LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score

as a Predictor of Necrosis and Perforation in Cases of Pediatric

Appendicitis in Haji Adam Malik Hospital Medan

Rizki Irwansyah Sembiring

, Fikri Erjan

and Zulfikar Lubis

Department of Surgery, Haji Adam Malik Hospital,Universitas Sumatera Utara, Medan, Indonesia

Department of Clinical Pathology, Haji Adam Malik Hospital, Universitas Sumatera Utara, Medan, Indonesia

Keywords: Appendicitis, Children, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score, Prognostic

Abstract: Pediatric Appendicitis Score has been used as a tool in assessing the risk of necrotizing fasciitis in cases of

soft tissue infection. This study aims to determine the LRINEC (Laboratory Risk Indicator for Necrotizing

Fasciitis) Score as a predictor of necrosis and perforation in cases of pediatric appendicitis in Haji Adam

Malik Hospital Medan. The study was prospective with patient data collection from January 2014 to

December 2014. Patient data were collected including age, LRINEC (Laboratory Risk Indicator for

Necrotizing Fasciitis) Score, and postoperative histopathology. For 12 months, 30 patients with acute

appendicitis who met the inclusion criteria obtained a strong correlation of Laboratory Risk Indicator for

Necrotizing Fasciitis (LRINEC) Score with operating findings, Pearson correlation coefficient (r) of .551

and p-value 0.002 (0.002 <0.05, significance 0.05). With the LRINEC score cutoff ≥ 9, it has a positive

predictive value of 78.5% (95% CI) and a negative predictive value of 62.5% (95% CI). The sensitivity

itself is 64.7% and the specificity is 76.9%. This can be utilized in the management of preoperative and

postoperative appendicitis patients in children.

1 INTRODUCTION

Appendicitis is cases of pediatric surgical

emergencies that are often encountered. The most

common complications are necrosis and perforation

which is one of the emergency abdomens that

requires immediate surgery (Ballester, 2009, Victor,

2012, Maki, 2012, Adelia, 2012, Huckins, 2013).

The incidence of acute appendicitis in children in

the world ranges from 1 - 8% of all pediatric patients

who come to the Emergency Department (Jangra,

2013). In 2009, 60 cases of acute appendicitis were

registered in the Haji Adam Malik Hospital, Medan

(Ivan, 2009).

There is no good scoring system to assess the

risk of necrosis and perforation in cases of pediatric

appendicitis. Previous research has been conducted

on the use of LRINEC (Laboratory Risk Indicator

for Necrotizing Fasciitis) score as a diagnostic tool

to determine the risk of necrotizing fasciitis in cases

of soft tissue infection. By the same principle of

pathophysiology, the author is interested in

researching LRINEC (Laboratory Risk Indicator for

Necrotizing Fasciitis) score as a predictor of necrosis

and perforation of appendicitis cases of children at

Haji Adam Malik Hospital, Medan.

2 MATERIALS AND METHODS

This study is an analytical study with a retrospective

design using a correlation test. The significant

number used is p <0.05. We retrospectively

reviewed all pediatric patients with a diagnosis of

appendicitis who underwent surgery at Haji Adam

Malik Hospital, Medan from January 1, 2014, to

December 31, 2014. Sampling in this study was

carried out in total sampling, where 30 samples were

obtained.

Statistical analyses were performed using the

SPSS statistical software (version 11.0, SPSS,

Chicago, IL). Sixth variables were analyzed. The

first biochemical and hematologic tests were done

on admission were analyzed. Variables analyzed

were age, gender, total white cell count, hemoglobin,

102

Sembiring, R., Erjan, F. and Lubis, Z.

LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score as a Predictor of Necrosis and Perforation in Cases of Pediatric Appendicitis in Haji Adam Malik Hospital Medan.

DOI: 10.5220/0009861301020105

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 102-105

ISBN: 978-989-758-469-5

serum sodium, glucose, creatinine (Cr), and C-

reactive protein (CRP).

The LRINEC score of each patient was

calculated by totaling the scores of each independent

variable. The predictive accuracy of the LRINEC

score was expressed as the area under the

receiver operating characteristic curve. The curve

represents the relationship between corresponding

values of sensitivity and specificity with all possible

values of probabilities as a cutoff point to predict for

the presence of necrosis and perforation.

3 RESULTS

Thirty pediatric patients with appendicitis were

analyzed, complicate appendicitis in 17 patients

(56.67%) and simple appendicitis in 13 patients

(43.44%). There were 16 males (53.3%) and 14

females (46.7%) with a mean age of 11 years.

LRINEC Score data are normally distributed.

The Kolmogorov-Smirnov test normality test

obtained the Asymp value. Sig. (2-tailed) of 0.519

(greater than 0.05). Of the 30 samples obtained an

average LRINEC score of 7.27 patients with the

highest total score was 7. The standard deviation for

the LRINEC Score is 3.65.

The moderate risk group (LRINEC score 6-7)

found 5 samples (63.5%) with complicated

appendicitis and 3 samples with simple appendicitis.

Whereas in the high-risk group (LRINEC score> 7)

there were 11 samples (73.3%) with complicated

appendicitis and 4 samples with simple appendicitis.

The higher value of the LRINEC score, the more

proportion of surgical findings is complicated. From

the chi-square statistical analysis of the LRINEC

risk group with the findings of the Asimp value. Sig

for 0.031 (0.031 <0.05). It was concluded that there

was a significant relationship between LRINEC

score and operating findings.

Correlation of Laboratory Risk Indicator for

Necrotizing Fasciitis (LRINEC) Score with

operating findings

Using Pearson correlation, Pearson correlation

coefficient (r) was equal to .551 or strong, with p-

value 0.002 (0.002 <0.05, significance 0.05). So that

the higher the Laboratory Risk Indicator for

Necrotizing Fasciitis (LRINEC) Score, the more

operational findings lead to complications.

Figure 1: Receiver operating characteristic curve

The area under the curve for LRINEC score as a

predictor of cases of pediatric appendicitis in this

study was 0.805 (95% Confident interval, 0.651-

0.960). The perfect predictor has an Az value of 1. A

score of ≥ 9 is the cut off point in this study.

Table 1: Sensitivity and specificity of LRINEC

Positive if Greater

Than or Equal To

Sensitivity

1 -

Specificity

Sensitivity +

Specificity

.00 1.000 1.000 1.000

1.50 1.000 .692 1.308

2.50 1.000 .615 1.385

4.50 .941 .538 1.403

6.50 .824 .462 1.362

7.50 .647 .308 1.339

8.50 .647 .231 1.416

9.50 .471 .077 1.394

10.50 .294 .000 1.294

11.50 .176 .000 1.176

12.50 .118 .000 1.118

14.00 .000 .000 1.000

Table 2: Prediction value of LRINEC score

Histopathology

Total

Simple Complicate

LRINEC

Score<9 10 6 16

Score≥9 3 11 14

Total 13 17 30

With LRINEC cutoff score of ≥ 9 has a positive

predictive value of 78.5% (CI 95%) and negative

predictive value 62.5% (CI95%). The sensitivity is

64.7% and the specificity is 76.9%.

LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score as a Predictor of Necrosis and Perforation in Cases of Pediatric

Appendicitis in Haji Adam Malik Hospital Medan

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4 DISCUSSION

From the results of this study, the majority of the

samples were male as many as 16 patients (53.3%)

and the remaining women were 14 patients (46.7%).

From epidemiological data, there were no

differences in the incidence of appendicitis between

men and women in children (Schwartz, 2009).

Most cases in this study were complicated

appendicitis, 17 patients (56.67%). Patients with

simple appendicitis were 13 patients (43.33%). This

is supported by previous research conducted in the

Netherlands (Rotterdam Hospital) by V.C

Cappendijk et al. Of the 129 acute appendicitis

samples in children found 71% with perforated

appendicitis.

Necrotizing Fasciitis is associated with severe

sepsis. SIRS and sepsis cause changes in

biochemical and hematological variables. LRINEC

score is very important in measuring this change and

predicts the probability of necrotizing fasciitis based

on the severity of sepsis.

Research by Maurer et al. (2014) showed that

hyponatremia, fever, and tachycardia had moderate

to high specifications for colonic perforation.

LRINEC score can be used for early detection of

cases of necrotizing fasciitis in patients with severe

soft tissue infections. LRINEC score of more than 5

has a positive predictive value of 92.0% (95% CI),

while a score of more than 7 has a positive

predictive value of 93.4%.

The higher the value of the LRINEC score, the

more the proportion of surgical findings is obtained.

In the moderate risk group (LRINEC Score 6-7),

there were 5 patients (62.5%) of surgical

complications of appendicitis. Whereas in the high-

risk group (LRINEC Score 8-13) there were 11

patients (73.3%) with complicated appendicitis.

Previous research by Wong (2004) in the case of

LRINEC score necrotizing fasciitis was able to

classify patients into 3 risk categories low (LRINEC

score <6) with a risk of soft tissue necrosis <50%,

moderate (LRINEC score 6-7) with the risk of

necrosis soft tissue 50-75%, and high (LRINEC

score> 7) with the risk of soft tissue necrosis> 75%.

From the results of Laboratory Risk Indicator for

Necrotizing Fasciitis (LRINEC) correlation

statistical analysis with the findings of operations,

the Pearson correlation coefficient (r) is equal to

.551 or strong. Based on existing criteria, the

relationship between the Laboratory Risk Indicator

variables for Necrotizing Fasciitis (LRINEC) scores

with surgical findings is significant because of the

significance is 0.02. (the significance is < 0.05). The

area under the curve for LRINEC score as a

predictor of cases of pediatric appendicitis in this

study was 0.805 (95% Confident interval, 0.651-

0.960). The cut-off LRINEC score 9 has a positive

predictive value of 78.5% (95% CI) and a negative

predictive value of 62.5% (CI95%). The sensitivity

is 64.7% and the specificity is 76.9%.

Based on research by Chin-Ho Wong and Kok-

Chai Tan in 2014 at Changi General Hospital

Singapore, LRINEC score of more than 5 had a

positive predictive value of 92.0% (95% CI), while a

score of more than 7 had a positive predictive value

of 93.4 %.

Liao et al from Tzu Chi University in 2012

validated LRINEC scores in cases of necrotizing

fasciitis at Tzu Chi General Hospital, Chiayi

Taiwan. From a sample of 3155 patients, it was

concluded that a score of> 5 LRINEC scores had a

sensitivity of 59.2% and a specificity of 83.3%, a

positive predictive ratio of 37.9% and a negative

predictive ratio of 92.5%.

The study by Kaser et al. (2013) concluded that

temperature, heart rate, serum sodium levels, CRP

and leukocytes correlated significantly with

perforated colonic diverticulitis and perforated

appendicitis. Where there was an increase in

temperature (P = 0.029, OR = 1.508), heart rate,

decreased serum sodium level (P = 0.047, OR =

0.912), increase in CRP (P <0.001, OR = 1,006).

Mosele et al (2010) retrospectively assessed

laboratory results in 46 patients with colonic

ischemia proven by biopsy. Higher leukocyte means

scores (P <0.0001), creatinine (P = 0.003), urea

(P=0.008), and lactate dehydrogenase (LDH P

<0.0001) between groups with colon ischemia

compared to the control group.

Montoro et al (2011) prospectively studied 364

patients with definite and probable colonic ischemia.

Leukocytes> 15x109 / l, hemoglobin <12g / dL, and

albumin <2.8g / l were more frequent in patients

with severe ischemic colon.

Anon et al (2006) assessed 85 patients

retrospectively and found that patients with severe

colonic ischemia had a frequency of anemia (Hgb

<12g / dL, 37.5% vs 10.1%; P = 0.012) and

hyponatremia (serum sodium <136mEql / L , 46.6%

vs. 14.9%; P = 0.012) which is high.

Research by Cevikel (2004) concluded that there

was a correlation between CRP levels and bacterial

translocation in obstruction cases. Where an increase

in CRP is parallel with an increase in the number of

colonies forming units (CFU) from lymph node

mesenteric (MLN) and liver cultures (P <0.001)

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104

5 CONCLUSION

LRINEC (Laboratory Risk Indicator for Necrotizing

Fasciitis) score can be applied as a predictor of

necrosis and perforation in cases of pediatric

appendicitis in H. Adam Malik General Hospital

Medan with a cutoff of 9.

LRINEC Score can be included in the clinical

pathway in the policy of preoperative management

of appendix cases in children both BPJS programs

and other insurance programs and as a standard of

service in RSUP. H. Adam Malik Medan.

For further research on antibiotic variables that

have been given as well as secondary infections that

can be included as one of the variables in assessing

LRINEC score as predictors of cases of appendicitis.

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Anon et al. Factors predicting poor prognosis in ischemic

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Cevikel. C-reactive protein may be a marker of bacterial

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ANZ J Surg. 2004 Oct;74(10):900-4.

Chin-Ho Wong and Kok-Chai Tan. The LRINEC

(Laboratory Risk Indicator for Necrotizing Fasciitis)

score A tool for distinguishing necrotizing fasciitis

from other soft tissue infections. Crit Care Med 2004

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Liao et al. Validation of the laboratory risk indicator for

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diagnosis of necrotizing fasciitis. Tzu Chi Medical

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Montoro et al. Clinical patterns and outcomes of

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LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score as a Predictor of Necrosis and Perforation in Cases of Pediatric

Appendicitis in Haji Adam Malik Hospital Medan

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