We read with interest the article titled “Utility of magnetic resonance imaging for suspected appendicitis in pregnant women” written by Theilen et al published in the March 2015 issue of the American Journal of Obstetrics and Gynecology .

It is interesting to observe that the clinical diagnosis of acute appendicitis was proven to be wrong in 93% of patients who underwent magnetic resonance imaging (MRI) with suspicion of acute appendicitis. We wonder where our so-called “clinical acumen” has gone for a condition that has always been considered essentially a clinical diagnosis. Isn‘t it a clear sign of overutilization of MRI due to a low threshold for asking MRI? It is equally hard to believe how uncomplicated ovarian masses or uterine fibroids can be confused clinically with acute appendicitis even in pregnant patients at any gestation.

The authors’ comment about lack of additional diagnostic information by ultrasonography (USG) is totally incorrect. Let us reiterate that alternative/additional diagnosis is not unique to MRI alone. In fact, USG is known to be a versatile tool for proving alternative diagnosis in suspected cases of acute appendicitis. Of all the alternative conditions diagnosed by the use of MRI in the current study, the majority (>90%) of them (eg, ovarian mass, ovarian torsion, uterine fibroids, ectopic pregnancy, and nephrolithiasis) could have easily been diagnosed had a meticulous sonographic study (including transvaginal study wherever needed) been carried out in all such cases and possibly MRI study as the first modality was not warranted in most of these cases. It is also not clear how many alternative diagnoses were picked up by USG alone.

It is well known that visualization of appendix decreases with advancing gestational period irrespective of the modality of imaging, be it USG or MRI. Although the study mentions use of USG in 46 patients prior to MRI, it is not clear at what stage of pregnancy USG examinations were carried out.

Lastly, we strongly argue that there is no justification for questioning the recommendation of the American College of Radiology Appropriateness Criteria, which advocate use of USG as the first modality followed by MRI as a problem-solving tool in select cases, as the current study appears to be biased toward MRI.