Comparison of the use of neutrophil: lymphocyte count ratio (NLCR) to total leukocyte count in diagnosing appendicitis in adults

  • Rabindra K.C. Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu , Nepal
  • Ishwor Lohani Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu , Nepal


Introduction: Appendectomy is the most commonly performed emergency operation in the world. The life time risk of undergoing appendectomy is around 8% and maximal incidence occurs in the second and third decade of life. Diagnosis of acute appendicitis (AA) is purely based on history, examination and few laboratory investigations. However, it is often a perplexing diagnostic problem during the early stages of the disease. Failure to make an early diagnosis is a primary reason for morbidity and mortality. Leukocytosis is being used commonly to diagnose acute appendicitis. Recently, it has been proposed that netrophil: lymphocyte count ratio (NLCR) is a more sensitive marker than leukocytosis in patients with acute appendicitis.Method: This is a prospective study conducted over a period of one year in the department of surgery, Tribhuvan University Teaching Hospital TUTH from September 2013 to August 2014.Total 106 patients were  included in the study. AA was diagnosed by clinical and laboratory parameters. TLC and NLCR of patients diagnosed as AA was recorded in the proforma. Histological diagnosis was taken as the final diagnosis. SPSS software was used for analysis of data.Results: Male: Female ratio was 2.02:1, with mean age of 29.63 years .Right iliac fossa tenderness was the most common sign  and an average leukocyte count of 12534/ul. All cases diagnosed clinically as acute appendicitis were confirmed histopathologically. NLCR> 3.5 was observed on 90.56% of patient whereas 78.3% of patients had leukocytosis which was statistically significant (p= 0.0001).Conclusion: NLCR is a more sensitive laboratory parameter than TLC  in patients with acute appendicitis. 


Flum, D.R. and T. Koepsell, The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg, 2002. 137(7): p. 799-804.
2. Shelton, T., R. McKinlay, and R.W. Schwartz, Acute appendicitis: current diagnosis and treatment. Curr Surg, 2003. 60(5): p. 502-5.
3. Sigdel, G.S., P.J. Lakhey, and P.R. Mishra, Tzanakis score vs. Alvarado score in acute appendicitis. JNMA J Nepal Med Assoc, 2010. 49(178): p. 96-9.
4. Bundy, D.G., et al., Does this child have appendicitis? Jama, 2007. 298(4): p. 438-51.
5. Ma, K.W., et al., If not appendicitis, then what else can it be? A retrospective review of 1492 appendectomies. Hong Kong Med J, 2010. 16(1): p. 12-7.
6. Khan, I. and A. ur Rehman, Application of alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad, 2005. 17(3): p. 41-4.
7. John, H., U. Neff, and M. Kelemen, Appendicitis diagnosis today: clinical and ultrasonic deductions. World J Surg, 1993. 17(2): p. 243-9.
8. Saidi, R.F. and M. Ghasemi, Role of Alvarado score in diagnosis and treatment of suspected acute appendicitis. Am J Emerg Med, 2000. 18(2): p. 230-1.
9. Yoldas, O., T. Karaca, and M. Tez, External validation of Lintula score in Turkish acute appendicitis patients. Int J Surg, (2011 Nov 30): p. 2012;10(1):25-7.
10. Addiss DG, Shaffer N, Fowler BS, et al The epidemiology of appendicitis in the United States. Am J Epidemiolog 132:910-925, 1990
11. Sadr Azodi, O., et al., Impact of body mass index and tobacco smoking on outcome after open appendicectomy. Br J Surg, 2008. 95(6): p. 751-7.
12. Birnbaum, B.A. and S.R. Wilson, Appendicitis at the millennium. Radiology, 2000. 215(2): p. 337-48.
13. Fenyo, G., et al., Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system. Eur J Surg, 1997. 163(11): p. 831-8.
14. Cardall T et al. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Academic Emergency Medicine. October 2004; 11 (10): 1021-1027
15. Cornelis et al, lymphopenia as a marker of bacteramia ,critical care 2010 online journal
16. Lowsby et al, Neutrophil to Lymphocyte count ratio as an early indicator of blood stream infection in emergency department, Emergency Medicine Journal 2014
17. Goodman et al: Use of the neutrophil:lymphocyte ratio in the diagnosis of appendicitis.The American Surgeon. 1995 Mar;61(3):257-9
18. Mesut Yaz?c? et al Neutrophil/lymphocyte ratio in the diagnosis of appendicitis Turkish Journal of pediatrics . 2010 Jul-Aug;52(4):400-3.
19. Markar SR et al The diagnostic value of neutrophil: lymphocyte ratio in adults with suspected acute appendicitis. acta chirurgica belgica 2010 sept-oct
20. McKay Robert, The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis , American Journal of Emergency Medicine (2007) 25
21 Kaiser S,Jorulf H,Soderman E,et al: Impact of radiological imaging on the surgical decision making process in suspected appendicitis in children. Acad Radiol 11:971-979, 2004
How to Cite
K.C., Rabindra; LOHANI, Ishwor. Comparison of the use of neutrophil: lymphocyte count ratio (NLCR) to total leukocyte count in diagnosing appendicitis in adults. J Soc Surg Nep, [S.l.], v. 21, n. 2, p. 24 - 27, mar. 2019. ISSN 2392-4772. Available at: <>. Date accessed: 08 aug. 2020.
Original Article


Appendicitis; alvarado; NLCR; TLC.