Ultrasonography may complement clinical assessment in some patients

Papers p 919

“Diagnosis of appendicitis is usually easy”—thus wrote Sir Zachary Cope, but with the rider: “but there are difficulties which need to be discussed.”1 The essential features of appendicitis are well known to most clinicians; there is gradual onset of central abdominal pain, often followed by vomiting, with localisation of the pain to the right iliac fossa. Localised tenderness and evidence of peritoneal inflammation (guarding and percussion tenderness) make the diagnosis probable. Clinical diagnosis is based on showing that movement between adjacent inflamed peritoneal surfaces causes pain.2 Laboratory investigations usually contribute little and can be misleading. For example, the proportion of gangrenous and perforated appendixes in patients with a normal white count is the same as in those with an raised count.3 The diagnosis is essentially a clinical one—or so it would seem.

The “difficulty” alluded to by Cope relates to our inability to reliably diagnose appendicitis on clinical grounds. The vagaries …