Neutrophil-to-Lymphocyte Ratio as a Predictor of Complicated Acute Appendicitis: A Multicenter Retrospective Study in Tunisia

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Published Oct 11, 2026
https://doi.org/10.62438/tunismed.v104i09.7074
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Vol. 104 No. 09 (2026): Tunis Med Sept 2026

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Amina Chaka
General Surgery Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
Houda Ben Ayed
Department of Preventive and Hospital Hygiene, Hedi Cheker Hospital, Sfax, Tunisia
Nizar Kardoun
General Surgery Department, Habib Bourguiba Hospital, Sfax, Tunisia
Amine Zouari
General Surgery Department, Habib Bourguiba Hospital, Sfax, Tunisia
Manel Kadri
Department of Preventive and Hospital Hygiene, Hedi Cheker Hospital, Sfax, Tunisia
Ibtissem Korbi
General Surgery Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
Amine Chaabouni
General Surgery Department, Habib Bourguiba Hospital, Sfax, Tunisia
Sadok Ben Jabra
General Surgery Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
Hanen Zenati
General Surgery Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
Khaled Hadj Mahmoud
General Surgery Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
Sami Fendri
General Surgery Department, Habib Bourguiba Hospital, Sfax, Tunisia
Salah Boujelben
General Surgery Department, Habib Bourguiba Hospital, Sfax, Tunisia
Faouzi Noomen
General Surgery Department, Fattouma Bourguiba Hospital, Monastir, Tunisia

Abstract

Background: Distinguishing complicated from uncomplicated acute appendicitis (AA) at admission remains a clinical challenge with major therapeutic implications. The Neutrophil-to-Lymphocyte Ratio (NLR) has emerged as a promising composite biomarker of systemic inflammatory stress.
Objectives: To evaluate the diagnostic performance of NLR in predicting complicated acute appendicitis (CAA) and determine its optimal cut-off value in a Tunisian surgical population.
Methods: A multicenter retrospective observational study was conducted at the General Surgery departments of CHU Fattouma Bourguiba (Monastir) and CHU Habib Bourguiba (Sfax) over 18 months (June 2024 – December 2025). A total of 380 patients aged ≥16 years who underwent surgery for confirmed AA were included. NLR, PLR, CRP, and WBC were measured at admission. ROC curve analysis was used to assess discriminating performance and determine the optimal cut-off using the Youden index.
Results: Of 380 patients (male-to-female ratio: 1.17; median age: 30 years), 178 (46%) had CAA. NLR was significantly higher in the CAA group (6.2 ± 3.3 vs. 3.7 ± 1.5; p<0.001). ROC analysis revealed an AUROC of 0.75 (95% CI: 0.70–0.80...( abstract truncated at  250 words).

Keywords:

Acute appendicitis, Complicated appendicitis, Neutrophil-to-lymphocyte ratio, NLR, Biomarkers, ROC analysis, Surgical emergency, Tunisia

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