bowel wall may result, causing inflammation. Finally, arterial stasis and tissue
infarction occur with perforation of the appendix and leakage of bowel con-
tents into the peritoneum.
SYMPTOMS/EXAM
■ The classic symptom is diffuse periumbilical abdominal pain with migra-
tion to the right lower quadrant.
■ Fever may be present in only 20% of cases.
■ Pain is followed by anorexia, nausea, and vomiting.
■ Diffuse tenderness to palpation early with tenderness to deep palpation
overMcBurney pointas the illness progresses
■ Rovsing signis pain in the RLQ with palpation of the LLQ.
■ Theobturator signis induced by passively flexing the right hip and knee
and internally rotating the hip. A positive sign is indicative of an irritated
obturator internus muscle from a presumed inflamed appendix.
■ Thepsoas signis elicited by placing the patient in the left lateral decubitis
position and extending the right leg at the hip. It may also be performed
by providing resistance against the leg as the patient attempts to lift his
thigh off the table. These maneuvers will cause pain by stretching the
psoas muscle, which may be irritated by adjacent inflamed appendix or
mass.
■ Involuntary guarding, rebound tenderness, voluntary guarding, and ten-
derness on rectal exam may also be present.
DIFFERENTIAL
■ Appendicitis may be confused with any condition that causes abdominal pain.
■ Appendicitis is particularly difficult to diagnosis in the elderly, the pregnant
patient, and the pediatric patient.
■ Most common findings during laparotomy when appendicitis is diagnosis in
error are mesenteric lymphadenitis, no disease, PID, acute gastroenteritis.
■ Cholecystitis, perforated ulcer, diverticulitis, pancreatitis, small-bowel
obstruction, renal calculus, pylonephritis
■ Ovarian pathologies like abscess, torsion, cyst, or ectopic pregnancy
DIAGNOSIS
■ WBC, urinalysis, and temperature are of limited value but may be
abnormal.
■ Plain radiographs are abnormal in 24–95% of cases but are of limited
value. Findings may include appendiceal fecalith, appendiceal gas, and
free air.
■ CT scan is considered the best choice for initial evaluation. It has
excellent sensitivity (87–100%) and specificity (89–90%). Thin-slice
CT with rectal contrast has the highest specificity (98%) and avoids
oral contrast. However, rectal contrast can be difficult and inconve-
nient to administer.
■ CT is positive if it shows an inflammed appendix that does not fill with
contrast, pericecal inflammation, abscess, phlegmon, or fluid collection.
■ Graded compression ultrasound has a 94.7% sensitivity and 88.9% speci-
ficity if the appendix is noncompressible, >6 mm in diameter, or demon-
strates appendicolith or abscess. This is the test of choice in children and
pregnant patients.
■ Barium enemas, nuclear medicine scans, and MRI have also been used.
ABDOMINAL AND GASTROINTESTINALEMERGENCIESThe obturator sign is induced
by passively flexing the right
hip and knee and internally
rotating the hip. An inflamed
appendix may irritate the
obturator internus muscle.The psoas sign is elicited by
placing the patient in the left
lateral decubitis position and
extending the right leg at the
hip. The maneuver will cause
pain by stretching the psoas
muscle, which may be
inflamed by an adjacent mass.