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Category: Volume 06 Issue 04 April 2018
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Title: Serum CRP: A Marker of Bowel Gangrene in Acute Intestinal Obstruction

Authors: Dr Dileep Singh Thakur, Dr Chandan Tiwari2, Dr Uday Somashekar, Dr Reena Kothari, Dr Dhananjaya Sharma

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i4.164

Abstract

Acute Intestinal Obstruction remains one of the most common intra-abdominal problem faced by General Surgeon Its early recognition and aggressive treatment can prevent irreversible ischaemia and trans-mural necrosis, thereby reducing mortality and morbidity. Overall mortality rate for bowel obstruction rises many a fold if gangrene in obstructed segment ensues, which is 3% in simple obstruction compared to 30% in strangulated obstruction. Early resuscitation and surgical exploration may minimize morbidity and mortality in such patients. A number of clinical, haematological, biochemical or radiological marker to differentiate between simple and strangulated intestinal obstruction. Research are ongoing to clearly define their diagnostic use and potential role in determining which patient should be managed surgically. C-reactive protein is acute phase reactant synthesised in liver whose level rapidly increases in response to stress, tissue Injury, ischaemia, and other inflammatory conditions. CRP is used as marker of cardiac ischaemia in acute coronary syndromes and its prognosis, thus it is likely to be elevated in comparatively greater level in bowel ischaemia. We conducted study on 83 patients with diagnosis of acute intestinal obstruction which were greater than 14 years of age to evaluate usefulness of CRP. Semi quantitative CRP evaluation was done in subjects at time of presentation and preoperatively. Then statistical test chi square test and Pearsons correlation coefficient was applied on CRP results. On completion of study and application of statistical tests it was found that60% of patients with strangulated bowel obstruction have a positive serum CRP and was not raised in 73.6% patients with simple obstruction. The chi-square value was 9.121 and p-value was also significant (p=0.003).The mean CRP levels in patients of intestinal obstruction on admission was 8.80(+/-4.007) with non gangrenous bowel and was 20.16(+/-10.6097) with gangrenous bowel. It was statistically significant with a p value of 0.001.However the preoperative CRP level in patients with non gangrenous bowel was 12.68(+/-6.131) while with gangrenous gut was 20.80(+/-10.54) and this also showed correlation which was statistically significant with a p value of 0.01(p<0.05). The Pearson’s correlation coefficient between serum CRP on admission and length of gangrenous bowel were observed to be 0.10 and shows a positive but weak correlation and this was statistically significant. So it appear that serum CRP can be used as objective indicator to diagnose irreversible bowel ischaemia/ gangrene, as serum CRP can be measured noninvasively ,is readily available, cheaper, needs no expertise and results are reproducible.

References

  1. Maingot’s abdominal operations; Michael J Zinner, Stanley W Ashley, Mac Graw Hill Publication 11th Edition 479-482.
  2. Miller G,Boman J,Shrier J et al .Natural history of patient with Bowel obstruction. Br J Surgery 2000; 87:1240-1247.
  3. Sarr MG, Bulkely GB, ZuidemaGD; Preoperative recognition of intestinal obstruction: Preoperative evaluation of diagnostic capability. Am J Surgery145:176-182,1983.
  4. Maingot’s abdominal operations .Michael J Zinner, Stanley W Ashley, Mac Graw Hill Publication 11th Edition501-502.
  5. Clinical diagnosis and management by laparotomy methods. Todd Samford, Davidson John Bernard Henry, Saunders publication 17th edition 212-213.
  6. Engelhart T and Cuthbertson BH. Markers of myocardial damage and inflammation in unstable coronary artery disease. N Engl J Med 2001 :344:688-689.
  7. Griselli M, Herbert J, Hutchinson WL, Taylor KM ,Sohail M, Krauz T and Pepys MB.CRP and complements are important mediators of tissue damage in acute myocardial infarction Exp Med ;1999:190:1733-1740.
  8. Bailey and Love’s.Short practice of surgery Russell Norman S William and Christopher Bulstrode; Arnold publications 23rd edition,1060-1061.
  9. Sarr MG, Bulkily GB, Zuidema GB; preoperative recognition of intestinal strangulation obstruction, Prospective evaluation of diagnostic capability; Am j surgery;145 176-181,1983.
  10. Delaney CP, O Neil S et al .Plasma concentration of Glutathione S Transferase. Isoenzyme in patients with intestinal ischaemia; British journal of Surgery,1999.
  11. Kanda T,Fuji H ,Tani T et al :Intestinal Fatty Acids Binding protein is a useful diagnostic marker of mesenteric infarction in humans.Gastroenterology: 1996;100; 339-343.
  12. Ogata M, Imai S, Hosotani R et al; Abdominal Ultrasonography for the diagnosis of strangulation in small bowel obstruction: Br J Surgery 1994 ;81 421-424.
  13. Baerga –Valera Y. Small bowel obstruction .In Kelly KA, Sarr MG, Hinder RA eds; Mayo clinic,gastrointestinal surgery,1st edition Philadelphia :PA Saunders 2004 ,421-437.
  14. Richard WO, Gauraud GI, Allos SH et al ,Non invasive diagnosis of mesenteric ischemia using SQUID magnetometer,Ann Surgery ;1995:221 695-705.
  15. Pepys MB, Berger A ,The renaissance of C -reactive protein ;BMJ 2001 322 4-5
  16. Kaplan MH, Volkanis JE, Interaction of CRP with complement system, J immunol 1974 112 2135-2147.
  17. Nijmeijer R, Lagrand WK, Lubbers YT et al; CRP activates complement in infarcted myocardium. Am J Pathol 2003 163 269-275.
  18. Meier Ewert HK, Ridker PM et al .Absence of diurnal variation of CRP in healthy human Clinical Chemistry: 2001: 47:426-430.
  19. PerdizP ,Wachner N et al .Circadian variation of human acute phase response.Arch Med Res 1996:27-157-163.
  20. Koeing W et al .Predicting risk and treatment benefit in atherosclerosis; International journal Cardiology.205:98 (2)199-206.
  21. Rheumatoid Arthritis –Edward D Harris J.109- 110.
  22. Berger C ,Uehinger J et al. Comparison of WBC count and CRP. With differential in neonates at risk of septicaemia,.European Journal Paediatrics 1995 154; 138-144.
  23. Essential of paediatrics. O P Ghai,Paul VK Mehta publications, 5TH edition 275-276.
  24. NehmetHC,Hedef O et al.CRP may be marker of bacterial translocation in experimental intestinal obstruction. ANZ Journal of Surgery.2004 74:900.
  25. Tulip CRP,Diagnostic kit.

Corresponding Author

Dr Chandan Tiwari

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