The Correlation between Leukocyte, Neutrophil and C-reactive Protein Count with Non Perforated and Perforated Appendicitis in Pediatrics
Tubagus Odih1 and Ruankha Bilommi2
1Faculty of medicine of Riau University Arifin Ahmad General Hospital, Jakarta, Indonesia
2Faculty of medicine of YARSI University, Mitra Keluarga General Hospital, Jakarta, Indonesia
Submission: March 18, 2017; Published: May 23, 2017
*Corresponding author: Bilommi R, Department of Pediatrics Surgery, Mitra Keluarga Hospital, Indonesia.
How to cite this article: Tubagus O, Ruankha B. The Correlation between Leukocyte, Neutrophil and C-reactive Protein Count with Non Perforated and
Perforated Appendicitis in Pediatrics. Acad J Ped Neonatol. 2017; 4(4): 555699. DOI: 10.19080/AJPN.2017.04.555699
Background: A Pediatric Perforated Appendicitis is likely to be more often than non-perforated with the ratio of male and female is 3:2 in the highest incidence on 12-18years old. Generally leucocytes count slightly increased in non perforated appendicitis is about 11.000-14.000/mm3 and over 18.000/mm3 on perforated appendicitis, other markers for diagnose are neutrophils and C-reactive protein (CRP).
Method: During November 2015 until December 2016, obtained 30 patients who divided into 2 groups: 15 patients with non perforated appendicitis (A) and 15 patients with perforated appendicitis (B). Data is displayed descriptively and showed correlation between variables.
Result: The group of Non perforated appendicitis, there were 3 patient on aged <5 years old, 12 patient on aged >5 years old with 12 males and 3 females, the lowest leucocytes count was 8370/dL and the highest was 13.900/dL with Ratio (R) 10,776/dL, the lowest Neutrophils count was 68% and the highest one was 82% (R=77.2%), the lowest CRP count was <5ng/L and the highest was 192ng/L (R=30, 2ng/L). Sample on perforated appendicitis group was 1 patient in aged <5 years old,14 in aged >5 years old with 7 males and 8 females, the lowest leucocytes was 10.200/dL and the highest was 34.100/dL (R=21.380/dl),the lowest count of Neutrophils is 92% and the highest is 79% (R=93.87%), the lowest count of c-RP was 5ng/L, the highest one was 192ng/L (R=109, 3ng/L) The correlation of Leucocytes, neutrophils and C-RP count with group A and B was p<0.05.
Conclusion: There is a significant correlation between the leukocytes, neutrophils and C-RP count with perforation Appendicitis and non perforation appendicitis.
One of difficulty to early diagnose of Pediatric appendicitis is communication problems, because the patient is a children. This leads to perforation (30-60%) with group of 1-4 years old (70-75%) and 30-40% in adolescence are in the high risk. Pediatric Appendicitis in America showed 63.5% appendicitis perforation and 36.5% simple appendicitis. In the same study showed a comparison between the men and women is 3:2, with the highest incidence of age 12-18 years old.
In patients with acute appendicitis, the laboratory results show the increasing 70-90% of leukocytes and neutrophils,
although this is not the specific characteristic. Leukocytes count
is generally slightly increased in acute appendicitis. Leukocytes count in simple appendicitis is 11.000-14.000/mm3 and more than 18.000/mm3 showed in a perforated appendicitis. Increasing of leukocyte count more indicates on a bacterial infection rather than viral. Other conditions such as neutrophil is generally accompany in appendicitis.
Other inflammatory markers that can be used in the diagnosis of acute appendicitis is C-Reactive protein (CRP). Marker of acute inflammatory response (acute phase response) using CPR has been widely used in developed countries. The value of sensitivity and specificity CRP is 80-90% and more than 90%.
Data has conducted from patient during November 2015 to
December 2016 at Arifin Achmad Pekanbaru General Hospital.
The data collected included age, intervention, result of leukocytes,
neutrophils, and CRP count, as in the following Table 1.
The data explained that the age of the patient either perforated
or non perforated appendicitis is more happened in the group of
age over 5 years (school age).
The data by sex featuring in group A (non-perforated) is a
significant difference between male and female, while in group
B (perforated) the difference is thinner (female is more than the
Group A (non-perforated): 12 males (80%) and 3 females
Group B (perforated): 7males (47%) and 8 females (53%)
In Group A (non-perforated): The lowest of leukocyte count
is 8270/dL and the highest is 13.900/dL, with more detail as
follows: 11 patients (73%) with a normal leukocytes count and
4 patients (27%) over than the normal count. This can happen
because of Non Perforated appendicitis begins from simple
appendicitis/hyperemia up to superlative. Leukocytes count
increases at superlative stage.
C - reactive protein is known abnormal if valued> 5 mg/L
which indicated an infection. In A group obtained the lowest value
is 5% ng/L and the highest is 192ng / L, with details;
10 patients (67%) value of CRP <5 ng/L, 5 patients (33%) CRP
Obstruction is the most common etiology of appendicitis,
which develop to the stage of necrosis perforation (peritonitis/
severe pain). Non-perforated condition is still at the stage of
luminal obstruction of the appendix.
According Raffensperger theory that leukocytosis is a
condition when the count of leucocytes is more than 11,000/dL.
4.4.1. The data obtained: 14 patients 93%) is more than
11,000/dL, 1 patient (7%) is less than 11,000/dL. Peritonitis
(perforation) is a condition of severe infection, but there was one
patient (simple) who had leucocytes count less than 11,000/dL
Based on Alvarado scores that neutrophil count is significant
if the count is more than 75%. Group B got 100% value is more
than 75% that indicating patients in acute condition and requires
C-reactive protein is significant if the value is greater than
5mg/L which indicated a severe infection. Group B showed
100% value greater than 5 mg/L. This is in accordance with the
pathogenesis, when the perforation means obstruction condition,
resulting necrosis (Table 3).
Data presented the differences of leukocytes count between
groups A and B clearly, from 30 patients were divided 15 patients
in each group. It refers to the correlation with the patoetiologi
appendicitis (Table 4).
Neutrophil is one of indicator for acute inflammatory process,
refer to the components of Alvarado Score. Neutrophils value of
significant acute infection when obtained more than 75% (Table
In group B, which showed peritonitis condition (which is a
severe infection of the abdominal cavity), wholly meaningful more
than 75%, with the highest count is 92% and the lowest is 81%. In
group A, which is a condition of the appendix lumen obstruction
and have not reached to perforation stage obtained in 12 patients
(%)> 75% and 3 patients (%) <75% (Table 6) (Figure 1-3).
Based on the research results those 30 patients appendsitis
divided into two groups: 15 patients in group A (non-perforated
appendicitis) and 15 patients in group B (perforated appendicitis).
It showed in a group A that 12 patients (80%) were male and 3
patient were female (0.20%), whereas in the group of B, there
were 7 male (47%) and 8 female (53%).
In group A, the number of male more than female, this is in
agreement with Cloud , Hartman  and Jablonski . However,
it was different condition in group B that the number of female
patient more than male.
Data based on aged group that the age group of >5 years old
more than <5 years old group, both in group A or group B. This is
consistent with Jablonski’s  research in the multi-ethnic race in
the United States.
Blood tests showed that in group A and B showed mixed
In group A: leukocytes with the lowest count is 8370/dL and
the highest is 13,900/dL, with an average is 10,776/dL.
In group B: leukocytes with the lowest count is 10,200/dL
and the highest is 34,100/dL, with a average is 21.380/dL.M
Group A (non-perforated) based on pathoetiology and
pathogenesis occurs only at the stage of appendicitis with the
appendix lumen obstruction to superlative phase, that means it is still at the phase of obstruction lumen if leukocytes count was
normal (11 patients (73%) with leukocyte count <11,000/dL) ,
others (4 patients (27%) are in the phase of superlative (not being
perforated) with leukocytes count >11,000/dL with a maximum
count of 13,000/dL. It is in line with what was described by
Group B (perforated) which is a condition has occurred
peritonitis infection of the abdominal cavity, the leucocytes count
was dominant obtained from 14 patients (93%)>11,000/dL and
only 1 patient (7%)<11,000/dL. It is also in accordance with what
is described by Raffensperger  and Kim et al.  that leukocytes
count more than 14,000/dL was found in appendicitis perforation,
while there was one patient (%) with a value of <11,000/dL is very
likely the patient has gained previous antibiotic therapy, although
granting antibiotic is not much affect the perforations and cannot
Group A : 10 patients <5mg/dL and 5 patients >5m/dL.
Group B: 1 patients <5mg/dL and 14 patients>5mg/dL.
Value possibility CRP count is more than 5ng/dL mean Reactive
which is a sign on the inflammatory response. Showed from the
data that the group B which is an acute and severe conditions a
CRP count was dominant >5ng/dL.
This is in agreement with a research by Kim & Shili  that
CRP has a value sufficiently high sensitivity, so that it can be used
as indicators of an inflammatory response (Table 7).
Leucocyte, neutrophils and CRP count based on statistics obtained
variable p<0.05, so as to show a significant Correlation in both