Diagnosis of acute appendicitis

Editor—We read with interest the randomised controlled trial of ultrasonography in the diagnosis of acute appendicitis reported by Douglas et al.¹ This trial would add more to the literature if it were to acknowledge sex differences in the management of abdominal pain.

On every surgical take, the investigation of pain in the right iliac fossa differs between men and women. Often women have an ultrasound examination 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 pain in the right iliac fossa 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 pain in the right iliac fossa from the first three months of 2000 at the Royal Infirmary of Edinburgh. Of 30 men, three (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 (seven out of eight, one confirmed appendix mass) and had been used to exclude alternative diagnoses before appendicectomy.

A Medline search of the past two years did not find any papers in which men and women had been considered separately with regard to ultrasonography in appendicitis. Meaningful data can come only from trials that separate men and women. We would be interested to see if Douglas et al had separate data available.