Clinical, laboratory, operative, and appendiceal morphometric correlates of histopathological appendicitis severity: A retrospective cohort study from Palestine

Background Clinical, laboratory, and imaging correlates of complicated appendicitis are well studied, but routinely recorded gross-pathology morphometrics and pathology-confirmed evidence from Palestine are less well characterized. We evaluated correlates of histopathological severity and adjusted associations with complicated appendicitis. Methods This retrospective cohort included appendectomy encounters at Al-Makassed Islamic Charitable Society Hospital from December 2015 to July 2025. Source reconciliation identified 1,287 unique encounters; 245 histologically normal appendices and 32 records without a classifiable severity category were excluded, leaving 1,010 patients. Complicated appendicitis was defined as gangrenous or perforated disease. Group comparisons used chi-square or Monte Carlo exact tests and Kruskal-Wallis tests. A prespecified logistic model included age, sex, appendicolith, white blood cell count (WBC), and C-reactive protein (CRP). Results The cohort included 227 catarrhal/simple, 458 suppurative, 262 gangrenous, and 63 perforated cases. Operative approach, nausea and/or vomiting, other intraoperative findings, appendicolith, WBC, neutrophil percentage, operative duration, and hospital stay differed across severity categories. In the adjusted model (n = 991), appendicolith was associated with higher odds of complicated appendicitis (adjusted odds ratio 2.20, 95% confidence interval 1.37–3.52; P = 0.001), whereas WBC showed an unexpected inverse association (adjusted odds ratio 0.938 per 1 × 10⁹/L, 95% confidence interval 0.906–0.971; P < 0.001). Age, sex, and CRP were not independently associated. Discrimination was weak (area under the receiver operating characteristic curve 0.594, 95% confidence interval 0.557–0.632). Maximum diameter, wall thickness, and appendix length showed no significant adjusted linear associations. Conclusions Appendicolith was associated with complicated appendicitis, but weak discrimination and limited explained variation preclude use of the model as a clinical prediction tool. The inverse WBC association and negative linear morphometric findings require cautious interpretation.