APPENDICITIS

(Revised)

Important Concepts
Appendicitis refers to inflammation of the vermiform appendix. It is of two types i.e. Catarrhal
appendicitis and Obstructive appendicitis. In either case, they cause pain in the abdomen which being
inflammatory in origin develops gradually and is felt in areas corresponding to the peritoneum involved.
Initially, inflammation involves the visceral peritoneum of appendix. As a result, pain is felt around the
umbilicus and is associated with
nausea (and vomiting once or
Summary of Abdominal Examination
twice) and mild pyrexia.
Classically, symptoms of
obstruction are also present in  Introduction
early appendix i.e. colicky pain.  Consent
With development of the  Positioning of the Patient
inflammation, parietal  Proper Exposure
peritoneum is involved which  Inspection of the Abdomen (shape,
leads to a more intense pain symmetry, visible distension or lumps,
localized to right iliac fossa (the scars, visible veins)
area overlying appendix). Unlike  Superficial Palpation (pain, mass and
the colicky pain of early tenderness)
appendicitis, this pain is  Deep Palpation (deep masses and
continuous in nature and may tenderness)
cause the patient to scream.  Palpation of masses(site, position, size,
When perforation occurs, surface, edge, consistency, fluid thrill,
generalized peritonitis ensues resonance, pulsatility)
due to insufficient walling of  Visceral Palpation (liver, spleen,
the inflammation. Signs of urinary bladder, aorta)
peritonitis (board-like rigidity of  Supraclavicular lymph nodes
the abdominal wall, intense  Hernial orifices
pain involving the whole  Femoral pulses
abdomen, high grade fever,  Genitalia
rapid pulse, absence of bowel  Percussion of Abdomen (Masses and
sounds, absence of abdominal Areas of tenderness)
breathing movements, rebound  Auscultation of Abdomen (Bowel
tenderness) can be observed in sounds, Aortic bruit, Renal bruit,
such patients. Splenic bruit, Hepatic bruit)
In certain cases, an appendiceal abscess may develop that is felt in the right iliac fossa as a mass. It is
associated with up shooting of the pyrexia. Other causes of right iliac fossa mass include caecal
carcinoma and crohn’s disease.

Appendix may occur at places other than the McBurney’s point (junction of lateral one third and medical
two thirds of a line drawn between the anterior superior iliac spine and umbilicus). When located
higher, it must be differentiated from the pain of cholecystitis, and when located in the pelvis the rigidity
of abdominal wall muscles may be absent. In pelvic appendix, the irritation of rectum and bladder lead
to development of early diarrhea and frequent micturition. In such cases, rectal examination usually
reveals tenderness in the rectovesical pouch or pouch of Douglas.

History
History of appendicitis is usually characterized by abdominal pain, anorexia, nausea, vomiting, fever,
obstruction and abdominal distension, constipation and in some cases diarrhea. Other unusual
symptoms may also occur especially in the elderly.

Abdominal pain encountered in appendicitis is usually indicative of the progression of appendicitis. In

early appendicitis, pain is poorly localized colicky due to midgut discomfort. Patient may describe it as a
vague pain encompassing the periumbilical and sometimes the epigastric regions (or even the whole
abdomen). The pain is not intense and patient may continue with his routine activities. Within a few
days or even in hours, sudden intensification and shifting of the pain to right iliac fossa occurs (Kocher’s
sign). At this stage, pain is continuous in nature and may cause the patient to scream with agony. It is at
this stage that patients usually rush to the hospital for consulting the doctor.

Anorexia and Nausea occurs early in appendicitis. Many patients refrain from eating anything while
appendicitis lasts and are, therefore, dehydrated if they have come to the hospital after 2 or 3 days.
Vomiting is most frequently encountered in children but is uncommon in the elderly. Nevertheless,
most patients have vomited at least once or twice before coming for medical checkup.

Pyrexia in appendicitis is due to the ongoing inflammation. In imperforated appendicitis, it develops

after about six hours of onset of pain, is mild and maybe associated with headache. Suddenly upshot
fever may indicate perforation or development of an appendiceal abscess.

Intestinal Obstruction and Abdominal Distention may be observed in appendicitis due to irritation of
the intestines. It may be associated with retro-ileal appendix.

Constipation is frequently encountered in cases of acute appendicitis. However, in pelvic appendicitis

early Diarrhea may develop as well as frequent micturition.

Some patients may complain of sore throat that will indicate a preceding viral infection before acute
appendicitis developed.

It must be remembered that appendicitis may prove to be the easiest to diagnose or even the most
elusive diagnosis because it may present with a wide array of symptoms. Therefore the diagnosis of
appendicitis on the basis of patient’s medical history still proves to be a challenge and is a reminder of
the art of clinical diagnosis and surgical skill.

Examination
Clinical Signs
The clinical signs encountered in acute appendicitis usually include an unwell patient with low grade
pyrexia. Localized tenderness in right iliac fossa with muscle guarding and rebound tenderness are also
characteristics of classic appendicitis.

General Physical Examination

The patient usually looks unwell and usually lies with his right hip flexed. He may lie still in the bed if
perforation has already occurred. In such cases, the movements of abdominal wall will be limited.

Pulse will be slightly raised in acute appendix but if perforation has occurred then it may exceed 100.

While examining the oral cavity, attention should be paid to the furry tongue and, in most patients, fetor
oris. Tonsillitis (along with palpable cervical lymph nodes) will point towards mesenteric adenitis.

When history points to appendicitis in children, then chest should be examined for signs of right side
basal pneumonia.

Abdominal Examination
A read should be given to the general abdominal examination to understand how to proceed with
examination for appendicitis. Following are the findings that are to be expected in a patient of
appendicitis.

During examination, all preliminaries including introduction, consent, positioning and exposure should
be followed.

On inspection, the patient’s abdomen maybe slightly distended. Right hip maybe slightly flexed. There
may be pain on coughing or sudden movements. On careful inspection, absence of movements of the
abdominal wall overlying the appendix maybe noted. If generalized peritonitis has developed then
breathing movements of the whole abdomen will be decreased.

On palpation, tenderness will be noted in the right iliac fossa. Accordingly, muscle rigidity will be
present. In case of perforation, the whole abdomen will exhibit board-like rigidity. If possible, the site of
maximum tenderness should be assessed. It can be done by percussion or gently palpating the abdomen
while asking the patient where it hurts the most. Usually, the patient may point to the area of most
tenderness when asked (pointing sign). Rebound tenderness will be positive over the area of
tenderness in case of inflamed appendix. This can be done through percussion or asking the patient to
take a deep breath and applying pressure, maintaining it for 2 – 3 seconds and then briskly releasing it
during inspiration. While palpating the left iliac fossa, pain may be experienced in the right iliac fossa
(Rovsing’s sign). Furthermore, applying pressure on the left iliac fossa and then releasing it may also
elicit pain in the right iliac fossa. In case of retrocecal appendix, however, any attempts to elicit
tenderness or rebound tenderness may prove futile because the intervening bowel doesn’t allow
pressure to reach the inflamed appendix (silent appendix). In some cases, a tender, indistinct mass
maybe felt in the right iliac fossa. It will be fixed posteriorly and will be dull to percussion.

In patients with peritonitis, percussion usually elicits pain in the area (rebound tenderness). In
imperforated appendicitis, this rebound tenderness will be limited to the area overlying appendix. In
perforated appendix, the whole abdomen will demonstrate rebound tenderness due to generalized
parietal peritoneum irritation.

On auscultation, bowel sounds will be absent if perforation has already occurred.

Special Clinical Signs and Examination Maneuvers in appendicitis

In appendicitis, the following clinical signs may be elicited during abdominal examination.

Pointing Sign
When asked to point to the area of maximum tenderness, patient usually points to the McBurney’s
point (i.e. the area overlying appendix). This is the pointing sign.

Rovsing’s Sign
Continuous deep palpation starting from the left iliac fossa upwards (anti clockwise along the colon) may
cause pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus
increasing pressure around the appendix. This is the Rovsing's sign.

Psoas Sign
Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with either the passive
extension of the patient's right hip (patient lying on left side, with knee in flexion) or by the patient's
active flexion of the right hip while supine. The pain elicited is due to inflammation of the peritoneum
overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out
the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and
therefore also causes pain.

Obturator Sign The Alvarado (MANTRELS) Score

If an inflamed appendix is in
contact with the obturator  Migratory RIF pain (1)
internus, spasm of the muscle  Anorexia (1)
can be demonstrated by flexing
 Nausea and Vomiting (1)
and internal rotation of the hip.
 Tenderness (2)
This maneuver will cause pain
in the vagina hypogastrium.  Rebound Tenderness (2)
 Elevated Temperature (1)
Dunphy’ Sign  Leucocytosis (2)
When asked to cough (patient
 Shift of Leucocytes to left (1)
may be asked to look to the left
and cough), there will be pain in the right lower quadrant.
Summary of Appendix
This is the Dunphy’s sign.
Examination
Kocher (Kosher)’s Sign  Introduction
From the history given, the appearance of pain in the  Consent
epigastric region or around the stomach at the beginning of  Positioning (for
disease with a subsequent shift to the right iliac region is abdominal examination)
positive Kocher’s sign.  Exposure (for abdominal
examination)
Sitkovskiy (Rosenstein)'s sign  Inspection of abdomen
Increased pain in the right iliac region as patient lies on (Distension, Flexion of
his/her left side. right hip, Abdominal
Bartomier-Michelson's sign movements)
Increased pain on palpation at the right iliac region as patient  Dunphy’s Sign
lays on his/her left side compared to when patient was on  Pointing Sign
supine position.  Palpation (Tenderness,
Muscle rigidity,
Aure-Rozanova's sign Rovsing’s sign,
There is increase pain on palpation with finger in right Petit Blumberg sign)
triangle (the inferior lumbar triangle, formed medially by the  Percussion (Rebound
lattissmus dorsi muscle, laterally by the external abdominal tenderness,
oblique muscle and inferiorly by the iliac crest) - typical in Appendiceal mass)
retrocecal position of the appendix.  Obturator Sign
Blumberg sign Ask patient to lie on his left side
It is also referred to as rebound tenderness. Deep palpation
of the viscera over the suspected inflamed appendix followed  Rosentein’s sign
by sudden release of the pressure causes the severe pain on  Bartomier Michelson’s
the site indicating positive Blumberg's sign and peritonitis. sign
 Psoas sign
For clinical diagnosis of appendix, a scoring system most
 Aure – Rozanova’s sign
widely used is the Alvarado score. It has been given in the (when ileocaecal
test box. A score of 7 or more is highly predictive of acute
appendix is suspected)
appendix. In patients with an equivocal score (5 – 6),
abdominal ultrasound or contrast-enhanced CT examination Ask patient to lie supine again
further reduces the rate of negative appendicectomy.
 Auscultate abdomen
(Bowel sounds)
Real – Life Scenarios
Scenario I
A female patient of 12 years age presented to the emergency
with exacerbation of her right iliac fossa pain. She had visited
the hospital 1 week earlier with mild peri-umbilical pain. She was diagnosed with acute appendicitis and
advised with immediate surgery. However, her parents refused to the surgery and took her home. On
the second day home, she developed nausea and mild pyrexia. She didn’t eat anything due to nausea for
the rest of the week and only drank juices. The pain continued and was relieved with frequent analgesic
medication. However, at the end of the week, the patient developed a severe pain in the right iliac fossa
and sudden increase in temperature along with dizziness. Her parents became worried and took her to
the hospital.

On examination, she was found to have a very tender right iliac fossa and the abdominal movements
were considerably reduced with significant rigidity throughout the abdomen. Obturator sign and Psoas
sign were positive. The rest of the signs were not elicited because the patient was unwilling for further
examination.

Lab investigation revealed a leucocyte count of 8000/mm 3.

She was operated upon soon and finding was a near to rupturing appendix at McBurney’s point.

Scenario II
A 35 year old male was rushed to the hospital due excruciating pain in the right iliac fossa. He had been
experiencing lower intensity pain in the same region for the last 6 years at intervals of 3 to 6 months.
However, last night he developed a much more severe pain in the region with vomiting and high fever.
Due to lack of transportation and far flung location, patient reached to the hospital in the following
afternoon.

On the examination, the patient was found to be lying still in the bed and had a very wasted look about
him. His pulse was 110 and his blood pressure was slightly reduced, if not normal. His abdomen was
found to be extremely tender, particularly concentrated in the epigastrium and the right iliac fossa.
However, any pressure in the abdomen elicited severe pain. Guarding and rigidity of the abdomen
present. No breathing movements were observed in the right iliac fossa and were significantly limited in
the rest of the abdomen... Rovsing’s sign, obturator sign and rebound tenderness were elicited and
found positive. Dunphy’s sign was also positive.

Differentials of Chronic tuberculous abdomen, pyelonephritis or hydronephrosis were considered while

making the diagnosis of appendicitis.

The patient was immediately operated upon and his appendix was found to be perforated.