To the Editor.
—Dr Wagner and colleagues1 have made an interesting and valuable contribution by correlating a number of the large-scale studies regarding acute appendicitis over the last 20 years. As a practicing general surgeon, I can attest to the protean manifestations of acute appendicitis and the difficulties that sometimes occur in making the diagnosis. The enumeration by the authors of a number of the more important aspects of the history and examination is, for the most part, accurate. However, I must take exception to the conclusion "astute clinicians will recognize that the absence of anorexia, nausea, or vomiting has little impact on the likelihood of appendicitis." To the contrary, anorexia is an extremely common finding in acute appendicitis, and it is rare to find a patient with appendicitis who is hungry. The absence of anorexia should cause the physician to question the diagnosis of appendicitis in a patient
Schneider TM. Does This Patient Have Appendicitis?. JAMA. 1997;277(8):625. doi:10.1001/jama.1997.03540320027016