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LETTERS: Stephen Attwood and Peter F Jones Ultrasonography in diagnosis of acute appendicitis BMJ 2001; 322: 615 [Full text]

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?Appendicitis” is a separate clinical entity in men and women

Luke Devey, James Henderson, Christian Wakefield   (13 March 2001)

Gender data from Douglas et al

Charles Douglas   (7 April 2001)

?Appendicitis” is a separate clinical entity in men and women 13 March 2001
Luke Devey, Basic Surgical Trainee, Basic Surgical Trainee, Lecturer in surgery The Royal Infirmary of Edinburgh, Edinburgh EH3 9DY, James Henderson, Christian Wakefield Send response to journal: Re: ?Appendicitis” is a separate clinical entity in men and women	EDITOR: We read with interest the randomised controlled trial of ultrasonography in the diagnosis of acute appendicitis by Douglas et al (BMJ 321: 919-922, 14/10/2000). It is our opinion that this trial would add more to the literature if it were to acknowledge the obvious sex differences in the management of abdominal pain. On every surgical take, the investigation of right iliac fossa pain differs between men and women. Frequently, women undergo ultrasound of the pelvis and abdomen primarily to exclude gynaecological or pelvic pathology. Conversely, men are much more commonly assessed by repeated clinical examination. Given the marked difference in the differential diagnosis of Right Iliac Fossa pain in men and women, we argue that it should be seen as two separate clinical problems. To illustrate the above difference, we performed a retrospective analysis of 59 consecutive cases of right iliac fossa pain from the first three months of 2000 at the Royal Infirmary of Edinburgh. Of 30 men, 3 (10%) underwent ultrasound examination compared with 14 of 29 women (48%). Of those women who underwent ultrasound and subsequent appendicectomy, the ultrasound examination was usually negative (7 out of 8, 1 confirmed appendix mass) and had been used to exclude alternative diagnoses prior to appendicectomy. A “Medline” search of the last two years failed to find any papers in which men and women had been considered separately with regard to ultrsasonograpy in appendicitis. It is our belief that meaningful data can only come from trials which separate men and women. We would be interested to see if Douglas et al had separate data available. Dr Luke Devey. Basic Surgical Trainee Dr James Henderson. Basic Surgical Trainee Mr Christian Wakefield FRCS. Lecturer in surgery The Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EH3 9DY
Gender data from Douglas et al 7 April 2001
Charles Douglas, Surgical registrar John Hunter Hospital, NSW, Australia Send response to journal: Re: Gender data from Douglas et al	Thankyou for raising the question of gender, which we did not address in the original article in the interests of being concise. It is well recognised that the diagnosis of appendicitis in women is harder, principally due to a number of alternative gynaecological causes for pain. In our study, 10 of 73 women (13.6%) in the control group had a non- therapeutic operation, compared to 9/73 (12.3%) in the intervention group. In males, the numbers were 5/69 (7.2%) in the control group and 5/87(5.7%)in the intervention group. Numbers of cases of delayed treatment in association with perforation (DTAP) were as follows: in females, control 1/73, intervention 2/73; and in males, control 1/69, intervention 3/87. Mean duration of stay was slightly longer in men, but did not differ between groups on gender subgroup analysis. Time to therapeutic operation differed between groups, much as it did in the overall analysis, but the difference did not reach statistical significance in the male subgroup analysis. In short, although there are gender differences that affect diagnosis and subsequent management, there is no evidence that ultrasonography improves outcomes in either subgroup.