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Ann R Coll Surg Engl. 2009 September; 91(6): 538–539.
PMCID: PMC2966231

Authors' Response

In answer to Birchley's comments, his study,1 where all patients underwent appendicectomy, and ours, where all-comers with lower abdominal pain were included, are clearly representative of different populations and, therefore, the results cannot be compared. Furthermore, re-calculating predictive values in Birchley's study population using a reference range from the Edinburgh laboratory is unlikely to provide useful information.

Our study population is also bound to be ‘less unwell’ than that of Birchley's study, as in his everyone underwent appendicectomy. Birchley is incorrect to suggest that the patients in our study presented with ‘non-specific abdominal pain’ and there was no diagnostic concern of appendicitis. Our cohort included a heterogeneous and unselected population of patients with lower abdominal pain, some of whom were indeed discharged after observation, but some of whom had surgical intervention, including appendicectomy. It is entirely possible that, in our hospital, a similar study involving only patients who had appendicectomy would yield similar results to those of Birchley's study.

We concluded from our study that those patients in whom there is a low suspicion of acute appendicitis following clinical assessment, in whom both white blood cell count and C-reactive protein level were normal, can be safely allowed home. This advice clearly needs to be interpreted in the context of the study, each individual patient and the experience of the clinician, but will hopefully be of use as one of many clinical and laboratory parameters used in the assessment of patients with abdominal pain in whom the diagnosis is unclear.


1. Birchley D. Patients with clinical acute appendicitis should have pre-operative full blood count and C-reactive protein assays. Ann R Coll Surg Engl. 2006;88:27–32. [PMC free article] [PubMed]

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