SciELO - Scientific Electronic Library Online

 
vol.117 issue6Effects of contamination and climate in the Pediatric Emergency Department visits for acuterespiratory infection in the City of Buenos AiresPrognostic factors of severity of invasive community-acquired Staphylococcus aureus infections in children author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

  • Have no cited articlesCited by SciELO

Related links

  • Have no similar articlesSimilars in SciELO

Share


Archivos argentinos de pediatría

Print version ISSN 0325-0075On-line version ISSN 1668-3501

Arch. argent. pediatr. vol.117 no.6 Buenos Aires Dec. 2019  Epub Dec 01, 2019

http://dx.doi.org/10.5546/aap.2019.375 

Original articles

Role of mean platelet volume-to-lymphocyte ratio in the diagnosis of childhood appendicitis

Gulcin Bozlua 

Asuman Akarb 

Fatma Duraka 

Necdet Kuyucub 

aDepartment of Pediatrics

bDivison of Pediatric Infectious Diseases. University of Mersin Faculty of Medicine, Mersin Turkey

ABSTRACT

Introduction

Mean plate let volume-to-lymphocyte ratio (MPVLR) has emergedas a novel parameter of inflammation andthrombosis. The aim was to evaluate whether MPVLR has a role in the diagnosis of childhoodappendicitis.

Population and methods

Retrospectively reviewed the medical records up to 18 yearwith suspected acute appendicitis (AA) who underwent appendectomy between January 2016 and December 2017. Based onhistopathological evaluation, the patients wereclassified into normal appendix, and simpleand perforated appendicitis. Preoperative meanplatelet volume (MPV), platelet distributionwidth (PDW), MPVLR, platelet-to-lymphocyteratio (PLR), counts of platelets and white bloodcells (WBC), and C-reactive protein (CRP) levelswere measured.

Results

A total of 219 children with clinically suspected AA who underwent surgical treatmentfor appendicitis were reviewed, and 100 gender-age matched healthy subjects were included. Compared with the controls, the mean levels of MPVLR, PLR, WBC and CRP were significantlyhigher in the children underwent appendectomy (p <0.001). These values were significantly higherin simple appendicitis than in normal appendices (p<0.01). Compared with simple appendicitis, these levels were significantly higher in thechildren with perforated appendicitis (p <0.001). The area under curves for MPVLR and PLR were 0.771 and 0.726 in the prediction of appendicitis and 0.693 and 0.722 in the prediction ofperforation, respectively.

Conclusions

Increased level of MPVLR may be valuable for aiding the diagnosis of pediatric AA. In addition, it can help discriminatesimple and perforated appendicitis in children.

Key words Acute appendicitis; Child; Diagnosis; Meanplatelet volume to/lymphocyte ratio

INTRODUCTION

Acute appendicitis (AA) is the most common reason forurgent abdominal operation andapproximately 20-30 % of childrenwith acute abdominal pain admittedto pediatric emergency departmenthave AA.1 A delay in diagnosis of AA may result in life-threateningcomplications such as perforationand peritonitis. In children, thiscondition often presents late or withatypical features. Therefore, carefuldiagnosis and prompt management ofpediatric appendicitis is imperative.2 Although several laboratory tests andimaging investigations have beenused for fast and accurate diagnosis, they had limitations to differentiateappendicitis from other causes ofabdominal pain.3

Recently, there has been growing interest in simple hematologicalparameters, such as mean plateletvolume (MPV) and platelet-to-lymphocyte ratio (PLR), which arethought to be useful markers of theseverity of the systemic inflammatoryresponse. Mean platelet volume-to-lymphocyte ratio (MPVLR) is aparameter calculated and providedby automatic blood count equipmentduring routine blood counts. Hudzik et al.4 demonstrated that MPVLR has emerged as a noveland readily available marker ofinflammation and trombosis inadults. In addition, recent studieshave been reported that MPVLR level has clinical implications invarious pathologies such as systemicinflammation, myocardial infarctionand impaired coronary collateralcirculation.5,6 On the other hand, no study has evaluated the role of MPVLR in children and the diagnosticvalue of MPVLR in children with AA.

In the present study, we aimed to evaluate the role of MPVLR in the diagnosis of childhoodappendicitis.

POPULATION AND METHODS

This study was conducted after obtaining an approval from Mersin University Clinical Research Ethics Committee (the protocol numberthat was attributed by the ethics committee was:32/2018 and the date of approval was January 18,2018). We retrospectively reviewed the medicalrecords of the children aged 18 year or youngerwith clinically suspected AA who underwentappendectomy at our institution between January2016 and December 2017. Gender-age matchedhealthy subjects, who had been admitted topediatric clinic and did not have any disease, were taken as a control group (we have a healthyoutpatients clinic in our Pediatrics Department. Periodically, healthy children are given controltests such as hemogram and urine tests). Childrenwith incomplete medical records, with knownhematological diseases (platelet or coagulationabnormalities), allergic diseases, malignant andinflammatory diseases and receiving drugs thatcan impact the hematological parameters wereexcluded from the study.

Patient characteristics and preoperative laboratory parameters including MPV, plateletdistribution width (PDW), and counts of plateletsand white blood cells (WBC), and C-reactiveprotein (CRP) levels were measured. The MPVLR and PLR were calculated by dividing MPV and platelet count by the lymphocytecount respectively. Based on postoperativehistopathological evaluation, the patientswere classified into normal appendix, simpleappendicitis and perforated appendicitis. Thelevels of preoperative laboratory parameters werecompared.

Statistical analyses: The sample size was calculated with Med Calc 18.9 software (numberof cases in patient group was 187 children, and number of cases in control group was94 children for 95 % CI). All continuous variablesare expressed as mean ± standard deviation. Data of patients and healthy controls werecompared. Preoperative laboratory parameters ofthe patients who underwent appendectomy werealso compared with regard to histopathologicalevaluation. The t test, analysis of variance andreceiver operating characteristic (ROC) curvewere used for statistical analysis. Multiplecomparisons were made using one-way ANOVA with post-hoc Tukey's test. The ROC curveswere used to examine the diagnostic value of MPVLR and PLR in suspected AA group. Thearea under curves (AUC) were calculated forthese parameters. The appropriate cutoff valuesof MPVLR and PLR were determined usingmaximum sum of sensitivity and specificity. Sensitivity, specificity, positive predictivevalue (PPV), negative predictive value (NPV) and overall accuracy rates were calculated. Multivariate logistic regression models were usedto identify predictors of appendix perforation inchildren with AA. The results were consideredstatistical significance if p values were lessthan 0.05.

RESULTS

After exclusion, a total of 219 children who undrewent appendectomy and 100 sex-agematched healthy subjects, who had been admittedto pediatric clinic and did not have any disease, were included. The characteristics of the patientsand controls are presented in Table 1. Therewas no significant difference in age, gender, platelet counts, MPV and PDW between thepatients and controls (p>0.05). Compared with healthy controls, a significant increase in MPVLR, PLR, WBC and CRP was noted in children whounderwent appendectomy (p < 0.001, Table 1).

Table 1 Comparison of characteristic of patients and controls 

The pathological diagnoses were normal appendices in 46 (21 %), simple appendicitisin 141 (64.3 %) and perforated in 32 (14.6 %) children. The parameters for patients with normalappendices, simple appendicitis and perforatedappendicitis were displayed in Table 2. MPVLR, PLR, WBC and CRP levels were significantlyhigher in simple appendicitis than in the childrenwith normal appendices (p < 0.01). Comparedwith simple appendicitis, MPVLR, PLR, WBC and CRP levels were significantly higher in thechildren with perforated appendicitis (Table 2, p < 0.001).

Table 2 Comparison of blood parameters among patients with normal appendices, simple appendicitis and perforated appendicitis

The AUCs for MPVLR and PLR were 0.771 and 0.726 in the prediction of appendicitis (Figure 1) and 0.693 and 0.722 in the predictionof perforation (Figure 2), respectively. Thesensitivity, specificity, PPV, NPV and accuracyvalues were detailed in Table 3. In the multivariateanalysis discriminating perforated from nonperforated appendicitis, MPVLR was significantparameter for predicting appendiceal perforation (Table 4).

Figure 1 Receiver operating characteristic curves for MPVLR and PLR in predicting acute appendicitis 

Figure 2 Receiver operating characteristic curves for MPVLR and PLR in predicting perforated appendicitis 

Table 3 Sensitivity, specificity, PPV and NPV rates for MPVLR and PLR for predicting acute appendicitis and perforated appendicitis 

Table 4 Multivariate analysis with parameters for predicting appendix perforation 

DISCUSSION

To our knowledge, diagnostic value of MPVLR in children with AA has not been studied before. This study showed that children who underwentappendectomy had significantly higher levels of MPVLR, PLR, WBC and CRP than the control subjects. The results of our study also indicatedthat the levels of MPVLR, PLR, WBC and CRP inchildren with simple and perforated appendicitiswere significantly increased than did those withnormal appendix. Furthermore, it was shownthat those parameters were significantly higher inchildren with perforated appendicitis comparedto the children without.

Although its classical signs and symptoms are well known, the clinical diagnosis of AA is still problematic in children.1,2 A delay indiagnosis is associated with perforation andincreased complication rate. On the otherhand, misdiagnosis appendicitis may lead tounnecessary surgery.7 In clinical practice, historyand clinical examination remain the cornerstoneof diagnosis, but, several studies have beenfocused on the diagnostic value of laboratorymarkers in acute appendicitis.3,8,9

MPV is a marker of platelet function and activation, can be easily measured in routinecomplete blood count test cycle. It has beendemonstrated that MPV is a laboratory markerof inflammatory conditions.10 Firstly, Labara et al.,11 found that a statistically significant decreasein MPV was noted in adult patients with AA compared with healthy controls. They suggestedthat MPV may guide the management of patientssuspected to have AA. The mechanism fordecreased MPV in inflammatory diseases remainsunclear. It may be the presence of a defect in theregulation of thrombopoiesis in inflammatoryconditions.10,12 On the other hand, limited numberof studies reported the role of MPV in diagnosis of AA in children. They have reported contradictoryresults. Bilici et al.,13 indicated that MPV wassignificantly lower in pediatric AA patientscompared to the control. Contrarily, Uyanik et al.,14 detected that MPV has no diagnostic value inpediatric AA cases. However, we found that therewas no significant difference between AA casesand control subjects with respect to MPV levels. It has been suggested that clinical utility of MPV to discriminate AA from other acute abdomenhave to be analyzed separately among genders.15 In our study, there was no significant difference ingender between the patients and controls.

Blood MPVLR levels were calculated by dividing the MPV value by the lymphocytecount. MPVLR has emerged as a novel laboratorytest of inflammation and trombosis. There hasbeen relatively little research on the usefulnessof MPVLR. Hudzik et al.,4 investigated theprognostic significance of MPVLR in diabeticpatients with in ST elevation myocardialinfarction. They concluded that MPVLR plays apivotal role in developing intravascular thrombusin ST elevation myocardial infarction and elevated MPVLR is an independent risk factor of mortalityin patients with acute myocardial infarction. Increased levels of MPVLR are associated withangiographic no-reflow and impaired coronarycollateral circulation.5,6 More recently, it hasbeen reported that MPVLR may be helpful inpredicting coronary artery lesions in patients with Kawasaki disease.16

The role of MPVLR has not been defined in pediatric AA and the findings from the studiesmentioned above led us to evaluate whether MPVLR may have a value in children with AA. We found a significantly higher MPVLR levelin children with AA compared to control. Ourresults also showed that the mean MPVLR levelof perforated AA was significantly higher thanchildren with non-perforated AA. It has beenreported that ROC analysis revealed moderatediagnostic value of MPVLR in prediction ofhospital death in diabetic patients with in ST elevation myocardial infarction in patients.4 In ourstudy, ROC curve analysis revealed that AUCs for MPVLR were 0.771 and 0.693 in the prediction ofacute appendicitis and perforation of appendicitisrespectively.

Platelets are cells that help in modulating various inflammatory conditions; therefore, changes in PLR may be a prognostic indicatorof acute infection, cardiovascular events andcancer.17,18 There are only a few studies examiningthe relationship between PLR and AA. Nazik et al.,19 found a significantly higher PLR level inpediatric patients with AA compared with inhealthy controls. In the pregnant women, the levelof PLR was significantly higher in appendectomygroup compared with healthy control group.20 In the current study, PLR value in children with AA was statistically significantly higher thanin control subjects, which was in accordancewith results reported in the previous studies. Moreover, we also found that pediatric perforatedappendicitis group had a significantly higher PLR than simple appendicitis group. In thisstudy, AUCs for PLR were 0.726 and 0.722 in theprediction of acute appendicitis and perforationof appendicitis respectively.

There were limitations to our study. It was a retrospective study and our findings may needto be confirmed in prospective studies. However, we were unable to analyze the correct diagnosesof the patients with normal appendix. Samplesize analyses may be more appropriate to havechildren with confirmed appendicitis versuschildren with normal appendices or differentseverity of appendicitis. On the other hand, ourstudy has several strengths as well. Ultrasoundimaging is essential for the differential diagnosisof children with AA and all of the childrenhad ultrasonographic evaluation. Despite thelimitations, we present the first study to examinethe value of MPVLR in pediatric AA. The greatestadvantage with using MPVLR and PLR is theirlow cost of evaluation.

CONCLUSIONS

In conclusion, this is the first study that has been focused on the role of MPVLR in childrenwith AA. We demonstrated that increased level of MPVLR may be valuable for aiding the diagnosisof pediatric AA. Moreover, MPVLR may serveto aid in discriminating between simple andperforated appendicitis in children.

Acknowledgements

We would like to acknowledge Prof. Dr. Ali Nayci (Head of Pediatric Surgery Department) who helped in data collection.

REFERENCES

1. Rentea RM, Peter SD, Snyder CL. Pediatric appendicitis: state of the art review. Pediatr Surg Int. 2017;33(3):269-83. [ Links ]

2. Rothrock SG, Pagane J. Acute appendicitis in children: emergency department diagnosis and management. Ann Emerg Med. 2000;36(1):39-51. [ Links ]

3. Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic accuracyof history, physical examination, laboratory tests, and point-of-care ultrasound for pediatric acute appendicitis in theemergency department: a systematic review and meta analysis. Acad Emerg Med. 2017;24(5):523-51. [ Links ]

4. Hudzik B, Szkodzinski J, Lekston A, Gierlotka M, et al. Mean platelet volume-to-lymphocyte ratio: a novel markerof poor short- and long-term prognosis in patients withdiabetes mellitus and acute myocardial infarction. J Diabetes Complications. 2016;30(6):1097-102. [ Links ]

5. Kurtul A, Acikgoz SK. Usefulness of mean platelet volume-to-lymphocyte ratio for predicting angiographic no-reflowand short-term prognosis after primary percutaneouscoronary intervention in patients with st-segment elevationmyocardial infarction. Am J Cardiol. 2017;120(4):534-41. [ Links ]

6. Ornek E, Kurtul A. Relationship of mean platelet volumeto lymphocyte ratio and coronary collateral circulation inpatients with stable angina pectoris. Coron Artery Dis. 2017;28(6):492-7. [ Links ]

7. Dubrovsky G, Rouch J, Huynh N, Friedlander S, et al. Clinical and socioeconomic factors associated with negativepediatric appendicitis. J Surg Res. 2017;218:322-8. [ Links ]

8. Shogilev DJ, Duus N, Odom SR, Shapiro NI. Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. West J Emerg Med. 2014;15(7):859-71. [ Links ]

9. Saucier A, Huang EY, Emeremni CA, Pershad J. Prospective evaluation of a clinical pathway for suspected appendicitis. Pediatrics. 2014;133(1):e88-95. [ Links ]

10. Gasparyan AY, Ayvazyan L, Mikhailidis DP, Kitas GD. Mean platelet volume: a link between thrombosis and inflammation? Curr Pharm Des. 2011;17(1):47-58. [ Links ]

11 Albayrak Y, Albayrak A, Albayrak F, Yildirim Ret al. Mean platelet volume: a new predictor in confirming acute appendicitis diagnosis. Clin Appl Thromb Hemost. 2011;17(4):362-6. [ Links ]

12. Liu R, Gao F, Huo J, Yi Q. Study on the relationship between mean platelet volume and platelet distribution width with coronary artery lesion in children with Kawasaki disease. Platelets. 2012;23(1):11-6. [ Links ]

13. Bilici S, Sekmenli T, Goksu M, Melek M, Avci V. Mean platelet volume in diagnosis of acute appendicitis in children. Afr Health Sci. 2011;11(3):427-32. [ Links ]

14. Uyanik B, Kavalci C, Arslan ED, Yılmaz F, et al. Role ofmean platelet volume in diagnosis of childhood acute appendicitis. Emerg Medlnt. 2012; 2012:823095. [ Links ]

15. Yang JJ, Cho SY, Ahn HJ, Lee HJ, et al. Mean platelet volume in acute appendicitis: a gender difference. Platelets. 2014;25(3):226-7. [ Links ]

16. Bozlu G, Karpuz D, Hallioğlu O, Unal S, Kuyucu N. Relationship between mean platelet volume-to-lymphocyteratio and coronary artery abnormalities in Kawasaki disease. Cardiol Young. 2018;28(6):832-6. [ Links ]

17. Kawamura Y, Takeshita S, Kanai T, Yoshida Y, Nonoyama S. The combined usefulness of the neutrophil-to-lymphocyteand platelet-to-lymphocyte ratios in predicting intravenous immunoglobulin resistance with Kawasaki disease. J Pediatr. 2016;178:281-4.e1. [ Links ]

18. Yodying H, Matsuda A, Miyashita M, Matsumoto S, et al. Prognostic significance of neutrophil-to-lymphocyte ratioand platelet-to-lymphocyte ratio in oncologic outcomesof esophageal cancer: a systematic review and meta analysis. Ann Surg Oncol. 2016;23(2):646-54. [ Links ]

19. Nazik S, Avci V, Kusku Kiraz Z. Ischemia-modified albuminand other inflammatory markers in the diagnosis of appendicitis in children. Ulus Travma Acil Cerrahi Derg. 2017;23(4):317-21. [ Links ]

20. Yazar FM, Bakacak M, Emre A, Urfalioğlu A, et al. Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci. 2017;31(11):591-6. [ Links ]

Received: September 12, 2018; Accepted: May 30, 2019

Conflict of interest

None.

Creative Commons License Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons