{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T05:44:41Z","timestamp":1788327881227,"version":"build-2803163510"},"reference-count":45,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2022,12,22]],"date-time":"2022-12-22T00:00:00Z","timestamp":1671667200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objecitves: Appendicitis is one of the most frequent surgical emergencies in pediatric surgery. Complicated appendicitis can evolve with appendicular peritonitis characterized by the diffusion of the pathological process to the peritoneal cavity, thus producing generalized or localized inflammation of the peritoneum. The capacity to anticipate the possibility of perforation in acute appendicitis can direct prompt management and lower morbidity. There is no specific symptom that could be used to anticipate complicated appendicitis, and diagnostic clues include a longer period of symptoms, diffuse peritoneal signs, high fever, elevated leukocytosis and CRP, hyponatremia, and high ESR. Imagistic methods, particularly US and CT, are useful but not sufficient. There are no traditional inflammation biomarkers able to predict the evolution of uncomplicated to complicated appendicitis alone, but the predictive capacity of novel biomarkers is being investigated. Materials and Methods: The present study represents a retrospective evaluation of children hospitalized between January 2021 and July 2022 in the Grigore Alexandrescu Clinical Emergency Hospital for Children with a diagnosis of acute appendicitis settled based on clinical characteristics, traditional and novel biomarkers, and ultrasonographic features. The children were subsequently grouped into two groups based on the existence of appendicular peritonitis on intraoperative inspection of the abdominal cavity. The aim of this report is to establish the predictors that may aid physicians in timely identifying pediatric patients diagnosed with acute appendicitis at risk for developing complicated appendicitis with evolution to appendicular peritonitis. Results: The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte radio (PLR) are representative severity markers in infections. This report analyzes the benefit of these markers for distinguishing uncomplicated appendicitis from complicated appendicitis in pediatric patients. Conclusions: Our study suggests that a value of neutrophil-to-lymphocyte ratio greater than 8.39 is a reliable parameter to predict the evolution to appendicular peritonitis.<\/jats:p>","DOI":"10.3390\/medicina59010021","type":"journal-article","created":{"date-parts":[[2022,12,23]],"date-time":"2022-12-23T02:09:03Z","timestamp":1671761343000},"page":"21","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["Predictors of Complicated Appendicitis with Evolution to Appendicular Peritonitis in Pediatric Patients"],"prefix":"10.3390","volume":"59","author":[{"given":"Laura","family":"B\u0103l\u0103nescu","sequence":"first","affiliation":[{"name":"Pediatric Surgery Department, \u201cGrigore Alexandrescu\u201d Clinical Emergency Hospital for Children, 011743 Bucharest, Romania"},{"name":"Pediatric Surgery Department, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 020022 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandru Emil","family":"B\u0103etu","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia and Intensive Care, \u201cGrigore Alexandrescu\u201d Clinical Emergency Hospital for Children, 011743 Bucharest, Romania"},{"name":"Department of Anaesthesia and Intensive Care, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 020022 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ancu\u021ba Mihaela","family":"Cardoneanu","sequence":"additional","affiliation":[{"name":"Pediatric Surgery Department, \u201cGrigore Alexandrescu\u201d Clinical Emergency Hospital for Children, 011743 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreea Alecsandra","family":"Moga","sequence":"additional","affiliation":[{"name":"Pediatric Surgery Department, \u201cGrigore Alexandrescu\u201d Clinical Emergency Hospital for Children, 011743 Bucharest, Romania"},{"name":"Pediatric Surgery Department, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 020022 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Radu Ninel","family":"B\u0103l\u0103nescu","sequence":"additional","affiliation":[{"name":"Pediatric Surgery Department, \u201cGrigore Alexandrescu\u201d Clinical Emergency Hospital for Children, 011743 Bucharest, Romania"},{"name":"Pediatric Surgery Department, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 020022 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,12,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1278","DOI":"10.1016\/S0140-6736(15)00275-5","article-title":"Acute appendicitis: Modern understanding of pathogenesis, diagnosis, and management","volume":"386","author":"Bhangu","year":"2015","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"19","DOI":"10.46831\/jpas.v2i1.131","article-title":"The predictive value of neutrophil-to-lymphocyte ratio to diagnose acute appendicitis and grade its severity","volume":"2","author":"Afzal","year":"2022","journal-title":"J. Pediatr. Adolesc. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Feng, W., Zhao, X.-F., Li, M.-M., and Cui, H.-L. (2020). A clinical prediction model for complicated appendicitis in children younger than five years of age. BMC Pediatr., 20.","DOI":"10.1186\/s12887-020-02286-4"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1","DOI":"10.23937\/2469-584X\/1510042","article-title":"Acute Appendicitis in Pediatric Patients: An Updated Narrative Review","volume":"3","author":"Podany","year":"2017","journal-title":"J. Clin. Gastroenterol. Treat."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"962","DOI":"10.1097\/SLA.0000000000003059","article-title":"Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children","volume":"271","author":"Cameron","year":"2020","journal-title":"Ann. Surg."},{"key":"ref_6","first-page":"e28619","article-title":"Predicting the Severity of Acute Appendicitis in Children Using Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR)","volume":"14","author":"Ayeni","year":"2022","journal-title":"Cureus"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"15","DOI":"10.30654\/MJS.10015","article-title":"Serum Laboratory Biomarkers to Estimate the Probability of Complicated Appendicitis: CRP and LDH","volume":"5","author":"Virani","year":"2022","journal-title":"Mathews J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"znab312.079","DOI":"10.1093\/bjs\/znab312.079","article-title":"Nuetrophil-To-Lymphocyte Ratio (NLR) as a Predictor of Acute Appendicitis","volume":"108","author":"Tasleem","year":"2021","journal-title":"Br. J. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1016\/j.amjsurg.2019.04.018","article-title":"Neutrophil-to-lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis","volume":"219","author":"Hajibandeh","year":"2019","journal-title":"Am. J. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1","DOI":"10.4103\/ajps.AJPS_47_16","article-title":"Role of laboratory markers in predicting severity of acute appendicitis","volume":"15","author":"Virmani","year":"2018","journal-title":"Afr. J. Paediatr. Surg."},{"key":"ref_11","first-page":"7097","article-title":"Neutrophil-to-lymphocyte ratio for the diagnosis of pediatric acute appendicitis: A systematic review and me-ta-analysis","volume":"25","author":"Eun","year":"2021","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Daldal, E., and Dagmura, H. (2020). The Correlation between Complete Blood Count Parameters and Appendix Diameter for the Diagnosis of Acute Appendicitis. Healthcare, 8.","DOI":"10.3390\/healthcare8010039"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"4608053","DOI":"10.1155\/2019\/4608053","article-title":"Laboratory Markers in the Prediction of Acute Perforated Appendicitis in Children","volume":"2019","author":"Yang","year":"2019","journal-title":"Emerg. Med. Int."},{"key":"ref_14","first-page":"135","article-title":"Perforation risk in pediatric appendicitis: Assessment and management","volume":"9","author":"Howell","year":"2018","journal-title":"Pediatr. Heal. Med. Ther."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Khanafer, I., Martin, D.-A., Mitra, T.P., Eccles, R., Brindle, M.E., Nettel-Aguirre, A., and Thompson, G.C. (2016). Test characteristics of common appendicitis scores with and without laboratory investigations: A prospective observational study. BMC Pediatr., 16.","DOI":"10.1186\/s12887-016-0687-6"},{"key":"ref_16","first-page":"76","article-title":"Predictive Value of Neutrophil\/Lymphocyte Ratios in the Diagnosis of Acute Appendicitis","volume":"16","author":"Akyuz","year":"2020","journal-title":"Med. J. Bakirkoy"},{"key":"ref_17","first-page":"e29177","article-title":"Single-Center Retrospective Analysis of Neutrophil, Monocyte, and Platelet to Lymphocyte Ratios as Predictors of Complicated Appendicitis","volume":"14","author":"Halaseh","year":"2022","journal-title":"Cureus"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"103266","DOI":"10.1016\/j.amsu.2022.103266","article-title":"Inflammatory parameters as predictive factors for complicated appendicitis: A retrospective cohort study","volume":"74","author":"Ribeiro","year":"2022","journal-title":"Ann. Med. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e9593","DOI":"10.5812\/ijp.9593","article-title":"Investigation of the Diagnostic Value of Neutrophil to Lymphocyte Ratio in Pediatric Appendicitis Cases","volume":"27","author":"Yilmaz","year":"2017","journal-title":"Iran. J. Pediatr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1816","DOI":"10.1016\/j.jpedsurg.2020.09.066","article-title":"Hyponatremia as a predictor of perforated acute appendicitis in pediatric population: A prospective study","volume":"56","year":"2021","journal-title":"J. Pediatr. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"423","DOI":"10.5505\/tjtes.2014.75044","article-title":"The clinical value of leucocyte count and neutrophil percentage in diagnosing uncomplicated (simple) appendicitis and predicting complicated appendicitis","volume":"20","author":"Sahbaz","year":"2014","journal-title":"Turk. J. Trauma Emerg. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.jss.2016.07.023","article-title":"Factors predictive of complicated appendicitis in children","volume":"206","author":"Pham","year":"2016","journal-title":"J. Surg. Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3126\/njmr.v5i1.44179","article-title":"The Role of Neutrophil Lymphocyte Ratio in Predicting Acute Appendicitis in Adult","volume":"5","author":"Giri","year":"2022","journal-title":"Nepal J. Multidiscip. Res."},{"key":"ref_24","first-page":"1","article-title":"Negative paediatric appendicectomy rates","volume":"113","author":"Sharkey","year":"2020","journal-title":"Ir. Med. J."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.yasu.2010.05.021","article-title":"Distinguishing Acute from Ruptured Appendicitis Preoperatively in the Pediatric Patient","volume":"44","author":"Gosain","year":"2010","journal-title":"Adv. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Sack, U., Biereder, B., Elouahidi, T., Bauer, K., Keller, T., and Tr\u00f6bs, R.-B. (2006). Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children. BMC Surg., 6.","DOI":"10.1186\/1471-2482-6-15"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1016\/j.surge.2020.01.002","article-title":"Hyponatremia as a marker of complicated appendicitis: A systematic review","volume":"18","author":"Giannis","year":"2020","journal-title":"Surgeon"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/j.amsu.2019.10.013","article-title":"Accuracy of neutrophil lymphocyte ratio for diagnosis of acute appendicitis in children: A diagnostic study","volume":"48","author":"Prasetya","year":"2019","journal-title":"Ann. Med. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1002\/jmrs.154","article-title":"Ultrasound of paediatric appendicitis and its secondary sonographic signs: Providing a more meaningful finding","volume":"63","author":"Reddan","year":"2016","journal-title":"J. Med Radiat. Sci."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1007\/s13244-013-0275-3","article-title":"Ultrasound assessment of acute appendicitis in paediatric patients: Methodology and pictorial overview of findings seen","volume":"4","author":"Quigley","year":"2013","journal-title":"Insights Imaging"},{"key":"ref_31","first-page":"702","article-title":"The neutrophil-to-lymphocyte ratio: A narrative review","volume":"10","author":"Faria","year":"2016","journal-title":"Ecancermedicalscience"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1007\/s10654-018-0472-y","article-title":"The neutrophil-to-lymphocyte ratio is associated with mortality in the general population: The Rotterdam Study","volume":"34","author":"Fest","year":"2019","journal-title":"Eur. J. Epidemiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e14834","DOI":"10.1097\/MD.0000000000014834","article-title":"Prognostic significance of blood inflammatory biomarkers NLR, PLR, and LMR in cancer\u2014A protocol for systematic review and meta-analysis","volume":"98","author":"Kumarasamy","year":"2019","journal-title":"Medicine"},{"key":"ref_34","first-page":"1","article-title":"Role of Circulating Lymphocytes in Patients with Sepsis","volume":"2014","author":"Monserrat","year":"2014","journal-title":"BioMed Res. Int."},{"key":"ref_35","first-page":"117","article-title":"Different cytokine profiles in patients with a history of gangrenous or phlegmonous appendicitis","volume":"143","author":"Berg","year":"2006","journal-title":"Clin. Exp. Immunol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1016\/j.pedneo.2021.08.018","article-title":"The lymphocyte-to-monocyte ratio may distinguish complicated from non-complicated pediatric appendicitis: A retrospective study and literature review","volume":"63","author":"Nissen","year":"2021","journal-title":"Pediatr. Neonatol."},{"key":"ref_37","first-page":"257","article-title":"Use of the neutrophil:lymphocyte ratio in the diagnosis of appendicitis","volume":"61","author":"Goodman","year":"1995","journal-title":"Am. Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1080\/00015458.2010.11680673","article-title":"The Diagnostic Value of Neutrophil: Lymphocyte Ratio in Adults with Suspected Acute Appendicitis","volume":"110","author":"Markar","year":"2010","journal-title":"Acta Chir. Belg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1007\/s00595-015-1125-3","article-title":"A lower neutrophil to lymphocyte ratio is closely associated with catarrhal appendicitis versus severe appendicitis","volume":"46","author":"Shimizu","year":"2016","journal-title":"Surg. Today"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"19","DOI":"10.5505\/tjtes.2014.20688","article-title":"Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis","volume":"20","author":"Kahramanca","year":"2014","journal-title":"Turk. J. Trauma Emerg. Surg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"299","DOI":"10.9738\/CC161.1","article-title":"Neutrophil-to-Lymphocyte Ratio Has a Close Association With Gangrenous Ap-pendicitis in Patients Undergoing Appendectomy","volume":"97","author":"Ishizuka","year":"2012","journal-title":"Int. Surg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1007\/s11845-017-1667-z","article-title":"Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis","volume":"187","author":"Khan","year":"2018","journal-title":"Ir. J. Med Sci."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Mori, M., Narushima, K., Hirano, A., Kano, Y., Chiba, F., Edamoto, Y., and Yoshida, M. (2022). Preoperative neutrophil-to-lymphocyte ratio may contribute to the prediction of postoperative infectious complications in patients with acute appendicitis: A retrospective study. BMC Surg., 22.","DOI":"10.1186\/s12893-022-01529-8"},{"key":"ref_44","first-page":"317","article-title":"Ischemia modified albumin and other inflammatory markers in the diagnosis of appendicitis in children","volume":"23","author":"Nazik","year":"2017","journal-title":"Turk. J. Trauma Emerg. Surg."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1089\/sur.2019.042","article-title":"Role of Platelet to Lymphocyte Ratio as a Biomedical Marker for the Pre-Operative Diagnosis of Acute Appendicitis","volume":"20","author":"Aydin","year":"2019","journal-title":"Surg. Infect."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/1\/21\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:48:08Z","timestamp":1760147288000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/1\/21"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12,22]]},"references-count":45,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,1]]}},"alternative-id":["medicina59010021"],"URL":"https:\/\/doi.org\/10.3390\/medicina59010021","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,12,22]]}}}