The role of the halp score in indicating the severity of acute appendicitis and predicting clinical prognosis

Abstract

AimIt is important to make this distinction with biomarkers when discussing conservative treatment in uncomplicated Acute Appendicitis (AA) cases. The aim of this study is to examine the potential of the HALP score to determine AA severity and predict clinical prognosis.MethodsIn this retrospective study, 94 patients whose HALP score could be calculated at the time of admission, among patients who were hospitalized and operated on due to AA in the 3rd level hospital emergency department between 2015 and 2024, were included in the study. According to the pathology reports, the patients were divided into two groups: complicated and uncomplicated.ResultsOf the 94 patients included in our study, 43 were female and 51 were male, and their average age was determined as 33.45 ± 13.24. 60 (63.8%) of the patients are in the uncomplicated appendicitis group, and 34 (36.2%) are in the complicated appendicitis group. In our study, no significant statistical difference was found between the complicated and uncomplicated AA groups in terms of complete blood count and biochemistry tests (p>0.05). No significant difference was observed between the complicated and uncomplicated groups in terms of HALP score (p=0.200).ConclusionThe findings of our study suggest that the use of the HALP score as a routine prognostic tool in the management of AA is limited. Future studies should comprehensively evaluate not only the HALP score but also the prognostic value of other laboratory and clinical parameters.

Keywords

Introduction

Acute appendicitis (AA) is one of the most common intraabdominal emergencies requiring urgent surgical intervention and holds a significant place among global health concerns.¹ The lifetime prevalence has been reported as 6.7% in women and 8.6% in men.² The frequency of appendiceal perforation at the time of diagnosis ranges between 17–20%.³ AA can exhibit considerable variability in clinical course and prognosis among individuals. Although appendectomy remains the primary treatment option today, the use of conservative approaches in uncomplicated AA cases is increasing.^4-5 Therefore, identifying reliable biochemical and clinical markers that can accurately assess the severity of the disease and predict prognosis is of great importance.
The diagnosis of AA relies heavily on physical examination, laboratory tests, and imaging methods. Complete blood count (CBC) tests, particularly the evaluation of early inflammatory markers such as white blood cell (WBC) and neutrophil counts, are widely used.⁶ Assessing multiple parameters together rather than a single parameter can enhance the accuracy and severity assessment of the disease. The literature suggests that data such as platelet (PLT) count and neutrophil-to-lymphocyte ratio (NLR) are also significant in identifying inflammatory pathologies.^7-9 Additionally, serum albumin levels have been associated with postoperative mortality and morbidity as an acute phase reactant of inflammation.^10-11
In recent years, there has been an increase in studies examining the usability of combinations of hematological and biochemical parameters in the diagnosis and prognosis of diseases. In this context, the potential of the Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score has garnered significant attention. The HALP score can provide insights into patients’ nutritional status and immunological responses and has been proposed as a prognostic marker in various malignancies.^12-15
In cases of acute appendicitis, the severity of inflammation can directly impact the course of the disease and surgical outcomes. Therefore, the potential use of the HALP score as a biomarker for determining the severity of AA and predicting clinical prognosis is being investigated. Although research on the HALP score in acute appendicitis cases is limited, a study by Benli et al. published in 2023 revealed that the HALP score is a significant measure for identifying complications in acute appendicitis. The study demonstrated that a low HALP score is associated with high-risk factors, suggesting that this score could be evaluated as a potential biomarker for determining disease severity and predicting clinical prognosis.¹⁶ In our study, we aim to provide important findings on how the HALP score can be assessed in clinical practice.

Materials and Methods

Study Design and SettingsThis retrospective study was conducted with ethical committee approval on patients diagnosed with acute appendicitis in the Adult Emergency Department of Kanuni Sultan Süleyman Training and Research Hospital between January 1, 2015, and January 1, 2024. The demographic data, clinical characteristics, and laboratory results of the patients included in the study were examined.Selection of ParticipantsDuring the study period, we identified a total of 106 patients who were admitted to the emergency department and underwent surgery for acute appendicitis, with albumin levels measured at the time of admission. Four patients were excluded from the study: one with mucinous carcinoma, one with mesenchymal carcinoma, one with appendiceal diverticular disease, and one with a normal appendix. Additionally, eight patients were excluded due to the unavailability of complete blood count results. Thus, a total of 94 patients were included in the study. Patients aged 18 and older diagnosed with acute appendicitis were included, while those under 18, not diagnosed with acute appendicitis, or whose records were inaccessible, were excluded from the study. According to pathology reports, patients were classified as uncomplicated and complicated appendicitis. Perforated appendicitis, gangrenous/necrotic appendicitis, and periappendicular abscesses were accepted as complicated appendicitis, whereas patients diagnosed with AA were classified as non-complicated appendicitis.
Patient data were retrospectively obtained from electronic medical records. The collected data included age, gender, complete blood count results (WBC, neutrophil, lymphocyte, platelet counts, hemoglobin, hematocrit), biochemical tests (ALT, AST, albumin, CRP, glucose, creatinine, urea, BUN, sodium, potassium), and HALP scores. The HALP score was calculated as follows:
HALP Score = Hemoglobin (g/dL) × Albumin (g/dL) / Lymphocyte Count (×10⁹/L) × Platelet Count (×10⁹/L)Ethical ApprovalThe Ethics committee of our institution reviewed the study before its initiation and approved the study (Date: 28.03.2024, Decision No: KAEK/2024.03.67).Statistical AnalysisData analysis was performed using the statistical package program IBM SPSS 27.0 (Armonk, NY: IBM Corp.). In the study, patients were divided into two groups: those with or without complications. The suitability of the data for normal distribution was analyzed with Kolmogorov–Smirnov and Shapiro–Wilk tests and skewness and kurtosis values. Continuous variables were expressed as mean ± standard deviation (SD) or median (interquartile range, IQR). The Mann–Whitney U test was used to evaluate the differences between the complicated and uncomplicated appendicitis groups. Results with a p-value <0.05 were considered statistically significant.Reporting GuidelinesThis study was reported according to the STROBE guidelines.

Results

The study group consisted of 43 female (45.7%) and 51 male (54.3%) patients. The mean age of the female patients was 42.14 ± 17.76 years, and the mean age of the male patients was 37.69 ± 15.50 years, with no statistically significant difference (p=0.934). Sixty patients (63.8%) were in the uncomplicated appendicitis group, while 34 patients (36.2%) were in the complicated appendicitis group.
Complete blood count analysis did not show significant differences in WBC count, hemoglobin level, neutrophil count, lymphocyte count, and hematocrit level between the uncomplicated and complicated appendicitis groups (p>0.05). Although platelet counts tended to be higher in the complicated group in our study, they were on the borderline of statistical significance (p=0.096). Similarly, in the biochemical tests, there were no significant differences between the groups in terms of ALT, AST, albumin, CRP, glucose, creatinine, and other parameters (p>0.05). Specifically, despite CRP being an indicator of inflammation as an acute-phase reactant, CRP levels did not differ between the complicated and uncomplicated groups in our study (p=0.944). Statistical data related to complete blood count and biochemical tests are shown in Table 1 and Table 2.
Additionally, the comparison of clinical characteristics such as hospital stay duration, appendix diameter, symptom duration, and HALP score did not reveal statistically significant differences between the uncomplicated and complicated appendicitis groups. The relevant data are shown in Table 3.

Discussion

In our study, WBC levels did not show a significant difference between the complicated and uncomplicated groups. This finding is consistent with the study by Benli et al., who also reported that WBC levels did not significantly predict complications in acute appendicitis (p>0.05).¹⁶ Similarly, some studies in the literature have shown that hemoglobin and hematocrit levels are not associated with complications in acute appendicitis, as observed in our study. Neutrophil and lymphocyte counts were also found to be insufficient in predicting complications of acute appendicitis, similar to the literature.¹⁶ These parameters may change in cases of inflammation or infection, but such a relationship was not found in our study.
In the literature, elevated platelet counts have been indicated as significant markers in inflammatory diseases and are associated with the risk of complications.¹⁵ In our study, although there were noticeable differences in platelet counts between the complicated and uncomplicated groups, statistical significance was not achieved. The limited size of our data set may have contributed to this result.
In biochemical tests, no significant differences were observed between the groups, particularly in CRP values. In a study by Gavela et al. on the role of CRP in determining the severity of acute appendicitis in a pediatric age group, elevated CRP at admission was found to be associated with the severity and complication of appendicitis.¹⁷ The limited size of our data set and the fact that our study was conducted in an adult age range may have led to different results compared to the literature.
Various studies in the literature have indicated that the HALP score is used as a prognostic marker in different inflammatory and malignant diseases. For instance, a study by Huishan Han et al. (2022) demonstrated that the HALP score is a significant predictor of ICU mortality in acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In this study, a low HALP score was reported to be associated with a higher risk of ICU mortality in AECOPD patients (p<0.05).¹⁸ Similarly, another study on acute appendicitis and the HALP score found that a low HALP score was positively correlated with complicated appendicitis (p<0.05).¹⁶ In our study, HALP scores did not show a significant difference between the groups with and without complications (p=0.200). We believe that our results, which are inconsistent with the literature, are due to the limited size of our data set. Additionally, considering that the acute-phase reactants included in the scoring peak within 4–8 hours, factors such as the early presentation of patients to our emergency department, the short time frame in which laboratory tests were performed, and the exclusion of preoperative tests may have contributed to these findings.

Limitations

Our study’s retrospective nature, single-center design, and small sample size limit the generalizability of our findings. Another limitation of our study is the exclusion of preoperative tests from our analysis.

Conclusion

In conclusion, the data obtained in our study suggest that the use of the HALP score as a routine prognostic tool in the management of acute appendicitis (AA) is limited. Future studies should conduct more comprehensive research to evaluate the prognostic value of the HALP score along with other laboratory and clinical parameters. Additionally, studies conducted in different patient groups and geographical regions can enhance the overall validity and reliability of this scoring system.

Declarations

Abbreviations

References

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