4-71
appendicitis. The sensation of constipation or “gas stoppage” is common, but defecation does not bring relief
of symptoms. With time the pain gradually increases, but may then subside for a period after the appendix
perforates, and resume with greater intensity and generalization. In the field environment, peritonitis and
death are likely at that point.
Objective: Signs
Using Basic Tools: Temperature: Fever (101-102°F) frequently develops over 24 hrs. Higher fever is
atypical.
Inspection: Guarding, abdominal pain with cough
Palpation: Abdominal tenderness: more common in RLQ, may be localized over the appendix at McBurney’s
Point (2 inches from the anterior superior iliac spine along a line that intersects with the umbilicus); rebound
tenderness; costovertebral angle tenderness (CVAT) in retrocecal appendicitis; positive psoas sign: pain
extending the right hip while patient lies on his left side ; positive obturator sign: With the patient supine and
the right hip and knee exed, pain when right leg passively crosses over left (internal rotation).
Perform pelvic and rectal exams.
Using Advanced Tools: Lab: WBC with differential (>10,000/ml, in over 90% of appendicitis), pregnancy
test, urinalysis.
Assessment:
Differential Diagnosis: Quite extensive (see Symptom: Abdominal Pain)
Industrialized nations:
Females - pelvic inammatory disease, ovarian cysts, Mittelschmerz (pelvic bleeding from a ruptured ovarian
follicle) and ectopic pregnancy (see Symptom: GYN Problems). History and abnormal pelvic exam can identify
these conditions.
Gastroenteritis or mesenteric lymphadenitis - nausea, vomiting precede abdominal pain. Diarrhea, not a
sensation of constipation, is common.
Ureteral colic, acute pyelonephritis - colicky pain, dysuria, abnormal urinalysis.
Constipation - LLQ pain; positive rectal exam
Food Poisoning - history, vomiting and/or diarrhea
Peritonitis - may have multiple etiologies; usually higher fever or rigors, different pain prole (see Symptom:
Abdominal Pain section).
Bowel obstruction - vomiting, different pain prole
Developing countries:
Intussusceptions (a section of the bowel telescoping into another) are much more common and
diverticultis is much less common because of the high fiber diets. Colonic and even small bowel volvuli
(twisting) are also common.
Typhoid fever - RLQ pain often with headache, fatigue, splenomegaly, normal WBC, and roseola-type rash.
Amebic colitis - often begins as RUQ pain but the hepatic abscess will progress and rupture. By gravity, it
collects in the RLQ. Once the diagnosis is made antibiotics can quickly resolve the symptoms.
Ascaris infestation (Southern China, India and Central Africa) can lead to bowel obstruction or
perforation, cholecystitis, and appendicitis. Similarly, filariasis (India) often mimics appendicitis but with
higher (103-104°F) fevers, nausea, RLQ pain. It does not normally progress to peritoneal signs.
Sickle cell disease - usually abdominal pain accompanied by neurologic symptoms
Acute porphyria - 20-40 year old females, southern Africa, often precipitated by sulfa drugs, alcohol or
barbiturates. Severe colicky pain with nausea, vomiting, and constipation, and neurologic symptoms.
WBC often normal and abdominal exam more benign than the complaint of pain. The patients will have a
low-grade fever and jaundice/dark urine.
Gonococcal (females) and pneumococcal peritonitis is becoming more common in developing countries.
Malaria - fever, chills, vomiting, history of travel to a malaria-endemic area
Tuberculous peritonitis/psoas abscess (Pott’s disease)
Lead poisoning/colic - vague, persistent abdominal pain