Vohmw 93 Number 4
E~fitorial correspomh, twe
breast-feeding when their infants were three to four months of age. Sampling theory predicts this value to be accurate with an error o f plus or minus five percentage points (99% level o f confidence).~ For our PurPoses, this was an acceptable margin o f error and our final conclusions would not have changed, whether the higher or lower figures were used. The infants in the study were those sick enough to warrant hospitalization. The majority o f them were, therefore, seriously ill and showing some evidence o f dehydration. Obviously, the)' were clinically a rather heterogenous group with respect to severity o f 9 illness and types of infections. We did tabulate cultures, but it was not felt that the results were pertinent to the present report. in fact, few enteric pathogens were isolated; we did not attempt to isolate viral pathogens or toxigenic Escherichia coil 9 Our study did not address the question o f whether there were differences between breast- and bottle-fed infants for "outpatient gastroenteritis." However, the incidence ofserious illness, requiring hospitalization, is vastly higher in the bottle-fed group. We agree that a prospective study would be a worthwhile addition to the literature, ltowever, we cannot imagine how a prospective approach to our particular population .over the three-year period involved could have resulted in a different conclusion. The essence o f our report is this: We have a l~.rge pediatric practice with an active in-patient service to which large numbers ofchildren are admitted with diarrhea and dehydration. Breast-feeding is quite prevalent in our community, but hospitalization o f breast-fed infants for gastroenteritis is almost nil. We think the conclusion that breast-feeding is protective is inescapable. Spencer A. Larsen, M.D. Daryl R. Homer, M.D. Department o f Pediatrics Kaiser-Permanente Medical Center 27400 Hesperian Blvd. Hayward, CA 94545 REFERENCES I.
2.
3. 4. 5. 6.
Wheatley D: Incidence and treatment of infantile gastroenteritis in general practice, Arch Dis Child 43:53, 1968. Alexander MB: Infantile diarrhea and vomiting. A review o f 456 infats treated in a hospital unit for enteritis, Br Med J 2:973, 1948. Robinson M: Infant morbidity and mortality. A study o f 3,266 infants, Lancet 1:788, 1951. Ironside AG, Tuxford AF, and tteyworth B: A survey o f infantile gastroenteritis, Br Med J 3:20, 1970. Cunningham AS: Morbidity in breast-fed and artificially fed infants, J PEDIA'rR 90:726, 1977. Colton T: Statistics in Medicine, Boston, 1974, Little, Brown Company, 1974, pp 162-163.
B a r i u m e n e m a re a c u t e appendicitis.
To the Editor: The fact that a barium enema is a useful tool in the diagnosis of acute appendicitis is borne out in the article by Lev/'in, Mikity,
727
and Wingert? In their hands, a correct diagnosis was attained in 100,o of the cases, llowever, there are reports 2 indicating that false negative results do occur; this should have been alluded to and included in the list o f references. We wish to describe briefly one such case from our recent experience. CASE REPORT A 12-year-old obese boy presented to the Emergency Room with worsening midline lower abdominal pain o f ten hours' duration, associated with frequency and pain on urination. The patient looked pale and apprehensive. Bowel sounds were normal. There was tenderness and guarding in the suprapubie 9region and the right lower quadrant. Rectal examination elicited tenderness anteriorly. No mass was felt. Leukocyte count was 10,200 WBC with 78% neutrophils. Urine contained 8 to 10 WBC/high-powered field. The clinical assessment was hampered by the marked obesity o f the child, and because of the suspicion ofacute appendicitis a barium enema ",','asperformed immediately. The radiograph showed a normal cecum and distal ileum with an apparently normally filled appendix. The patient was admitted for observation. Further studies included urine culture, scan for Meckel diverticulum, and abdominal ultrasound; the results were all normal. The clinical picture deteriorated over the next 24 hours and at laparotomy it was found that he had a long appendix which extended deep into the pelvis; the proximal two-thirds appeared normal but the distal third was gangrenous. The tip was perforated and walled off by fibrous adhesions. 1
COMMENT The patient's obesity and inconclusive symptoms and signs made him a natural candidate for a barium enema in the diagnosis o f acute appendicitis. However, the proximal twothirds of his long appendix filled, giving it a normal radiographic appearance. In addition, the diseased part o f the appendix was apparently too far down in the pelvis and thus failed to cause cecal or ileal radiologic signs. The widespread enthusiastic acceptance o f the barium enema as a diagnostic aid in acute appendicitis demands the note o f caution implied in our letter. Mark A. Ra~nan, M.D. Moshe Berant, M.D. . Department o f Pediatrics Peninsula IIospital Center Far Rockawa), N Y 11691 REFERENCES I.
2.
Lewin GA, Mikity V, and Wingert WA: Barium enema: An outpatient procedure in the early diagnosis o f acute appendicitis, J PEI~tAIR 92:451, 1978. Fee HJ Jr, Jones PC, and Kadell B: Radiologic diagnosis o f appendicitis, Arch Surg 112:742, 1977.
R pty To the Editor: We appreciate Drs. Raifman's and Berant's report on the fallibility of barium enema, especially when the location o f the appendix is ectopic. Just as other intra-abdominal disease entities
E~fitorial correspomh, twe
breast-feeding when their infants were three to four months of age. Sampling theory predicts this value to be accurate with an error o f plus or minus five percentage points (99% level o f confidence).~ For our PurPoses, this was an acceptable margin o f error and our final conclusions would not have changed, whether the higher or lower figures were used. The infants in the study were those sick enough to warrant hospitalization. The majority o f them were, therefore, seriously ill and showing some evidence o f dehydration. Obviously, the)' were clinically a rather heterogenous group with respect to severity o f 9 illness and types of infections. We did tabulate cultures, but it was not felt that the results were pertinent to the present report. in fact, few enteric pathogens were isolated; we did not attempt to isolate viral pathogens or toxigenic Escherichia coil 9 Our study did not address the question o f whether there were differences between breast- and bottle-fed infants for "outpatient gastroenteritis." However, the incidence ofserious illness, requiring hospitalization, is vastly higher in the bottle-fed group. We agree that a prospective study would be a worthwhile addition to the literature, ltowever, we cannot imagine how a prospective approach to our particular population .over the three-year period involved could have resulted in a different conclusion. The essence o f our report is this: We have a l~.rge pediatric practice with an active in-patient service to which large numbers ofchildren are admitted with diarrhea and dehydration. Breast-feeding is quite prevalent in our community, but hospitalization o f breast-fed infants for gastroenteritis is almost nil. We think the conclusion that breast-feeding is protective is inescapable. Spencer A. Larsen, M.D. Daryl R. Homer, M.D. Department o f Pediatrics Kaiser-Permanente Medical Center 27400 Hesperian Blvd. Hayward, CA 94545 REFERENCES I.
2.
3. 4. 5. 6.
Wheatley D: Incidence and treatment of infantile gastroenteritis in general practice, Arch Dis Child 43:53, 1968. Alexander MB: Infantile diarrhea and vomiting. A review o f 456 infats treated in a hospital unit for enteritis, Br Med J 2:973, 1948. Robinson M: Infant morbidity and mortality. A study o f 3,266 infants, Lancet 1:788, 1951. Ironside AG, Tuxford AF, and tteyworth B: A survey o f infantile gastroenteritis, Br Med J 3:20, 1970. Cunningham AS: Morbidity in breast-fed and artificially fed infants, J PEDIA'rR 90:726, 1977. Colton T: Statistics in Medicine, Boston, 1974, Little, Brown Company, 1974, pp 162-163.
B a r i u m e n e m a re a c u t e appendicitis.
To the Editor: The fact that a barium enema is a useful tool in the diagnosis of acute appendicitis is borne out in the article by Lev/'in, Mikity,
727
and Wingert? In their hands, a correct diagnosis was attained in 100,o of the cases, llowever, there are reports 2 indicating that false negative results do occur; this should have been alluded to and included in the list o f references. We wish to describe briefly one such case from our recent experience. CASE REPORT A 12-year-old obese boy presented to the Emergency Room with worsening midline lower abdominal pain o f ten hours' duration, associated with frequency and pain on urination. The patient looked pale and apprehensive. Bowel sounds were normal. There was tenderness and guarding in the suprapubie 9region and the right lower quadrant. Rectal examination elicited tenderness anteriorly. No mass was felt. Leukocyte count was 10,200 WBC with 78% neutrophils. Urine contained 8 to 10 WBC/high-powered field. The clinical assessment was hampered by the marked obesity o f the child, and because of the suspicion ofacute appendicitis a barium enema ",','asperformed immediately. The radiograph showed a normal cecum and distal ileum with an apparently normally filled appendix. The patient was admitted for observation. Further studies included urine culture, scan for Meckel diverticulum, and abdominal ultrasound; the results were all normal. The clinical picture deteriorated over the next 24 hours and at laparotomy it was found that he had a long appendix which extended deep into the pelvis; the proximal two-thirds appeared normal but the distal third was gangrenous. The tip was perforated and walled off by fibrous adhesions. 1
COMMENT The patient's obesity and inconclusive symptoms and signs made him a natural candidate for a barium enema in the diagnosis o f acute appendicitis. However, the proximal twothirds of his long appendix filled, giving it a normal radiographic appearance. In addition, the diseased part o f the appendix was apparently too far down in the pelvis and thus failed to cause cecal or ileal radiologic signs. The widespread enthusiastic acceptance o f the barium enema as a diagnostic aid in acute appendicitis demands the note o f caution implied in our letter. Mark A. Ra~nan, M.D. Moshe Berant, M.D. . Department o f Pediatrics Peninsula IIospital Center Far Rockawa), N Y 11691 REFERENCES I.
2.
Lewin GA, Mikity V, and Wingert WA: Barium enema: An outpatient procedure in the early diagnosis o f acute appendicitis, J PEI~tAIR 92:451, 1978. Fee HJ Jr, Jones PC, and Kadell B: Radiologic diagnosis o f appendicitis, Arch Surg 112:742, 1977.
R pty To the Editor: We appreciate Drs. Raifman's and Berant's report on the fallibility of barium enema, especially when the location o f the appendix is ectopic. Just as other intra-abdominal disease entities
