DOI: https://doi.org/10.53350/pjmhs20221612696 ORIGINAL ARTICLE 696 P J M H S Vol. 16, No. 12, December, 2022 Accuracy of C-Reactive Protein Level in the Diagnosis of Acute Appendicitis on Histopathology ASAD ULLAH KHAN 1 , MAAZ REHMAN 2 , MUHAMMAD ISHFAQ 3 , HABIBULLAH YOUSAFZAI 4 , KUNWAR WAJAHAT 5 , AHMAD ARSALAN TAHIR 6 1 Senior Registrar, Department of Surgery, Kuwait Teaching Hospital, Peshawar. 2 Medical Officer, General Surgery, Khyber Teaching Hospital, Peshawar, Pakistan 3 Senior Registrar, Department of Surgery, Kuwait Teaching Hospital, Peshawar. 4 Trainee medical officer, Department of Surgery, Kuwait Teaching Hospital, Peshawar. 5 House officer, Department of Surgery, Kuwait Teaching Hospital, Peshawar. 6 Assistant Professor, Department of Surgery, Kuwait Teaching Hospital, Peshawar. Corresponding author: Ahmad Arsalan Tahir, Email: drarsalantahir@gmail.com ABSTRACT Background: Acute appendicitis (AA) is one among most common condition requiring emergency surgery throughout the world. Acute appendicitis most common diagnosis in patients seeking medical help in emergency room due to acute abdomen causing 72,000 deaths among 16 million cases reported globally. This study will help the surgeons in making timely decisions, thus reducing the morbidity and mortality associated with complicated appendicitis. The aim of this study was to accuracy of C - reactive protein (CRP) levels in acute appendicitis. Material and Methods: Six-month descriptive cross-sectional research from 16 February to 16 August 2019 was completed. The Khyber Teaching Hospital in Peshawar served as the study's location. A total of 216 patients were monitored throughout this investigation. The history, clinical examination, and regular laboratory tests, such as the total leucocyte count (TLC) and differential leucocyte count (DLC) on admission, were used to make the diagnosis of acute appendicitis. All of these patients were given Nil by Mouth to prepare them for emergency surgery, and baseline testing included HBs Ag and Anti-HCV serology as well as pre-operative serum CRP levels (Liver function tests, renal function tests and serum electrolytes). Following preparation, every patient on the emergency list had surgery. Intra-operative results were recorded, and a biopsy was collected from the excised appendices and forward to histopathology for further processing. Results: The mean age in this research was 48 years, with an SD of 12.311. Male patients made up 55% of the total population, while female patients made up 45%. The diagnostic accuracy of C-reactive protein levels was determined to be 84.2% in this study. The specificity was found to be 33.3%, while the sensitivity was observed to be 85.7%. By using histopathology, it was discovered that the positive predictive value was 97.2% and the negative predictive value was 84.2%. Conclusion: According to our study, using histopathology, the diagnostic accuracy of C-reactive protein levels was 84.25% with sensitivity of 85.71%, specificity of 33.33%, and positive predictive values of 97.25% and 184.25%. The findings will also open the door for any further research in this area. . The higher CRP levels will therefore predict the complexity of acute appendicitis and help the general practitioners to do early referrals therefore avoiding life threatening complications Keywords: Acute Appendicitis, C-Reactive Protein, Histopathology, CRP, Gold Standard INTRODUCTION Acute Appendicitis is one among the frequent cause of acute abdominal pain necessitating emergency surgery both worldwide and in our country 1,2 . Most common surgical condition requiring emergency surgery worldwide 1 . According to Global burden of disease 2013, Acute Appendicitis is the most common diagnosis in patients seeking medical help in emergency room due to acute abdomen causing 72,000 deaths among 16 million cases reported globally 2,3 . The life time risk of AA is 16.33% for males and 16.34% for females in South Korea 4 . In Pakistan, about 400,000 appendectomies are routinely carried out in surgical departments each year. 5 Despite significant improvements in diagnostic techniques, nearly 30–40% of patients still require the surgeon's clinical judgment 3 . This increases the percentage of unsuccessful appendectomies to about 20%, which entails both mortality and morbidity risks 4, 6 . One of the key contributing elements in diagnostic mistakes is atypical clinical presentations, which are rather common since many inflammatory and non-inflammatory conditions resemble the clinical picture of the disease. Women in the reproductive age range and patients at the age extremes commonly make these diagnostic errors. The most difficult clinical scenario is caused by the variability in organ anatomical placements 5, 7 . The patient's medical history, physical examination, and a few supplementary tests, notably the Total Leukocyte Count, play a significant role in the diagnosis of acute appendicitis (TLC). In order to improve diagnostic accuracy, scoring systems like the Alvarado, Ohmann, and Eskelinen scores have been developed 7 . In addition, abdominal computerised tomography (CT scan) and ultrasonography (USG) are employed to aid in disease diagnosis; nevertheless, each has its own inherent drawbacks. The TLC test is frequently used to identify acute appendicitis. Though it is difficult to find a sensitivity and specificity of TLC greater than 83% and 62.1%, respectively, when searching the literature 8 . Other inflammatory indicators that may be useful in the diagnosis of acute appendicitis have recently attracted more attention. Hepatocytes produce the acute phase protein C-reactive protein (CRP), which is a marker for acute inflammation 9 . Within 4 to 6 hours of stimulation, its blood levels begin to rise, peaking 36 to 48 hours later. Many writers have emphasised the CRP's accuracy in the diagnosis of acute appendicitis, despite the fact that it is a non- specific test 9 . Their research has shown that in persons with symptoms of the condition for more than 24 hours, a normal level of CRP has a negative predictive value for acute appendicitis of about 100% 10,11 . CRP testing is a fairly easy and non-invasive laboratory procedure. There are no health risks to the patient from it. It is independent of the operator. The clinician has access to the test findings in one hour. The whole price is one hundred Pakistani rupees. For patients in our setting, it is quite advantageous and cheap due to all these features taken together. Most patients appear in complicated states as a result of challenging diagnoses, inadequate healthcare infrastructure, and low knowledge in our nation. CRP is a low-cost and practical test that is routinely applied to patients in emergency rooms who are feverish or infected. It has been widely employed as a prognostic or severity indication in many acute and chronic disorders, as well as several cancers. It has also been used as a biomarker for therapy monitoring 10, 11, 12 . According to Kim et al., the serum CRP level was one of the important variables that could reliably differentiate between difficult and non-complicated appendicitis 11 . CRP has a good predictive accuracy for difficult appendicitis diagnosis, 12 . In a retrospective study various blood indicators was looked at, including CRP, and concluded that CRP may have a role in