On the role of laboratory parameters in differentiating acute diverticulitis and epiploic appendagitis

Letter to the Editor On the Role of Laboratory Parameters in Differentiating Acute Diverticulitis and Epiploic Appendagitis Dear Editor, I have read the article by Şahin et al., “The role of laboratory parameters in discriminating between acute diverticulitis and acute epiploic appendagitis: a comprehensive analysis,” published in the Journal of Medicine and Palliative Care. The authors have conducted a valuable study on the differential diagnosis of two diseases that are frequently confused in general surgical practice: acute diverticulitis (AD) and epiploic appendagitis (EA). Acute diverticulitis and epiploic appendagitis can present with similar clinical findings, particularly in patients presenting with left lower quadrant pain; however, the course and treatment approaches of these two diseases are significantly different. While acute diverticulitis may require antibiotic treatment, interventional procedures, or surgery, epiploic appendagitis is mostly treated conservatively and is a self-limiting disease. Therefore, early and accurate diagnosis is crucial for preventing unnecessary hospitalizations, antibiotic use, and surgical interventions.1,2 One of the key aspects of this study is that the Ramcho Score (RS), developed by the authors, comprises readily accessible clinical and laboratory parameters, including age, neutrophil count, hemoglobin, albumin, creatine kinase, and C-reactive protein (CRP). The study demonstrates that the RS showed a higher diagnostic performance than laboratory parameters used alone, highlighting the importance of combined biomarker approaches in clinical decision-making. The study results are consistent with existing literature. Previous studies have reported higher CRP and neutrophil-to-lymphocyte ratio (NLR) levels in patients with acute diverticulitis than in those with epiploic appendagitis.3,4 Similarly, the significantly higher CRP, NLR, and CRP/albumin ratio (CAR) values in the diverticulitis group in this study are important indicators of the severity of the inflammatory response. However, we believe that some limitations of the study should also be considered. In the multivariate analysis, age, neutrophil, and albumin values ​​remained independent predictors, whereas gender, lymphocytes, hemoglobin, CK, and CRP lost significance. Nevertheless, they were included in the final score. Further explanation of the rationale for including these variables will strengthen the study's methodological transparency. Although the Ramcho Score presented in the article exhibited promising diagnostic accuracy, its derivation from a retrospective single-center cohort rightly raises concerns about external validity. Clinical predictive models generally underperform when applied to independent populations due to differences in demographic characteristics, disease prevalence, laboratory methodologies, and institutional treatment protocols. According to TRIPOD recommendations for predictive model development and validation, external validation before application to routine clinical practice represents a critical step.5 Therefore, external validation in independent cohorts is necessary before recommending the Ramcho Score for routine clinical practice. In conclusion, the study by Şahin et al. provides important data regarding the use of laboratory parameters in the differential diagnosis of acute diverticulitis and epiploic appendagitis. We believe that the developed Ramcho Score has the potential to contribute to the diagnostic process, especially in emergency departments and general surgery practice; however, it needs to be validated in larger patient series and prospective studies before it can be routinely used. We congratulate the authors again for their valuable work and believe that further research on this subject will make significant contributions to the literature.