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EDITORIALS: Spencer W Beasley Can we improve diagnosis of acute appendicitis? BMJ 2000; 321: 907-908 [Full text]

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We can improve diagnosis of acute appendicitis

Susan Clamp   (19 October 2000)

Another view of appendicitis by Zachary-Cope

Rupert Negus   (20 October 2000)

Improving the diagnosis of appendicitis

Guy Nash   (28 October 2000)

Appendicitis Exemplifying Universal Disorders

M G Baggot   (13 November 2000)

CT scanning can improve the diagnosis of acute appendicitis

John Buckingham   (20 November 2000)

Other methods of diagnosis

Faisal.R Khan, Dr.Zain-ul-Abadin   (12 August 2006)

We can improve diagnosis of acute appendicitis 19 October 2000
Susan Clamp, Lecturer Clinical Information Science Unit, School of Medicine, University of Leeds Send response to journal: Re: We can improve diagnosis of acute appendicitis	Sir Zachary Cope's view that "the diagnosis of appendicitis is usually not especially difficult" was limited by his statement that "Acute appendicitis can mimic initially any intra-abdominal process". A negative appendectomy rate of 20-40% in young women supports this view. Although diagnosis may be straightforward in some cases the misdiagnosis of acute appendicitis results in high costs for patients and the NHS, despite the use of technologies such as ultrasound and laparoscopy1. Cope's first principle was the need to take a thorough history and physical examination. The fact that the rate of adverse outcomes (perforation, negative appendectomy, and unnecessary admissions) has not improved over the last 20 years indicates that the training of junior staff in this area has not improved. There has been complacency among the medical profession regarding the diagnosis of acute abdominal pain. This complacency is reflected in the fact that in the UK, unlike in many other countries in Europe, it is junior doctors, with limited experience, who often make the first decisions. It is unreasonable to expect them to have the same experience as more senior clinicians in this difficult area. One way to address the problem could be to implement the use of decision aids. However the scoring systems referred to by Professor Beasley as having shown improvements in clinical performance have not been integrated into the routine clinical practice. Douglas et al2 are to be congratulated for setting up a RCT investigating the role of ultrasound and the Alvarado score in improving diagnosis in appendicitis. I would suggest that one of the reasons they did not show a reduction in adverse outcomes is due to the fact that these techniques do not address the problem of poor clinical skills and in fact are imposed on top of this problem. The only decision support system shown to reduce adverse outcomes in real clinical situations has been the one developed in Leeds, now enhanced to form "AAPHelp" 3456. The success of the Leeds program may well be because it does act as an 'ongoing stimulus to good clinical practice' and is built on the need to take a good clinical history and examination7. However, with a few exceptions, it has not become a routine clinical procedure for diagnosis in AAP. The reasons for this are not simply to do with the program, but include the working environments, the prevailing cultures and the structures in the NHS. It seems to me therefore that the problems indicated are at least two fold: · The failure to appreciate that the use of scoring systems and technologies are not a substitute for good clinical skills. · The cultures and structures that prevent effective decision support tools being adopted as diagnostic procedures. Further studies are needed not only into improving the care of patients with abdominal pain but also to look at ways that effective decision aids can become an integrated part of the routine clinical practice. References 1 Sheriden WG, Harvard T, White AT, Crosby DL. Non-Specific Abdominal Pain: the resource implications. Ann Roy Coll Surg Eng 1992;74:181-185 2 Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000;321:1-6 3 Adams ID, Chan M, Clifford PC, Cooke WM, Dallos V, de Dombal FT, Edwards MH, Hancock DM, Hewett DJ, McIntyre N, Somerville PG, Spiegelhalter DJ, Wellwood J, Wilson DH. Computer aided diagnosis of acute abdominal pain: a multicentre study. BMJ 1986;293:800-4. 4 McAdam WAF, Brock BM, Armitage T, Davenport P, de Dombal FT. Twelve years experience of computer-aided diagnosis in a District General Hospital. Ann Roy. Coll. Surg 1990;72: 140-6. 5 Gunn AA. The acute abdomen: the role of computer-assisted diagnosis. Baillieres Clinical Gastroenterology. 1991; 5:639-663 6 de Dombal FT, de Baere H, van Elk PJ, Fingerhut A, Henriques J, Lavelle SM, Malizia G, Ohmann C, Pera C, Sitter H, Tsfitsis D. Objective Medical Decision Making - Acute abdominal pain. In Advances in Biomedical Engineering. Eds Beneken JEW, Thevenin V. Amsterdam: IOS Press 1993: 65- 87. 7 de Dombal FT, Dallos V, McAdam WAF. Can computer aided teaching packages improve clinical care in patients with acute abdominal pain? BMJ 1991; 302:1495-1497
Another view of appendicitis by Zachary-Cope 20 October 2000
Rupert Negus, Specialist Registrar in Gastroenterology St Mary's Hospital, London, W2 Send response to journal: Re: Another view of appendicitis by Zachary-Cope	Dear Sir, The recent editorial concerning the diagnosis of acute appendicitis1 quotes Sir Zachary Cope as writing 'Diagnosis of appendicitis is usually easy'2. However, he also wrote as the poet Zeta, and he had the following to say about acute appendicitis in 'The Acute Abdomen in Rhyme'3; Of all the ills within the abdomen Which cause affliction to the sons of men There's none more often puts them in a fix Than trouble in the worm-like appendix- That caecal tail which sometimes tells a story Or figures in a scene which may be gory, That arch-deceiver, symbol of the devil Which leads to every kind of septic evil, That unexploded bomb which soon or late Aperients may serve to detonate; That worm which often turns to bad effect And makes us treat it with a great respect, That foul assassin whose supreme delight Choosing the place and knowing well the site To stab below the belt and on the right is Causing that dread disease - appendicitis. Rupert Negus Specialist Registrar in Gastroenterology St Mary's Hospital, South Wharf Road, London, W2 1NY E mail rpmnegus75@hotmail.com 1. Beasley SW. Can we improve the diagnosis of acute appendicitis? BMJ 2000;321:907-8 (14 October). 2. Cope Z. The early diagnosis of the acute abdomen. 14th ed. London, Oxford University Press, 1972. 3. Zeta. The acute abdomen in rhyme. 2nd ed. London, H.K. Lewis & Co. Ltd, 1949.
Improving the diagnosis of appendicitis 28 October 2000
Guy Nash Send response to journal: Re: Improving the diagnosis of appendicitis	Editor - In response to Prof. Beasley's editorial 'Can we improve diagnosis of acute appendicitis', focus is placed upon the limited role of ultrasonography in this setting1. Interestingly, both computer assistance and barium enema have previously been shown to improve diagnostic accuracy, thus reducing negative laparotomy rates2. The article however does not mention the investigative procedure that perhaps shows most promise in improving diagnostic accuracy. As long ago as 1973, Sugarbaker and colleagues demonstrated that laparoscopy performed in patients with acute abdominal pain where the diagnosis was uncertain prevented unnecessary laparotomy3. Diagnostic laparoscopy, particularly in women of child- bearing age, has been demonstrated by many studies as a safe method to reduce negative appendicectomy rate when diagnostic uncertainty exists4,5. Rates of unnecessary appendicectomy, as high as 30 per cent, have created a strong argument amongst surgeons that all women with suspected appendicitis should undergo laparoscopy prior to open surgery being considered. Guy Nash general surgical registrar Hammersmith Hospital, DuCane Rd., London W12 OHS 1. Beasley SW. Can we improve diagnosis of acute appendicitis? BMJ 2000;321:907-8 2. Hoffmann J, Rasmussen OO. Aids in the diagnosis of acute appendicitis. British Journal of Surgery 1989;76(8):774-9. 3. Sugarbaker PH, Sanders JH, Bloom BS, Wilson RE. Preoperative laparoscopy in diagnosis of acute abdominal pain. Lancet 1975;1(7904):442- 5. 4. Borgstein PJ, Gordijn RV, Eijsbouts QA, Cuesta MA. Acute appendicitis--a clear-cut case in men, a guessing game in young women. A prospective study on the role of laparoscopy. Surgical Endoscopy 1997;11(9):923-7. 5. Thorell A, Grondal S, Schedvins K, Wallin G. Value of diagnostic laparoscopy in fertile women with suspected appendicitis. European Journal of Surgery 1999;165(8):751-4.
Appendicitis Exemplifying Universal Disorders 13 November 2000
M G Baggot, Staff physician Bellefountaine Rehabilitation Center Send response to journal: Re: Appendicitis Exemplifying Universal Disorders	APPENDICITIS EXEMPLIFYING UNIVERSAL DISORDERS Dr. Beasley's editorial about appendicitis is timely (B.M.J. October 14, 2000). Appendicitis comes in many forms without/with potential pathogens. Consequently its diagnosis can be difficult. It is a contractile chamber1 like the uterus, stomach, duodenum, heart, etc. As such it is prone to universal characteristic inherent disorders. These include mural spasm and endocameral hypertension which may be merely painful cramps or progress to mural rupture, complete or incomplete. An incomplete mural tear occurs superficially as ulceration or deeply as an endoparenchymal intralaminar breach e.g. diverticulum, dissecting aneurysm, pneumotosis intestinalis, pulmonic interstitial emphysema, interstitial cystitis etc. Mural hypertension proceeding to rupture causes hemorrhage and/or dislocation of the organ's contents into adjacent but inappropriate locations. Typical examples include air in the pleural cavity, fetus in the peritoneal cavity, bowel in the scrotum, blood in the internal capsule, milk in the interstitial tissues of the breast, sebum in the cutaneous parenchyma, and chyme in the appendicular mural tissues. Not all bad,2 bugs are not independently mobile. They cannot select and attack a prey. Their presence and actions depend on other factors--a mosquito, deer tick, traumatic or spontaneous breach in the integument, etc. Appendicitis begins as painful mural labor when its tight sphincter resists its discharging. This commonplace periodic conflict may resolve spontaneously, but sometimes desiccated fecal residue remains to become a fecolith. Otherwise mounting endocameral hypertension will ulcerate the wall and explode the organ's contents into or through that wall. When those fillings are merely chyme there will be just a foreign body reaction and inflammation in the mural tissues. Aseptic cellulitis can resolve with local primitive digestion and resorption. Potential pathogens if not initially present in the dislocated chyme, sooner or later normally passing through the bowels, abnormally will escape through the idiopathic mural perforation. Then they start to scavenge, resorb and recycle the chyme and damaged mural tissues. We eat animals, fish and fowl so carnivora and pathogens eat and recycle us to maintain the balance of Nature. Otherwise we would be stumbling over carcasses and skeletons dating back to before Adam and Eve, if stenches had not already killed us. The patient who starts with a more or less aseptic appendicitis3 when recovering spontaneously will get a serious setback when a party of opportunists happen to find the initial idiopathic perforation. The bugs will escape into and through the wall and start to recycle not just the dislocated chyme and damaged mural tissues but the whole patient. Surgeons are unfairly accused of removing normal appendixes when they properly excise organs in the early stages of idiopathic perforation. Aseptic appendicitis may resolve spontaneously but the condition is apt to recur and sooner or later the relapse will be complicated by marauding bugs eager to recycle the entire patient. Since this organ seems expendable, some people, for example those planning a trip to the South Pole or the Moon, even though healthy, should have this chamber removed lest it turn lethal when surgery would not be possible. In first world countries today the operation is quite safe. So suspicious behavior of a potential killer justifies its excision. M.G. Baggot, M.D P.O. Box 697, 2650 Edison Avenue, Granite City, IL 62040 1 Baggot, M.G. The Universal Muscular Chamber. A Basic Unit of the Genitourinary, cardio vascular, gastro-intestinal, skeletal, cutaneous, respiratory and other systems. Endocameral hypertension and spasm the key to their idiopathic diseases and arthropathies. Medical Hypotheses. 5:591 -597. (1979). 2 Baggot, M.G. The Big Bang and its Universal Hernias. A Sire of Pathologies. Medical Hypotheses. (1991). 35:136-139. 3 Baggot, M.G. Aseptic appendicitis, exemplifying the Universal Disorder, namely muscular and endocameral hypertension, which iniates various secondary diseases including infections. Medical Hypotheses. (1999). 53 (5) 429-431
CT scanning can improve the diagnosis of acute appendicitis 20 November 2000
John Buckingham Send response to journal: Re: CT scanning can improve the diagnosis of acute appendicitis	EDITOR - I was very surprised to read the lead editorial by Beasley(1) that no mention of CT scanning as an aid in the case of equivical appendicitis. CT scanning in such cases has an increasingly established role(2), is very simple and quick to organise from the casualty department or docors office, leads to less hospitalisation in negative cases and speedier surgery where positive. I recommend your readers consider it as an aid where the diagnosis is doubtful. John Buckingham,general surgeon Calvary Clinic, Bruce, ACT., Australia. 1. Beasley. S.W.Can we improve the diagnosis of acute appendicitis?BMJ2000;321:907-908 2. Cho,C.O.,Buckingham,J.M.,Pierce,M. and ardman,D.T:Computed Tomography in the diagnosis of equivical appendicitis.Aust.N.Z.J.Surg(1999)69.664-667.
Other methods of diagnosis 12 August 2006
Faisal.R Khan, FP2 ysbyty gwynedd bangor,wales, Dr.Zain-ul-Abadin Send response to journal: Re: Other methods of diagnosis	Dear Sir Misdiagnosis of appendicitis is a comon and cruicial problem in general surgery.And for the best posible accurate diagnosis different methods are used till now,but in reality making a diagnosis of appendicitis is really tricky. It may includes ,diffrent scoring systems like Akverodo,Combined appendicitis score and many more.The use of ultrasound in diagnosis is know adays very popular and diffreent studies have proved the effectiveness of its importance as well.In a study by Roe at el(1),explains the importance of CT scan in diagnosis.The role of nuclear scans in the diagnosis of appendicitis is highlighted by Wong at el(2). But no one has mentuioned the role of laproscopy in the diagnosis of appendicitis in this article or in the responses.In a study by L L Leepe (3),shows that it can reduce the negative appendicectomy from 10% to 1%. But a population based analysis(4),suggests that on a population level diagnosis of appendicitis has not improved with the avalability of advanced diagnostic tools. In my view ,the most reliable clinical method is repeated clinical examination,but it also includes the experience of examiners as well.The progression of clinical features should be the guide in furthter treatment with the help of advance diagnostic aids. Refferences : !);New England Journal of Medicine 338:3 Jan 15 1998 (141-146) Rao et al. Effect of Computed Tomography of the Appendix on Treatment of Patients and Use of Hospital Resources 2);Journal of the American College of Surgeons December 1997(535-543) Wong et al. Rapid Detection of Acute Appendicitis with Tc-99m Labeled Intact Polyvalent Human Immune Globulin 3); Ann Surg. 1980 April; 191(4): 410–413. 4); David R. Flum, MD; Arden Morris, MD; Thomas Koepsell, MD; E. Patchen Dellinger, MD JAMA. 2001;286:1748-1753 Competing interests: None declared