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Intern Emerg Med (2016) 11:141142

DOI 10.1007/s11739-015-1333-2


Can C-reactive protein and white blood cell count alone rule
out an urgent condition in acute abdominal pain?
Ciro Paolillo1 Ilenia Spallino1 Gruppo di Autoformazione Metodologica (GrAM)

Received: 30 September 2015 / Accepted: 5 October 2015 / Published online: 27 October 2015
 SIMI 2015

Abstract Up to 10 % of all patients at the Emergency determined as part of the workup of patients with an acute
Department present for acute abdominal pain. The C-reac- abdomen, but no data exist on their accuracy in discrimi-
tive protein (CRP) and white blood cell (WBC) are rou- nating between emergent and non-urgent conditions.
tinely determined as part of the workup of patients with
abdominal pain. Three large prospective cohort studies
comprising a total of 2961 adult patients with acute Summary
abdominal pain were selected. CRP levels and WBC counts
were compared between patients with urgent and nonurgent Gans et al. [2] did an individual patient data meta-analysis
final diagnoses. These studies conclude that the laboratory to evaluate the predictive accuracy of CRP level and WBC
values individually are weak discriminators and cannot be count in recognizing emergent conditions requiring
used as a triage instrument in the selection of patients with immediate management. The final diagnosis was based on
acute abdominal pain requiring additional diagnostic tests. all available data, including at least 3 months of follow-up,
and, if available, histopathology, imaging, or surgery
Keywords Abdominal pain  Acute abdomen  C-reactive reports. Emergent conditions were defined as conditions
protein (CRP)  White blood cell (WBC) requiring treatment within 24 h. [3] Three large prospec-
tive cohort studies were selected, comprising a total of
2961 adult patients presenting to the ED with acute
Background abdominal pain. The study designs and baseline charac-
teristics of the three cohorts were comparable. The inclu-
Up to 10 % of all patients in the Emergency Department sion criteria differed between the studies. In one study,
(ED) present for acute abdominal pain [1]. Underlying patients were included only when imaging was deemed
causes can be mild and self-limiting conditions, or can necessary by the treating physician, whereas the other two
require urgent or emergent treatment. Clinical evaluation studies included all consecutive patients with acute
alone is often insufficient to correctly diagnose the under- abdominal pain. In 1352 patients (46 %), the final diag-
lying cause. Furthermore, it is essential to rapidly distin- nosis was classified as emergent and in 1609 patients
guish between patients with an emergent condition, and (54 %) it was classified as non-urgent. The median CRP
those with a non-urgent condition. level was significantly higher in the emergent group
The inflammatory markers, C-reactive protein (CRP) (46.0 mg/L) as compared with the non-urgent group
and white blood cell (WBC) count, are often routinely (9.8 mg/L) (P \ 0.001). The median WBC count was also
significantly higher in the emergent group (12.8 9 109/L)
as compared with the non-urgent group (9.3 9 109/L)
& Ciro Paolillo (P \ 0.001). The usual CRP cutoff (CRP [ 10 mg/L)
leads to a sensitivity of 76.9 % and a specificity of 61.4 %.
SOC Medicina dUrgenza e Pronto Soccorso AOU S. Maria An elevated WBC count (WBC [ 10 9 109/L) shows a
della Misericordia, Udine, UD, Italy sensitivity of 73.9 % and a specificity of 57.5 %. The

142 Intern Emerg Med (2016) 11:141142

combination of an elevated CRP level and WBC count Any biochemical marker alone will hardly have enough
shows a sensitivity of 58.0 % with a specificity of 76.7 %. sensitivity to exclude an emergent condition in the
The median levels of CRP are higher in patients with a setting of abdominal pain. We wonder if combining
longer duration of complaints. The median levels of WBC some clinical clues with the markers would be more
remain the same, regardless of the duration of symptoms. effective and closer to clinical practice.
The authors conclusion is that the discriminatory value of
CRP levels and WBC count as single markers in differ-
entiating emergent from non-urgent conditions in patients
Clinical bottom lines
with acute abdominal pain is low, even with an increased
duration of symptoms.
CRP and WBC count alone are not helpful in the dis-
Overall, CRP levels and WBC count are insufficient
crimination between emergent and non-urgent conditions
markers to be used as a triage instrument in the selection
and cannot be used as a triage instrument in the selection of
for diagnostic imaging. A CRP value or WBC count within
patients with acute abdominal pain requiring additional
the reference range does not rule out an emergent condi-
diagnostic tests.
tion. There is no sufficient cutoff value that can adequately
distinguish patients with an emergent condition. Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict

of interest.
Strengths of the study
Statement of human and animal rights All procedures performed
Three large prospective cohort studies, comprising a in the study involving human participants were in accordance with the
total of 2961 adult patients, have been analyzed and all ethical standards of the institutional and national research committee
and with the 1964 Helsinki declaration and its later amendments or
the original data converted and recorded into a uniform comparable ethical standards. This article does not contain any studies
format; with animal performed by any of the author.
This study addresses a persistent old myth: normal
laboratory studies make an emergent abdominal disease Informed consent Informed consent was obtained from all indi-
vidual participants included in the study.

Weaknesses of the study
1. Gans SL et al (2015) Guidelines for the diagnostic pathway in
patients with acute abdominal pain. Dig Surg 32:2331
The study is an individual patient data meta-analysis; 2. Gans SL et al (2015) C-Reactive protein and white blood cell
however, no systematic search was done. This may count as triage test between urgent and nonurgent conditions in
have led to the exclusion of relevant studies; 2961 patients with acute abdominal pain. Medicine 94(9):19
Even if the characteristics of the patients enrolled in the 3. Lameris W et al (2009) Imaging strategies for detection of urgent
conditions in patients with acute abdominal pain: diagnostic
different studies were similar, no attempt to evaluate accuracy study. BMJ 338:b2431
the heterogeneity between the studies was formally


More information on the characteristics of the included

populations could be helpful to assess the studys
external validity and its applicability to daily practice;

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