Ann Surg Treat Res.  2023 Jun;104(6):332-338. 10.4174/astr.2023.104.6.332.

Might simple peripheral blood parameters be an early indicator in the prediction of severity and morbidity of cholecystitis?

• Yilmaz S
• Aykota MR
• Ozgen U
• Birsen O
• Simsek S
• Kabay B

• KMID: 2542797
• DOI: http://doi.org/10.4174/astr.2023.104.6.332

Abstract

Purpose
The aim of this study is to examine the effectiveness of the neutrophil-lymphocyte ratio (NLR) and CRP/albumin ratio (CAR) in evaluating disease severity and predicting clinical outcomes in patients diagnosed with acute cholecystitis (AC).
Methods
A total of 186 patients with AC were evaluated retrospectively. NLR, CAR, Mannheim Peritonitis Index (MPI), and P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) scores were compared with AC severity grade.
Results
The rates of the grade 1 patients (group 1) and the grade 2–3 patients (group 2) were 57.5% (n = 107) and 42.5% (n = 79) according to the disease severity according to Tokyo Guidelines criteria (TG) 18/TG13, respectively. The morbidity rates determined in groups 1 and 2 were 26.7% (n = 28) and 51.9% (n = 41), respectively. No mortality was found in group 1, whereas the mortality rate in group 2 was 6.3% (n = 5). According to multivariate analysis, CAR (odds ratio [OR], 1.234; P < 0.001) and MPI (OR, 1.175; P = 0.001) were found to be associated with moderate-severe disease while CAR (OR, 1.109; P = 0.035) and P-POSSUM morbidity (OR, 1.063; P = 0.007) variables were found to be associated with the presence of morbidity.
Conclusion
We have demonstrated that CAR can be used in predicting severity of AC and that CAR is an alternative simple parameter of P-POSSUM morbidity score in prediction of morbidity in these cases. In addition to other assessment methods, these scores can provide valuable and complementary information in assessment of disease severity and prognosis in AC.

Keyword

Acute cholecystitis; Albumins; C-reactive protein; Neutrophil-lymphocyte ratio

Figure

• 

  Fig. 1 A comparison regarding the area under the receiver operating characteristic (ROC) curve to assess the differentiation between grade 1 and grade 2–3 disease. NLR, neutrophil-lymphocyte ratio; CAR, CRP/albumin ratio; MPI, Mannheim Peritonitis Index.

• 

  Fig. 2 A comparison regarding the area under the receiver operating characteristic (ROC) curve to assess the prediction of morbidity. CAR, CRP/albumin ratio; P-POSSUM, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity.

Reference

1. Peery AF, Crockett SD, Barritt AS, Dellon ES, Eluri S, Gangarosa LM, et al. Burden of gastrointestinal, liver, and pancreatic diseases in the United States. Gastroenterology. 2015; 149:1731–1741. PMID: 26327134.

2. Yokoe M, Takada T, Hwang TL, Endo I, Akazawa K, Miura F, et al. Validation of TG13 severity grading in acute cholecystitis: Japan-Taiwan collaborative study for acute cholecystitis. J Hepatobiliary Pancreat Sci. 2017; 24:338–345. PMID: 28419779.

3. Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018; 25:41–54. PMID: 29032636.

4. Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25:55–72. PMID: 29045062.

5. Gomez D, Farid S, Malik HZ, Young AL, Toogood GJ, Lodge JP, et al. Preoperative neutrophil-to-lymphocyte ratio as a prognostic predictor after curative resection for hepatocellular carcinoma. World J Surg. 2008; 32:1757–1762. PMID: 18340479.

6. McMillan DC. An inflammation-based prognostic score and its role in the nutrition-based management of patients with cancer. Proc Nutr Soc. 2008; 67:257–262. PMID: 18452641.

7. Kinoshita A, Onoda H, Imai N, Iwaku A, Oishi M, Tanaka K, et al. The C-reactive protein/albumin ratio, a novel inflammation-based prognostic score, predicts outcomes in patients withhepatocellular carcinoma. Ann Surg Oncol. 2015; 22:803–810. PMID: 25190127.

8. Shimizu T, Ishizuka M, Kubota K. A lower neutrophil to lymphocyte ratio is closely associated with catarrhal appendicitis versus severe appendicitis. Surg Today. 2016; 46:84–89. PMID: 25686778.

9. Qin G, Tu J, Liu L, Luo L, Wu J, Tao L, et al. Serum albumin and C-reactive protein/albumin ratio are useful biomarkers of Crohn’s disease activity. Med Sci Monit. 2016; 22:4393–4400. PMID: 27848931.

10. Ranzani OT, Zampieri FG, Forte DN, Azevedo LC, Park M. C-reactive protein/albumin ratio predicts 90-day mortality of septic patients. PLoS One. 2013; 8:e59321. PMID: 23555017.

11. Sato N, Kinoshita A, Imai N, Akasu T, Yokota T, Iwaku A, et al. Inflammation-based prognostic scores predict disease severity in patients with acute cholecystitis. Eur J Gastroenterol Hepatol. 2018; 30:484–489. PMID: 29303882.

12. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg. 1998; 85:1217–1220. PMID: 9752863.

13. Jason Smith-Consultant Surgeon. P-POSSUM Scoring [Internet]. Jason Smith;c2023. cited 2021 May 19. Available from: www.riskprediction.org.uk. http://www.riskprediction.org.uk/index-pp.php .

14. Linder MM, Wacha H, Feldmann U, Wesch G, Streifensand RA, Gundlach E. [The Mannheim peritonitis index. An instrument for the intraoperative prognosis of peritonitis]. Chirurg. 1987; 58:84–92. PMID: 3568820.

15. Halldestam I, Enell EL, Kullman E, Borch K. Development of symptoms and complications in individuals with asymptomatic gallstones. Br J Surg. 2004; 91:734–738. PMID: 15164444.

16. Parker LJ, Vukov LF, Wollan PC. Emergency department evaluation of geriatric patients with acute cholecystitis. Acad Emerg Med. 1997; 4:51–55. PMID: 9110012.

17. Papadakis M, Ambe PC, Zirngibl H. Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation. World J Emerg Surg. 2015; 10:59. PMID: 26628907.

18. Fagan SP, Awad SS, Rahwan K, Hira K, Aoki N, Itani KM, et al. Prognostic factors for the development of gangrenous cholecystitis. Am J Surg. 2003; 186:481–485. PMID: 14599611.

19. González-Muñoz JI, Franch-Arcas G, Angoso-Clavijo M, Sánchez-Hernández M, García-Plaza A, Caraballo-Angeli M, et al. Risk-adjusted treatment selection and outcome of patients with acute cholecystitis. Langenbecks Arch Surg. 2017; 402:607–614. PMID: 27704274.

20. Beliaev AM, Angelo N, Booth M, Bergin C. Evaluation of neutrophil-to-lymphocyte ratio as a potential biomarker for acute cholecystitis. J Surg Res. 2017; 209:93–101. PMID: 28032577.

21. Pehlivan T, Alper Cevik A, Ateş E. [Relationships among ultrasonographic and demographic, clinical, laboratory findings of patients with acute cholecystitis]. Ulus Travma Acil Cerrahi Derg. 2005; 11:134–140. PMID: 15877244.

22. Gökçe FS, Gökçe AH. Is C-reactive protein a superior marker of inf lammation over the neutrophil/lymphocyte ratio or platelet/lymphocyte ratio in acute cholecystitis? Dicle Med J. 2019; 46:839–845.

23. Kelly ME, Khan A, Riaz M, Bolger JC, Bennani F, Khan W, et al. The utility of neutrophil-to-lymphocyte ratio as a severity predictor of acute appendicitis, length of hospital stay and postoperative complication rates. Dig Surg. 2015; 32:459–463. PMID: 26488396.

24. Kim MH, Ahn JY, Song JE, Choi H, Ann HW, Kim JK, et al. Correction: the C-reactive protein/albumin ratio as an independent predictor of mortality in patients with severe sepsis or septic shock treated with early goal-directed therapy. PLoS One. 2019; 14:e0225620. PMID: 31738808.

25. Mok KW, Reddy R, Wood F, Turner P, Ward JB, Pursnani KG, et al. Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe/gangrenous cholecystitis? Int J Surg. 2014; 12:649–653. PMID: 24856179.

26. Beliaev AM, Marshall RJ, Booth M. C-reactive protein has a better discriminat ive power than white cell count in the diagnosis of acute cholecystitis. J Surg Res. 2015; 198:66–72. PMID: 26038247.

27. Sökmen S, Coker A, Unek T, Tunçyürek P, Bora . [Effectiveness of the Mannheim Peritonitis Index in patients with peritonitis]. Ulus Travma Derg. 2001; 7:100–103. PMID: 11705031.

28. Chojkier M. Inhibition of albumin synthesis in chronic diseases: molecular mechanisms. J Clin Gastroenterol. 2005; 39(4 Suppl 2):S143–S146. PMID: 15758650.

29. Tominaga T, Nonaka T, Sumida Y, Hidaka S, Sawai T, Nagayasu T. The C-reactive protein to albumin ratio as a predictor of severe side effects of adjuvant chemotherapy in stage III colorectal cancer patients. PLoS One. 2016; 11:e0167967. PMID: 27930703.

30. Kaplan M, Ates I, Akpinar MY, Yuksel M, Kuzu UB, Kacar S, et al. Predictive value of C-reactive protein/albumin ratio in acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2017; 16:424–430. PMID: 28823374.