs/index.php/jnsrs/article/view/1
Coskun N, Kaba I. Diagnostic Performance of Immature Granulocytes in the Early Diagnosis of Acute and Perforated Appendicitis in Children: A Retrospective Study. Med Records. 2025;7(3):784-91.
Bellael M, Taher MB. Value of C- Reactive Protein and White Blood Cells Count in Confirming the Diagnosis of Acute Appendicitis. Alq J Med App Sci. 2024;17:1010-5. https://doi.org/10.54361/ajmas.247416
Peksöz R, Bayar B. The role of complete blood count parameters in diagnosing acute appendicitis and measuring the severity of inflammation. Ulus Travma Acil Cerrahi Derg. 2021 Nov;27(6):654-661. English. https://doi.org/10.14744/tjtes.2020.69195
Shahid M, Khalid M, Ali A, Shahid N, Qureshi JA, Noorain Z. Hyperbilirubinemia has Predictive Potential for Appendiceal Perforation. Pak J Med Health Sci. 2022;16(11):614-6. https://doi.org/10.53350/pjmhs20221611614
Sreedevi S, Meera SS, Kannan P, DhanaShree BV. Hyperbilirubinemia and CRP as Predictors of Appendiceal Gangrene or Perforation-A prospective study. Int J Acad Med Pharm. 2025;7(1):728-33.
Sen SK, Islam MK, Nasreen R. Hyperbilirubinemia is a Predictor of Gangrenous or Perforated Appendicitis. SAS J Surg. 2023;9(11):894-8. https://doi.org/10.36347/sasjs.2023.v09i11.006
Doma KA, Balbola MM, Shahin MM. Prospective Assessment of Elevated Serum Bilirubin in Diagnosis of Acute Appendicitis. Int J Med Arts. 2024;6(9):4933-40. https://doi.org/10.21608/ijma.2024.227793.1764
Basukala S, Gurung S, Tamang A, Shrestha O, Devkota M, Thapa N, et al. Diagnostic value of biochemical markers in prediction of perforation in acute appendicitis: a cross-sectional study. Ann Med Surg (Lond). 2024 Sep 17;86(11):6495-6501. https://doi.org/10.1097/MS9.0000000000002547
Banerjee A, Ratan SK, Neogi S, Goswami B, Dixit R, Panda SS. Ultrasound and markers in complicated appendicitis. J Indian Assoc Pediatr Surg. 2022;27(4):448–54. https://doi.org/10.4103/jiaps.jiaps_140_21
Emmanuel A, Murchan P, Wilson I, Balfe P. The value of hyperbilirubinaemia in the diagnosis of acute appendicitis. Ann R Coll Surg Engl. 2011 Apr;93(3):213-7. https://doi.org/10.1308/147870811X566402
Raza M, Shamsi G, Ali W, Sethi MR, Memon T, Malik AM. Diagnostic accuracy of serum CRP and leukocyte count in acute appendicitis. Rawal Med J. 2022;47(3):623-6.
Garg S, Chawla S, Jain R, Kumar A, Singh M, Sharma D. Comparison of biochemical markers in acute and perforated appendicitis. J Clin Diagn Res. 2021;15(6):PC01-PC04.
Anum T, Hussain T, Yousaf M, Shahid M, Nazir A, Riaz S. Diagnostic accuracy of raised total leukocyte count in acute appendicitis. Pak J Surg. 2022;38(2):85-9.
Sarkar S, Chattopadhyay S, Ghosh A, Biswas S, Biswas R, Saha ML. CRP and MPV as predictors of perforated appendicitis. Int Surg J. 2021;8(7):2204-8.
Sreeramulu PN, Shashidhar SS. Serum bilirubin and CRP as predictors in perforated appendicitis. Int J Contemp Med Res. 2022;9(4):D1-D4.
Ulusahin M, Unal A, Turkyilmaz S. Lab parameters in diagnosing complicated appendicitis. Farabi Med J. 2024;3(2):42-9. https://doi.org/10.59518/farabimedj.1392105
Additional Files
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 The authors retain the copyrights. Authors are permitted and encouraged to post their work online (e.g. in institutional repositories or on their website), as it can lead to productive exchanges, as well as greater citation of published work.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Readers may “Share-copy and redistribute the material in any medium or format” and “Adapt-remix, transform, and build upon the material”. The readers must give appropriate credit to the source of the material and indicate if changes were made to the material. Readers may not use the material for commercial purpose. The readers may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
