Serum cortisol level as a useful predictor of surgical disease in patients with acute abdominal pain

Introduction. The immediate aim should be to identify potentially resuscitative acute abdominal pain that requires prompt investigation or early surgical interven-tion. We aimed to evaluate whether serum cortisol levels differentiate surgical and non-surgical disease in patients with acute abdominal pain. 

Materials and methods. In this prospec-tive cross-sectional study, the primary end-point was defined as differences in serum cortisol levels between surgically and non-surgically treated patients with non-traumatic acute abdominal pain. The secondary end-point was to compare the cortisol levels with defined complete blood count (CBC) parameters in those groups. Results. One hundred eleven patients with acute abdominal pain were included in the study. Three most frequent diagnoses were nonspecific abdominal pain, acute appendicitis and dyspeptic complaints. Thirty patients were hospitalized and 22 of them were operated. The median cortisol level was 23.13 µg/dl in surgically treated patients and 13.94 µg/dl in non-surgically treated patients (p<0.001). The area under the ROC curve using cortisol to detect surgical disease was 0.750 (95% CI, 0.659-0.827) and the accuracy of cortisol to de-tect surgical disease was not inferior to de-fined CBC parameters. A cortisol value of 17.98 µg/dl had a sensitivity of 67.4% and a specificity of 77.3% for surgical disease. Conclusion. Operated patients had higher serum cortisol levels. High serum cortisol levels may indicate surgical disease at the early stage on admission in ED patients with acute abdominal pain and may be used as a marker in the prediction of acute surgical abdomen.

abdominal pain, cortisol, emer-gency department, surgery

1. National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables (cited 2018 August 15). Avail-able from: https://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf

2. Nagurney JT, Brown DF, Chang Y, Sane S, Wang AC, Weiner JB. Use of diagnostic testing in the emergency department for patients presenting with non-traumatic abdominal pain. J Emerg Med 2003;25(4):363–71.

3. Widmer IE, Puder JJ, König C, Pargger H, Zerkowski HR, Girard J, et al. Cortisol response in relation to the severity of stress and illness. J Clin Endocrinol Metab 2005;90:4579-86.

4. Beishuizen A, Thijs LG, Verries I. Patterns of corticosteroid binding globulin and free cortisol index during septic shock and multi trauma. Intensive Care Med 2001;27:1584-91.

5. Lovallo WR, Farag NH, Vincent AS, Thomas TL, Wilson MF. Cortisol responses to mental stress, exercise, and meals following caf-feine intake in men and women. Pharmacol Biochem Behav 2006;83:441-7.

6. King A, Munisamy G, de Wit H, Lin S. Attenuated cortisol response to alcohol in heavy social drinkers. Int J Psychophysiol 2006;59:203-9.

7. Coiro V, Capretti L, Volpi R, Davoli C, Marcato A, Cavazzini U, et al. Stimulation of ACTH/cortisol by intravenously infused sub-stance P in normal men: inhibition by sodium valproate. Neuroendocrinology 1992;56:459-63.

8. Vaughan GM, Becker RA, Allen JP, Goodwin CW Jr, Pruitt BA Jr, Mason AD Jr. Cortisol and corticotrophin in burned patients. J Trauma 1982;22:263-73.

9. Salluh JI, Shinotsuka CR, Soares M, Bozza FA, Lapa e Silva JR, Tura BR, et al. Cortisol levels and adrenal response in severe commu-nity-acquired pneumonia: A systematic review of the literature. J Crit Care 2010;25:541.e1-8.

10. Remmelts HH, Meijvis SC, Kovaleva A, Biesma DH, Rijkers GT, Heijligenberg R. Changes in serum cortisol levels during communi-ty-acquired pneumonia: the influence of dexamethasone. Respir Med 2012;106:905-8.

11. Yamaji M, Tsutamoto T, Kawahara C, Nishiyama K, Yamamoto T, Fujii M, et al. Serum cortisol as a useful predictor of cardiac events in patients with chronic heart failure: the impact of oxidative stress. Circ Heart Fail 2009;2:608-15.

12. Ito T, Saitoh D, Takasu A, Kiyozumi T, Sakamoto T, Okada Y. Serum cortisol as a predictive marker of the outcome in patients resus-citated after cardiopulmonary arrest. Resuscitation 2004;62(1):55-60.

13. Gracia-Iguacel C, González-Parra E, Egido J, Lindholm B, Mahillo I, Carrero JJ, et al. Cortisol levels are associated with mortality risk in hemodialysis patients. Clin Nephrol 2014;82:247-56.

14. Glumac S, Kardum G, Karanović N. A Prospective Cohort Evaluation of the Cortisol Response to Cardiac Surgery with Occurrence of Early Postoperative Cognitive Decline. Med Sci Monit 2018 Feb 17;24:977-86.

15. Dikme O, Dikme O. Serum Cortisol as a Predictor of Major Adverse Pulmonary Event in Emergency Department Acutely Dyspneic Patients. Emerg Med Int Volume 2018, Article ID 1758643.

16. Strittmatter M, Bianchi O, Ostertag D, Grauer M, Paulus C, Fischer C, et al. Altered function of the hypothalamic-pituitary-adrenal axis in patients with acute, chronic and episodic pain. Schmerz 2005;19(2):109-16.

17. Tennant F. The Physiologic Effects of Pain on the Endocrine System. Pain Ther 2013;2(2):75–86.

18. Pitts SR, Niska RW, Xu J, Burt CW.National Hospital Ambulatory Medical Care Survey 2006 emergency department summary. Natl Health Stat Report 2008;7:1-38.

19. Abbas SM, Smithers T, Truter E. What clinical and laboratory parameters determine significant intraabdominal pathology for pa-tients assessed in hospital with acute abdominal pain? World J Emerg Surg 2007;25;2:26.

20. Lukens TW, Emerman C, Effron D. The natural history and clinical findings in undifferentiated abdominal pain. Ann Emerg Med 1993;22:690-6.

21. Parker JS, Vukov LF, Wollan PC. Abdominal pain in the elderly: use of temperature and laboratory testing to screen for surgical disease. Fam Med 1996;28:193-7.

22. Markar SR, Karthikesalingam A, Falzon A, Kan Y. The diagnostic value of neutrophil: lymphocyte ratio in adults with suspected acute appendicitis. Acta Chir Belg 2010;110(5):543-7.

23. Cigsar G, Yildirim AC, Anuk T, Guzel H, Gunal E, Gulkan S, et al. Neutrophil to Lymphocyte Ratio on Appendectomy of Geriatric and Nongeriatric Patients. J Invest Surg 2017;30(5):285-90.

24. Tanrikulu Y, Sen Tanrikulu C, Sabuncuoglu MZ, Kokturk F, Temi V, Bicakci E. Is the neutrophil-to-lymphocyte ratio a potential diagnostic marker for peptic ulcer perforation? A retrospective cohort study. Am J Emerg Med 2016;34(3):403-6.