Role of C-Reactive Protein (CRP) in the Prediction of Anastomotic Leakage Following Gastrointestinal Surgery

Anastomotic leak following gastrointestinal surgery is the most serious postoperative complication.1 Anastomotic leakage was defined clinically by peritonitis resulting from the leakage, with signs of acute abdomen (fever, sepsis, pain abdomen), and suspicious quality or fecal discharge from drain wound is present.2 Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery.3 Routine imaging is neither reliable nor cost-effective for the detection of leaks and it carries the drawback of radiation. A serum marker would have great advantages provided that it is cost-effective and sensitive enough to allow safe discharge of the patient.4 C-reactive protein (CRP) has been used for the diagnosis of intra-abdominal surgical infection, as a general marker of an unfavorable postoperative course including surgical and non surgical complication.5-7 Anastomotic leakage increases the duration of in-hospi-tal stay, the risk of reoperation and also can lead to a fatal outcome. Systemic inflammation markers, including C-reactive protein (CRP) and white cell count, have been reported to provide early detection. However, their relative predictive value is unclear. The median normal concentration of CRP is 0.8mg/l, with 90 % of apparently healthy individual having value less than 3mg/l and 99 % less than 12mg/l. So, the reference range for CRP is 0-10 mg/l.8 C-reactive protein greater than 14 mg/l is sensitive and specific marker for anastomotic leak. C-reactive protein (CRP) test is done to check for infection after surgery. CRP levels normally rise within 2 to 6 hours of surgery and then go down by the third day after surgery. If CRP levels stay elevated 3 days after surgery, an infection may be present. Normal CRP values vary from lab to lab. Generally, there is no CRP detectable in the blood or there is little CRP in blood serum. The normal level of CRP is less than 10 mg/dl, and patient who have elevation greater than 150 mg/dl, usually have severe disease. C-reactive protein (CRP) is an acute phase protein synthesized by the liver, which levels raise in response to inflammation.9 It is a member of the pentraxin family of proteins.10 Human serum contains two pentraxins, c-reactive protein (CRP) and serum amyloid p component (SAP), are located on the proximal long arm of chromosome 1.11 C-reactive protein was the first pattern recognition receptor (PRR) to be identified.10 It has 224 amino acids, 11 has a monomer molecular mass of 25106 Da, The most striking difference between CRP and SAP is manifested during the acute phase response to inflammation. Whereas human SAP is expressed constitutely at relatively constant serum levels, C-reactive protein increases in concentration by up to 1000-fold in response to an inflammatory stimulus. C-reactive protein originally identified as a component present in the plasma of patients with acute infections, binds to the c-polysaccharide of streptococcus pneumoniae. Subsequently, it has been shown to have several immune related activities, for opsonisation of bacterial cell surfaces and activation of complement and to act as a scavenger for chromatin released by dead cells during inflammatory episodes. It plays a role in innate immunity as an early defense system against infections. CRP rises within two hours of the onset of inflammation, up to a 50, 000-fold, and peaks at 48 hours. Its half-life of 48 hours is constant, and therefore its level is determined by the rate of production and hence the severity of the precipitating cause. CRP is thus a screen for inflammation. CRP is used mainly as a marker of inflammation. Apart from liver failure, there are few known factors that interfere with CRP production.9 Measuring and charting CRP values can prove useful in determining disease progress or the effectiveness of treatments. ELISA, immunoturbidimetry, rapid immunodiffusion and visual agglutination are all methods used to measure CRP. A high-sensitivity CRP (hs-CRP) test measures low levels of CRP using laser nephelometry. The test gives results in 25 minutes with sensitivity down to 0.04 mg/L. CRP is not diagnostic of any condition, but it can be used together with signs and symptoms and other tests to evaluate an individual for an acute or chronic inflammatory condition. CRP is a more sensitive and accurate reflection of the acute phase response than the ESR (Erythrocyte Sedimentation Rate).12 ESR may be normal and CRP elevated. CRP returns to normal more quickly than ESR in response to therapy. Some medications - such as birth control pills, statins, nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Advil, Motrin, others), and acetaminophen (Tylenol, others) can affect your CRP level. Normal concentration in healthy human serum is usually lower than 10 mg/L, slightly increasing with aging. Higher levels are found in late pregnant women, mild inflammation and viral