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Open Access 
F u l l  L e n g t h  A r t i c l e  

 Acute Appendicitis: Relationship of Total Leucocyte Count with 

Per-Operative Stage  
 

Muneeb-ullah1, Awais Saeed Abbasi2, SeemabNiaz3, Umair Ashfaq4 
1, 2 Registrar, Accident and Emergency Department, Dr. Akbar Niazi Teaching Hospital, Islamabad 

3 Post Graduate Trainee, PIMS Hospital, Islamabad 
4 Registrar, CMH Rawalpindi 

A B S T R A C T  

Objective: To correlate total leucocyte count(TLC) with per-operative stage of acute appendicitis. 

Patients and Methods: This cross sectional study was conducted in department of surgery, Pakistan Institute of 

Medical Sciences (PIMS) from June 2016 to June 2017. A total 77 patients were included through consecutive sampling 

technique. Statistical Package for Social Sciences (SPSS) version 20 was used to analyze data. 

Results: A total of 77 patients were included in the study, among them 47 (61%) were males, and 30(39%) were 

females. Mean age was 22.25 ± 5.19 years. Mean TLC was 12,900 ± 4087 cells/µL Patients having acute appendicitis 

were labeled as, acute appendicitis stage I which included 59 (76.6%) patients, Gangrenous appendicitis was named as 

stage II which included 11 (14.3%) patients. Perforated appendicitis was labeled as Stage III in which 7 (9.1%) patients 

were inducted. In stage I, mean age was 21.89 ± 5.50 years and mean TLC was 12,344 ± 4162 cells/µl. In stage II, 

mean age was 22.36 ± 3.90 years and mean of total leukocyte count was 15,072 ± 3497 cells/µl. In stage III, mean age 

was 25.57 ± 3.50 years and mean leukocyte count was 14,214 ± 4141cells/µl (p-value >0.05). 

Conclusion: Significant statistical association was not found in patients in different stages of appendicitis with respect to 

TLC (p value >0.05), although patients in all stages had raised mean TLC with mean TLC highest in patients having 

stage II (Gangrenous appendicitis). 

Key words: Acute appendicitis, Gangrenous appendicitis, Perforated appendicitis; Total leucocyte count. 

Author`s Contribution 
1
 Conception, synthesis, planning of research 

and manuscript writing Interpretation and 
discussion 
2 ,3 

Data analysis, interpretation and 
manuscript writing,  
4 

Active participation in data collection  

Address of Correspondence 
Muneeb-Ullah 
Email: muneebullah@gmaill.com 

Article info. 
Received:  October 7, 2017 
Accepted:  November 20, 2017 

Cite this article. Muneeb-ullah, Abbasi AS, Ashfaq U. Acute Appendicitis: Relationship of 
Total Leucocyte Count with Per-Operative Stage. JIMDC.2017;6(4): 

 

Funding Source: Nil 
Conflict of Interest: Nil 

I n t r o d u c t i o n  
 

Acute appendicitis is the most common surgical 

abdominal emergency in patients with abdominal pain, 

occurring in 10% of general population.1,2 Vermiform 

appendix can have a variable course, retrocecal being the 

most common.3 It is positioned near the ileocecal valve 

where the taenia coli converge on the cecum. Appendix is 

a true diverticulum of the cecum and it contains all layers 

of the colonic wall, i.e. mucosa, submucosa, muscularis 

and the serosa. This is in contrast to the acquired 

diverticular disease which only consists of protuberance 

of subset of the enteric wall layers.4 Incidence of 

appendicitis is approximately 233/100,000 population, 

being highest in the 10-19-year-old age group. It 

frequently occurs in the second and third decade of life. 

Male to female ratio is 1.4:1 and lifetime incidence is 8.6% 

in males as compared to 6.7% in females. The primary 

cause of appendicitis is proposed to be appendicular 

obstruction.5 Escherichia coli and streptococcus are the 

O R I G I N A L  A R T I C L E  



 

                           256 J I M D C   2 0 1 7  256 

common gram positive organisms to cause appendicitis.6,7 

Abdominal pain is reported as the most common 

symptom in almost all confirmed cases of appendicitis. 

Patients with acute appendicitis present with some of the 

classical symptoms as, anorexia, nausea, vomiting and 

right lower quadrant abdominal pain.8 Mc Burney’s point 

tenderness, rovsing’s sign, psoas sign and the obturator 

sign are some commonly described signs in acute 

appendicitis. Most of the patients with acute appendicitis 

have mild leukocytosis (white blood cell (WBC) count 

more than 10,000 cells/µL).9 Approximately 80% of the 

patients presenting with acute appendicitis have 

leukocytosis with left shift which is increased total 

leucocyte count (TLC), immature neutrophils (bands) and 

neutrophils.10 Sensitivity and specificity of TLC in acute 

appendicitis is 80% and 55% respectively. Except in very 

early course of disease, TLC is usually raised.11 Mean 

TLCs are higher in patients with gangrenous or perforated 

appendicitis. In Acute appendicitis level of TLC are found 

to be 15,500 ± 7300 cells/µL, in Gangrenous appendicitis 

levels are 17,100 ± 3900 cells/µL and in perforated 

appendicitis TLC count to be 17,900 ± 2100 cells/µL.12 

The main aim of this study was to find out the association 

of TLC with per-operative stage of acute appendicitis. It 

was also aimed to determine age group and gender 

distribution among patients with acute appendicitis. 

P a t i e n t s  a n d  M e t h o d s  

This cross sectional study was conducted in department of 

surgery, Pakistan Institute of Medical Sciences (PIMS) 

Hospital after approval from ethical review board. Duration 

of study was one year, from June 2016 to June 2017.Total 

77 patients presenting with signs and symptoms 

suggestive of acute appendicitis were included in this 

study13 through consecutive sampling technique. Patients 

having Alvarado score of 5-10 were included in the study. 

Patients on steroids, immunosuppressive medication, 

having serious co-morbid condition and pregnancy were 

excluded from the study. Total four milliliter of venous 

blood was drawn from all patients for estimation of TLC, 

before antibiotic administration. Complete blood count 

(CBC) was carried out on an automated 5-part differential 

Cell Dyn®3700 coulter counter from abbot Laboratories 

USA. Staging of acute appendicitis was based on surgical 

and pathological findings as follows: Stage 1: Acute 

appendicitis, Stage 2: Gangrenous appendicitis and Stage 

3: Perforated appendicitis.Statistical Package for Social 

Sciences (SPSS) version 20 was used to analyze and 

access data. Quantitative data was entered as mean±SD. 

Qualitative data was expressed as number and 

percentage. One-way ANOVA and chi-square test were 

applied to find out the association of different stages of 

appendicitis with TLC, gender and age.  

R e s u l t s  

Total 77 patients were included in the study. Among them 

61% were males and 39% were females with male to 

female ratio of 1.5:1. Age range of participants in study 

was from 14 years to 34 years with mean age of 22+ 5.22 

years (Table 1).  

 

Table 1: Age and gender distribution of 
participants (n=77) 

Characteristics Results 

Age (in years) 

Range (Mean±SD) 14-34 (22±5.22) 

Gender; n(%) 

Male           47(61) 

Female       30(39) 

Stage of Appendicitis; n(%) 

Stage 1      59 (76.6) 

Stage 2      11(14.3) 

Stage 3      07 (9.1) 
 

Total Leukocyte count ranged between 4900-26100/µl 

with mean of 12900+4087/µl. Association of different 

stages of appendicitis with TLC count was non-significant. 

Maximum TLC levels was found in stage II (Table 2).  

 

Table 2: Association of different stages of 
appendicitis with TLC (n=77) 

Stages of 

Appendicitis 

TLC (cells/µl) 
(Mean ± SD) 

p-value 

Stage I (n=59) 12,344 ± 4162  

0.09 Stage II  (n=11) 15,073 ± 3497 

Stage III  (n=07) 14214 ± 3963 

 



 

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Association of stages of appendicitis with age and gender 

was also found to be non-significant. Out of 77 patients, 

maximum number of patients (both male and female) had 

stage I appendicitis. Mean age (third decade) was almost 

same in all three stages of appendicitis (Table 3). 

 

Table 3: Association of different stages of 
appendicitis with gender and age (n=77) 
Stages of 
appendicitis 

Gender p-

value 

Age 

Mean±SD 

p-

value Male 
n(%) 

Female 
n(%) 

Stage I 

(n=59) 

40(52) 19(25)  

0.069 

22 ±5.29  

0.864 

Stage II 

(n=11) 

5(6) 6(8) 22 ±4.24 

Stage III 

(n=7) 

2(3) 5(6) 21± 6.60 

 

D i s c u s s i o n  

Patient in our study were selected on the basis of 

Alvarado score which is a 10-point clinical scoring system, 

also known by the acronym MANTRELS. In this scoring 

system, migration of pain, anorexia, nausea, rebound 

pain, elevated temperature and shift of white blood cells 

to the left are given 1 point each, while tenderness in right 

lower quadrant and leukocytosis are given 2 points each. 

This score enables risk stratification, linking the probability 

of appendicitis to recommendations regarding discharge, 

observation or surgical intervention.13 

In present study a male predominance was noted among 

patients presenting with acute appendicitis; 61% males 

versus 39% females having male to female ratio of 1.5:1. 

In a study conducted in Saudi Arabia 67% patients were 

male and 33% were females having male to female ratio 

of 2:1.14 Male to female ratio was 1.4:1 in another study.4 

In one study conducted in Islamabad, 52.2% patients 

were male while 47.8% patients were females with male 

to female ratio of 1.1:1.15 Mean age was 22± 5.22 years in 

current study. In a similar study conducted in Islamabad 

mean age was 28.7 ± 11.9 years.15 In another study 

mean age was 26 ±12 years.16 Incidence of acute 

appendicitis has been reported highest in the 10-19-year-

old age group and it frequently occurs in the second and 

third decade of life.4 Current study clearly indicates 

highest frequency of acute appendicitis in third decade of 

life while it was noted to be highest in second decade of 

life in United States. 

In present study, mean TLC was 12,900 ± 4087 cells/µl in 

overall study group. In Stage I mean TLC was 12,344 ± 

4162 cells/µL; in Stage II mean TLC was 15,073 ± 3497 

cells/µL and in Stage III mean TLC was 14,214 ± 3963 

cells/µL. In one study, it was noted that mean TLCs are 

higher in patients with gangrenous or perforated 

appendix. Acute appendicitis (stage I): 15,500 ± 7300 

cells/µL, Gangrenous appendicitis (Stage II): 17,100 ± 

3900 cells/µL and perforated appendicitis (Stage III): 

17,900 ± 2100 cells/µL.12 Our study in comparison to 

above study is somewhat different as our study shows 

that mean TLC is highest in gangrenous appendicitis 

followed by perforated and acute appendicitis. 

C o n c l u s i o n  

Significant association was not noted in patients with 

different stages of appendicitis with respect to TLC, age 

and gender.  Although patients in stage II (Gangrenous 

appendicitis had highest mean TLC but it was not 

statistically significant. 

A c k n o w l e d g e m e n t  

Prof. Dr. Tanwir Khaliq, Dr. Tariq Abdullah, Dr. Azmat Ali. 

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