Acute abdominal pain (AAP) accounts for nearly 10% of all emergency department (ED) visits; appendicitis is one of the most common causes of AAP and one of the most frequent indications for abdominal surgery worldwide. (1,2)
What is it?
Appendicitis is inflammation of the appendix usually due to a blockage in the gastrointestinal tract (GIT) due to stool or a tumour but can also be caused by viruses, bacteria, and parasites in the GIT. Because the inflamed appendix can rupture and allow mucus, stool, and a myriad of bacteria to enter the abdominal cavity, it is considered a medical emergency. (3)
How does it present?
Appendicitis first presents as diffuse visceral periumbilical pain as the inflamed organ presses against the visceral peritoneum. Eventually, the inflammation then localises to right iliac fossa (RIF) as the organ presses on the parietal peritoneum. Other early symptoms include nausea, emesis, anorexia, constipation or diarrhoea which can progress into worsening symptoms such as tachycardia, pyrexia, and localised tenderness, guarding, and rebound in the RIF as the parietal peritoneum becomes involved. (1)
What are common physical signs you can quickly test in ED?
1. McBurney’s Point Tenderness - This point is 1/3 the distance laterally from the anterior superior iliac spine (ASIS) and the umbilicus. (1) It is the location of the base of the appendix and where the pain localises in the RIF.
2. Psoas Sign - Extend the hip and abduct the thigh while the patient lies on his/her left side. Why would this cause pain? Think of the anatomy! The inflamed appendix may lie against the right psoas muscle which would cause the patient to shorten the muscle by drawing up the right knee. (1,3)
3. Obturator Sign - In a supine position, the patient will feel right lower quadrant (RLQ) pain when the clinician flexes the patient’s right hip and knee then internally rotates the hip. Why? This time the inflamed appendix may be lying against the right obturator internus muscle. Always comes down to anatomy! (3)
4. Rovsing’s Sign - The patient will feel pain in the right lower quadrant (RLQ) upon palpation of the left lower quadrant. You can even check for rebound tenderness here too by seeing if the patient feels pain when pressure is removed from the abdomen (Blumberg’s Sign).
References
1. Martin, A. (2021, January 19). Acute appendicitis in adults: Clinical manifestations and differential diagnosis. Retrieved from https://www-uptodate-com.
2. Cervellin, G., Mora, R., Ticinesi, A., Meschi, T., Comelli, I., Catena, F., & Lippi, G. (2016). Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. Annals of translational medicine, 4(19), 362. https://doi.org/10.21037/atm.2016.09.10
3. Lowth, M., & Jarvis, S. (2019, July 29). Appendicitis. Patient.info. Retrieved from https://patient.info/doctor/appendicitis-pro.
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