Letters to the Editor

Sir,

Re: Alvarado score: an admission criterion in patients with right iliac fossa pain. Surg J R Coll Surg Edinb Irel 2003; 1: 39-41.

We read with interest the article by Chan et al. (2003). Though the Alvarado scoring system is useful in the evaluation of acute appendicitis, there are certain discrepancies in this study which we would like to highlight:

• The study, which included 45 females, did not describe the specificity and sensitivity of the Alvarado score in these different groups. Studies have shown that even with scores of 7 and above, more than one third of the women did not have an inflamed appendix ^2,3 Hence, our recommendation is an outpatient ultrasonography for such women, particularly of child bearing age, in the emergency department before admission.
  

• The Alvarado score was first described in 1986 and not in 1988.

• The laboratory findings of a shift of the neutrophils to the left of more than 75% (Score 1) is not done routinely in the majority of emergency laboratories. Thus, the Alvarado score is mostly scored out of 9 rather than 10.

REFERENCES

1. Chan MYP, Tan C, Chiu MT, Ng YY. Alvarado score: an admission criterion in patients with right iliac fossa pain. Surg J R Coll Surg Edinb Irel 2003; 1: 39-41.
2. Malik AA, Wani NA. Continuing diagnostic challenge of acute appendicitis: Evaluation through Modified Alvarado score Aust NZ J Surg 1998; 68: 504-5.
3. Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study Ann R Coll Surg Engl 1994; 76: 418-19.

Yours sincerely,

Mr K. Bhattacharya Mr A.N. Cathrine Department of Surgery Sri Ramachandra Medical College India

Sir,

We would like to thank Dr Bhattacharya and Dr Cathrine for their interest and comments on our article. The purpose of our study was to examine whether the Alvarado score could be used as an admission criterion in patients with right iliac fossa pain in the outpatient setting i.e. to select patients for observation who had a low Alvarado score. This study was not designed to look at the accuracy of a high Alvarado score in aiding the diagnosis of appendicitis. Indeed, several studies have shown that the Alvarado score is less accurate in females in the diagnosis of acute appendicits with a 22-33% negative appendicectomy rate.1 Ultrasound examination has been used as an adjunct to the diagnosis of appendicitis but it also has its disadvantages.2 The Alvarado score was first described in 1986 as reflected in our reference. Finally, in our practice, the laboratory result of a full blood count will include both the total white as well as the differential count and, thus, the Alvarado score can be calculated with a maximum score of 10.

REFERENCES
1. Malik AA, Wani NA. Continuing diagnostic challenge of acute appendicitis: evaluation through modified Alvarado score. Aust N Z J Surg 1998; 68:504-5.
2. Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of Alvarado score in acute appendicitis. J R Soc Med 1992; 85:87-9.
3. Rao PM, Boland GWL. Imaging of acute right lower abdominal quadrant pain. Clin Radiol 1998; 53:639-49.

Yours sincerely,

Mr M.Y.P. Chan Department of Surgery, Tan Tock Seng Hospital 11 Jalan Tan Tock Seng, Singapore 308433

Sir,

Re: Alvarado score: an admission criterion in patients with right iliac fossa pain. Surg J R Coll Edinb Irel 1; 2003(1):39-41.

I read with interest the article by Chan et al. (2003). Acute appendicitis or rather right iliac fossa pain is by far the commonest complaint for which a surgical referral is sought. The author’s observation on the use of the Alvarado score, as an admission criterion, certainly does appear to be a useful tool in their hands and for their group of patients.

We feel, however, that the authors have set out on an exercise, which definitely must have been time consuming and labour intensive but with a flawed goal. The authors rightly admit that acute appendicitis or, for that matter, right iliac fossa pain is difficult to diagnose and that good clinical acumen remains the mainstay of management.¹ Nonetheless, they then embark on trying to treat patients based on a scoring system which has not been properly validated and has certainly not been incorporated widely into clinical practice, although it was introduced nearly two decades ago.² The literature abounds with different scoring systems in this setting, the Ohmann and Eiskelinen scores to name a few, all of which have been found to be unreliable.³ The A&E departments are usually manned by junior doctors and to make a recommendation to base their admissions on a non-validated scoring system is doing injustice to them as well their patients. To bring patients back the following day would unnecessarily increase the workload of already stretched A&E departments.

The results section is very confusing with the readers trying their best to understand what happened to the patients. Their cohort of patients included a smaller percentage of women and there is no description with regards to their specific behaviour pattern.

On the whole this article was badly designed and written. It should not have gone past the editorial team and we regret that it has seen the light of day. We certainly need to encourage people to question current practices, be involved in research and publish but never at the expense of quality reporting.

REFERENCES

1. Wilcox RT, Traverso LW. Have the evaluation and treatment of acute appendicitis changed? Surg Clin North Am 1997; 77: 1355-70.
2. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15(5): 557-64.
3. Zeilke A, Sitter H, Rampp T, Bohrer T, Rothmund M.Clinical decision-making, ultrasonography, and scores for evaluation of suspected acute appendicitis. World J Surg. 2001; 25(5): 578-84.

Yours sincerely,

Mr S. Sinha Mr D. Neen Wycombe General Hospital Buckinghamshire U.K.

Sir,

I regret to hear that Dr Sinha and Dr Neen had difficulty understanding our article and that the results section had confused them. I shall attempt to address their confusion.

The study was not meant to look at surgical decision making of patients based on a scoring system as this requires good clinical acumen, which comes with experience. The emergency department’s junior doctors may not have enough experience in managing patients with pain in the right iliac fossa. The score is an attempt to provide these doctors with some objective criteria to employ before deciding on admission. In our cohort as well as others, it was found that none of the patients with a score less than five had appendicitis, thus, observation of these patients are safe.¹ However, review of patients with abdominal pain is good clinical practice, thus, our recommendation that a patient should have a review, especially if the pain had not subsided. The solution of an already stretched emergency department should not lie in discarding safe practices nor to admit every patient that comes through it, but to increase the manning of the department and to empower the doctors. I am sure Dr Sinha agrees that the safety of patients is paramount and no excuse should be used to compromise it.

We did not delve into the outcome of patients with right iliac fossa pain as this was not the intended aim of the article but those interested can refer to another publication where we did look at another cohort of patients with right iliac fossa pain.²

REFERENCES
1. Owen TD, Williams H, Stiff G, Jenkison LR, Rees BI. Evaluation of Alvarado score in acute appendicitis J R Soc Med 1992; 85: 87-89.
2. Chan MY, Teo BS, Ng BL. The Alvarado score and acute appendicitis Ann Acad Med Sing 2001; 30: 510-12.

Yours sincerely,

Mr M.Y.P. Chan Department of Surgery, Tan Tock Seng Hospital 11 Jalan Tan Tock Seng, Singapore 308433

Sir,

Re: The secret (GTN) of successful ERCP cannulation: a prospective randomised controlled study. J R Coll Edin 47 (4): 634-637.

We read with interest the above study by Ghori et al. As the authors point out, a number of studies of the effect of nitrates on the sphincter of Oddi and ERCP have been published previously. We, therefore, welcome the publication of the full details of the first randomised trial to deal with the specific issue of cannulation, following the publication of the author’s initial abstract in 1994.¹

The hypothesis that GTN makes ERCP easier and cannulation less traumatic was the basis for a recent randomised trial examining GTN’s effect on post ERCP pancreatitis.² The authors found a reduction in incidence of pancreatitis but not in the rate of cannulation.

The article by Ghori et al. has a number of methodological weaknesses which warrant highlighting in view of the authors’ conclusions.

Firstly, the investigators make no attempt at masking the intervention in the patients from the endoscopist. Secondly, no placebo was used. These issues introduce significant bias. Thirdly, the authors show an increase in time to cannulation from first sight of the ampulla in the GTN group, compared with the controls. This increase in time of over six minutes, to allow for the pharmacokinetics of GTN, may have had a further beneficial effect to the patients. It is known that there is a delay between the administration and the effects of midazolam with maximum sedation lagging significantly behind the peak plasma levels.3 As such, patients in the GTN group may have been better sedated, increasing patient compliance and facilitating cannulation.

The authors conclude that GTN can improve cannulation rates for both experienced and trained endoscopists. However, there is no statistically significant difference between cannulation rates for trainees (p=0.15).

Finally, the study does not have the statistical power to find such a difference. Indeed no such power calculation was reported. If an improvement in cannulation from 28.3% to 22.9% is felt to be clinically significant then some 2800 ERCPs would have to be performed by trainees to test this hypothesis and gain statistical significance with a 90% level of confidence.

Therefore, we do not believe that routine use of GTN can be recommended to improve cannulation rates on the basis of this trial.

REFERENCES
1. Donnelan I, Hallissey M, Nwokolo C, Loft D, Fraser I. Sublingual GTN spray improves success at ERCP cannulation. Gut 1994; 35: S36.
2. Sudhindran S, Bromwich E, Edwards PR. Prospective randomised double-blind placebo controlled trial of glyceryl trinitrate in endoscopic retrograde cholangiopancreatographyinduced pancreatitis. Br J Surg 2001; 88: 1178-82.
3. Hull CJ Intravenous anaesthetic agents in, Hull CJ, ed. Pharmacokinetics for anaesthesia Butterworth Heinemann, 1991: 253-83.

Yours sincerely,

Mr M.A. Chadwick Mr A.R. Weale Mr S. Dwerryhouse Southmead Hospital Bristol U.K.

Sir,

I am pleased to know that you have read our article with interest. As with any study, it is always possible to find areas where further improvement is possible. I agree with some of your criticism, in particular as the study was not blinded and no placebo was used.

Regarding the issue about success of cannulation by trained and trainee endoscopist, we never concluded that there is a statistically significant difference. As can be seen a very large number of patients will be needed to find any significant difference. Our result showed that both groups of endoscopist can benefit in achieving successful cannulation by the use of GTN.

Furthermore, I do not accept your view that better sedation resulted in increased success of cannulation in our study, as sedation with midazolam is more dose dependant than duration dependant.

Your last point, about the power of the study not being determined prior to our study. As you mentioned some 2800 ERCPs would have to be performed by trainees to test this hypothesis, this means that the study would need to be conducted over a period of 10 years to collect 3000 patients, which would be quite a challenge.

I look forward to seeing more studies in which some of the important points raised by you would be addressed. Until these issues are addressed we feel that routine GTN use can improve successful ERCP cannulation.

Yours sincerely,

Mr A Ghori Queen Elizabeth Hospital Birmingham U.K.

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