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ORIGINAL ARTICLE
Year : 2023 | Volume
: 14
| Issue : 2 | Page : 88-92
Systemic inflammation response index and systemic immune inflammation index for predicting acute cholecystitis
Gnay Yildiz1, Fatih Selvi1, Cihan Bedel1, kkes Zortuk1, Mustafa Korkut1, Umut Ogn Mutlucan2
1 Department of Emergency Medicine, Health Science University, Antalya Training and Research Hospital, Antalya, Turkey
2 Department of Neurosurgery, Health Science University, Antalya Training and Research Hospital, Antalya, Turkey
Correspondence Address:
Dr. Cihan Bedel
Health Science University, Antalya Training and Research Hospital, Kazim Karabekir Street, Muratpasa, Antalya 07100
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_5_23
Objective: Acute cholecystitis (AC) is a condition caused by acute inflammation of gallbladder. Many inflammatory markers are frequently used in the diagnostic process. In this study, we wanted to show the diagnostic efficacy of the systemic inflammatory response index (SIRI) and systemic immune inflammation index (SII) in patients with AC. Methods: This retrospective study was conducted in subjects diagnosed with AC between January 1, 2020, and June 1, 2022. The control group was randomly selected from subjects who attended to the emergency department with abdominal pain and did not need hospitalization, among subjects of similar age and gender to our study group. Demographic data and laboratory parameters of the patients were collected. Results: One hundred and thirty-three AC patients who met the inclusion criteria were included. Eighty-five patients with similar demographic data were included as a control group. The mean median SIRI levels of the patients were significantly higher than the control group (2.88 vs. 1.35; P < 0.001). In addition, the median SII levels of the patients were found to be significantly higher than the control group (1019.42 vs. 573.80; P < 0.001). Conclusions: We found that SIRI and SII are markers that can be used diagnostically in patients with AC and can be used as an option to C-reactive protein.
Keywords: Acute cholecystitis, systemic immune inflammation index, systemic inflammatory response index
Acute cholecystitis (AC) is a condition caused by acute inflammation, often accompanied by an obstruction in the biliary tract due to gallstones. High rates of AC can be seen in developed societies.[1],[2] Although the condition is caused by inflammation and the course of the disease often progresses with a mild symptomatic process, it can also present with a more severe symptomatic process, having mortality and morbidity, especially with diagnostic delays.[3] The diagnosis of AC can be made quickly by clinical and physical examination, laboratory tests, and imaging methods.[4] Although imaging methods used in the diagnosis of the disease are developing, the need for auxiliary diagnostic methods to show both the diagnosis and the severity of the disease remains on the agenda.[3],[4]
Many inflammatory markers, including white blood cell (WBC) count, C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), and sedimentation, are frequently used in the diagnostic process.[5],[6] Today, rapid and simple diagnostic markers continue to be the subject of research, as the importance of early prediction of the diagnosis of AC is known. The main ones are mean platelet volume (MPV), immature granulocyte, and platelet distribution width, which can be determined from a simple hemogram examination.[7],[8],[9],[10] The systemic inflammatory response index (SIRI) is an inflammatory marker that can be easily calculated from simple hemogram parameters. SIRI calculation: It is made by the formula of the ratio of neutrophil-monocyte multiplication to lymphocyte.[9],[10] Similarly, the systemic immune inflammation index (SII), which can be calculated by the ratio of neutrophils, platelets, and lymphocytes from hemogram parameters to each other, is effective as an inflammatory marker on many diseases, especially cardiovascular diseases and malignancy patients.[9],[10],[11],[12] There are few studies in the literature demonstrating the diagnostic utility of the SIRI and SII in patients with AC.[13] Therefore, in this study, we wanted to show the diagnostic efficacy of the SIRI and SII in patients with AC.
MethodsThis study was designed as a single-center, retrospective, observational and was conducted in the emergency department of a tertiary care and research hospital, having a foot fall of approximately 1500 patients applied daily. Patients aged ≥18 years and diagnosed with AC who applied to our emergency department between January 1, 2020, and June 1, 2022, were included in this study. The control group was randomly selected from patients who presented to the emergency department with abdominal pain and did not need hospitalization. The control group was age and gender matched with our study group. The study group consisted of subjects who were admitted to the emergency department with the complaint of abdominal pain and hospitalized with the diagnosis of AC after consultation by the general surgeon based upon clinical, radiological, and imaging results.
Presence of Murphy sign or right upper quadrant pain, tenderness, leukocyte count or CRP elevation, and characteristic imaging findings were helpful in the diagnosis of AC.[3] Exclusion criteria were under 18-year-old, those with malignancy or hematological disease that may affect SIRI and SII values, those receiving immunosuppressive therapy or using steroids and similar drugs that may affect laboratory values as drug use, trauma patients, and patients with lack of data. Demographic and laboratory parameters of the patients were collected from the data processing system. WBC count, hemoglobin, neutrophil count, lymphocyte count, and platelet count were recorded. (Neutrophil × Platelet)/Lymphocyte formula for SII calculation; For SIRI, the Neutrophil × monocyte)/Lymphocyte formula was used.
SPSS 21.0 software (IBM-SPSS Inc, Chicago, IL) in the analysis of the data in our study was used, and P < 0.05 was regarded statistically significant. Normality analysis of the data was performed.Mean ± standard deviation was used for continuous variables. Frequency and percentage (%) were used for categorical data. Pearson's Chi-square and Fisher's tests were used in the investigation of categorical variables. In the comparison of AC and control groups, Student's t-test was used for normally distributed variables and Mann–Whitney U test was used for nonnormally distributed variables. The receiver operating characteristic (ROC) analysis of the parameters (SIRI, SII, CRP) for the diagnosis of AC were performed, and patients with high area under the curve (AUC) have better diagnostic values.
ResultsOne hundred and thirty-three AC patients who met the inclusion criteria were included in the study. Eighty-five patients with similar demographic data were included in the study as a control group. The mean age of the patients in the AC group was 40.76 ± 9.34 years. 45.9% of the patients are men. The mean WBC and neutrophil levels of the patients were significantly higher than the control group, and the lymphocyte levels were significantly lower than the control group (P < 0.001). The median CRP, aspartate transaminase, alanine transaminase, and NLR levels of the patients were found to be significantly higher than the control group. The mean median SIRI levels of the patients were significantly higher than the control group [2.88 vs. 1.35; P < 0.001, [Table 1] and [Figure 1]]. In addition, the median SII levels of the patients were found to be significantly higher than the control group [1019.42 vs. 573.80; P < 0.001, [Figure 2]].
Figure 1: Comparison of SIRI levels between healthy control and AC groups. SIRI: Systemic inflammatory response index, AC: Acute cholecystitis
Figure 2: Comparison of SII between healthy control and AC groups. SII: Systemic immune inflammation index, AC: Acute cholecystitis
Table 1: Comparison of laboratory parameters between acute cholecystitis and control groupsIn this study, we examined the effectiveness of WBC, NLR, SIRI, SII, and CRP in predicting AC using ROC analysis. The AUC values of these variables were found to be statistically significant in predicting AC [Figure 3]. CRP had the highest AUC (0.929; P < 0.001), followed by SIRI, WBC, NLR, and SII (AUC = 0.783, 0.775, 0.769, and 0.742, respectively). Sensitivity (80%) and specificity (66.4%) were calculated for the SIRI > 1.21 cut-off value. Sensitivity (70%) and specificity (68.1) were obtained for SII >790.53 cut-off value [Table 2].
Figure 3: ROC curve of SIRI, SII and other inflammation parameters for predicting AC. ROC: Receiver operating characteristic, SIRI: Systemic inflammatory response index, SII: Systemic immune inflammation index, AC: Acute cholecystitis
Table 2: Diagnostic performances of parameters for distinguishing between acute cholecystitis and control groups Discussion Based on the results of our study, it has been shown that WBC, NLR, SIRI, SII, and CRP can be an inflammatory marker that can be used in the diagnosis of AC. This study demonstrated that SIRI and SII are significant markers for AC and can be used as an alternative to CRP.
As is comprehended, the diagnosis of AC is made based on clinical, laboratory, and imaging findings. While patients may frequently present with simple self-limiting inflammatory findings, local complications such as emphysema, gangrene, perforation, abscess, biliary peritonitis, and lienteric fistula may be encountered more frequently in diagnostic delays.[14] In the diagnosis of AC, upper right quadrant pain, shoulder and back pain, nausea, vomiting and fever are the main symptoms and signs. Patients often apply to the emergency department with complaints of increased abdominal pain after meals. The most significant diagnostic imaging method is ultrasonography. Biomarkers also help with diagnosis.[12],[13],[14],[15] The most frequently reported laboratory findings are high CRP (≥3 mg/dL) and elevated WBC and sedimentation.[16] However, the fact that these parameters do not increase in the early period of inflammation can be influenced by many conditions such as age, renal function values, and anemia. Therefore, there is a need for unique biomarkers that are both diagnostic aids and early detection of complications.[17] It has been shown that MPV, one of these parameters, was found to be significantly lower in AC patients compared to the control group.[18] It has been emphasized that NLR and PLR, which are other parameters, can be a guide in the diagnosis of AC.[5]
SII is a new and affordable biomarker that can be easily calculated using neutrophil, platelet, and lymphocyte counts. In recent years, studies have shown that it can be used in the diagnosis and prognostic process of many diseases.[11],[12],[13] The use of SII as a systemic inflammation and prognostic marker in oncological diseases, coronary artery disease, cerebrovascular diseases, and pulmonary diseases has been the subject of research in recent years.[10],[11],[19],[20] Huang et al. in a study by SII were reported to be higher in the moderate to severe stroke group than in the mild stroke group (932.73 vs. 581.21, P < 0.001).[10] Lin et al. in a study by AF patients with AF were found to have higher SII values (562.50 vs. 802.29; P < 0.001).[21] In another study, SII is useful as a new index that can show disease activity in rheumatoid arthritis patients.[22] In a study on the clinical use of SII in patients with AC, SII levels were found to be significantly higher in the nonsurvivor group than in the living group. In a study on the clinical use of SII in AC patients, SII levels were found to be significantly higher in the nonsurvivor group than in the living group.[23] In this study, we conducted with AC patients; we found that the median SII levels of the patients were found be significantly higher than the control group.
Similarly, another biomarker, SIRI, has also been used in the diagnosis and prognostic process of many diseases.[9] Chen et al. demonstrated the utility of SIRI in patients with localized or locally advanced renal cell carcinoma.[24] Qi et al. reported that SIRI can be used to predict survival of patients with pancreatic adenocarcinoma receiving chemotherapy and is potentially useful for aggressive management.[9] In a study on patients with COVID-19, the diagnostic status of SII and SIRI in showing disease prognosis was discussed, and it was reported that SII could indicate disease prognosis with higher predictivity.[25] Bilge et al. reported that significant, strong positive correlations were followed between measures of inflammation (SIRI) and angiogenesis in patients with Treatment-Resistant Bipolar Depression Disorder.[26] In our study, it was determined that the median SIRI levels in AC patients were found to be significantly higher in study subjects compared to the control group, and its diagnostic utility was demonstrated.
Our study had some limitations. The first of these is the difficulty of including the partially healthy group since our study was a retrospective study and the control group was the emergency room of the patient. Although it is known that inflammatory parameters may not show rapid activation in the acute period, one of our important limitations is the inability to detect the dynamic situation that may occur in these parameters. Another limitation of ours is the inability to detect the relationship between other inflammatory markers, interleukins and thromboxane, and SII and SIRI. Prospective multicenter studies are needed for the analysis of the data in our study.
ConclusionsSIRI and SII are markers that can be used diagnostically in patients with AC and can be used as an option to CRP. However, prospective studies involving many biomarkers are needed.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
References
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