Diagnosing acute appendicitis: is there any role of ultrasonography?

We read with interest the article titled ‘‘Examining the Relevance of the Physician’s Clinical Assessment and the Reliance on Computed Tomography in Diagnosing Acute Appendicitis’’ by Nelson et al in the April 2013 issue of the American Journal of Surgery. The study highlights the importance of clinical decision making as well the role of computed tomography (CT) in the diagnosis and management of acute appendicitis (AA). We have the following comments. The study reflects the liberal use of CT for the diagnosis of AA. The authors mention that the negative appendectomy rate on the basis of clinical assessment consistent with appendicitis was 4%, compared with 3% associated with CT. It is also mentioned that 82% of the cohort underwent CT regardless of the initial clinical impression. The authors mention that in a random sample of 100 cases, in 87%, the initial emergency department plan was based on computed tomographic findings. All these facts and figures indicate that findings on CT may have possibly influenced clinical decision making. Achieving a negative appendectomy rate of 4% with clinical assessment alone without any corresponding increase in the perforation or complication rate is a great accomplishment, which we think is virtually impossible. The exact negative appendectomy rate and perforation rate associated with clinical diagnosis can only be evaluated when the decision to operate is based solely on the clinical assessment and in a group of patients who preferably do not undergo any imaging test or at least the treating surgeon is blinded to the results of the imaging. The present study does not mention any of these factors. The study population consisted of young adults with a mean age of 31 6 16 years. Hence the data do not represent a true cross-section of the general population, including children. It may be noted here that clinical diagnosis of uncomplicated AA in young male patients is often straightforward. Women of reproductive age formed a sizable group of patients (37%) in this study. It is well