History and Physical Examination of Appendicitis

<a href=”http://www.appendicitisreview.com/wp-content/uploads/2009/10/pain.gif”><img class=”alignleft size-full wp-image-109″ title=”pain” src=”http://www.appendicitisreview.com/wp-content/uploads/2009/10/pain.gif” alt=”pain” width=”180″ height=”180″ /></a>As always, the diagnosis begins with a thorough history and physical examination. The patient should be asked about the classic symptoms of appendicitis, but the surgeon should not be dissuaded by the absence of many of the symptoms. Many patients with acute appendicitis do not have a classic history. Because the differential diagnosis of appendicitis is extensive, patients should be queried about certain symptoms that may suggest an alternative diagnosis. Surgeons must also remember that a previous appendectomy does not definitively exclude the diagnosis of appendicitis, as “stump appendicitis” (appendicitis in the remaining appendiceal stump after appendectomy), although rare, has been described.

On inspection, patients look mildly ill and may have slightly elevated temperature and pulse. They often lie still to avoid the peritoneal irritation caused by movement. The surgeon should systematically examine the entire abdomen, starting in the left upper quadrant away from the patient’s described pain. Maximal tenderness is typically in the right lower quadrant, at or near McBurney’s point, located one-third of the way from the anterior superior iliac spine to the umbilicus. This tenderness is often associated with localized muscle rigidity and signs of peritoneal inflammation, including rebound, shake, or tap tenderness. Right lower quadrant tenderness is the most consistent of all signs of acute appendicitis;its presence should always raise the specter of appendicitis, even in the absence of other signs and symptoms. Because of the various anatomic locations of the appendix, however, it is possible for the tenderness to be in the right flank or right upper quadrant, the suprapubic region, or the left lower quadrant. Patients with a retrocecal or pelvic appendix may have no abdominal tenderness whatsoever. In such cases, rectal examination can be helpful to elicit right-sided pelvic tenderness.

Multiple signs can be detected on physical examination to contribute to the diagnosis of appendicitis. Rovsing’s sign, pain in the right lower quadrant on palpation of the left lower quadrant, is further evidence of localized peritoneal inflammation in the right lower quadrant. Psoas sign, pain with flexion of the leg at the right hip, can be seen with a retrocecal appendix due to inflammation adjacent to the psoas muscle. The obdurator sign, pain with rotating the flexed right thigh internally, indicates inflammation adjacent to the obdurator muscle in the pelvis.

In cases of perforated appendicitis, patients can look gravely ill, appearing flushed with dry mucous membranes and considerable elevations in temperature or pulse. If sepsis has developed, blood pressure can be depressed. If the perforation has been walled off by surrounding structures to create an abscess or phlegmon, a mass may be palpable in the right lower quadrant. If free intraperitoneal rupture has occurred, the patient can have signs of generalized peritonitis with diffuse rebound tenderness.