Correspondence to: Bilirubin; a diagnostic marker for appendicitis

We read this article1 with great interest. In the article it is stated that the observed Bilirubin rise is due to a combination of inflammatory cytokines and endotoxins causing cholestasis. These are known to be inflammatory mediators within the sepsis cytokine cascade, hence any cause of intra-abdominal sepsis may result in their increase and a resultant hyperbilirubinaemia. Is it also not plausible that in the presence of sepsis, dehydration and impaired fluid balance may account for the resultant hyperbilirubinaemia? Therefore on this basis alone, Bilirubin cannot be a diagnostic marker of just acute appendicitis but it may serve as a diagnostic marker of any intra-abdominal sepsis. Indeed we agree with the authors that any test (whether its laboratory based or radiological) must be used in conjunction with the clinical picture of the patient. Although Bilirubin may provide an additional tool in aiding the diagnosis of acute appendicitis, we would argue that the inclusion of this test is unlikely to change the rates of surgical intervention and negative appendicectomy rates. The diagnosis of acute appendicitis still remains a challenge for the emergency General Surgeon and thus far the Alvarado scoring system has probably shown to be the most consistent in predicting the accuracy of diagnosis of acute appendicitis.