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INTRODUCTION

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Appendicitis is one of the most common surgical emergencies. Despite advances in laboratory testing and imaging, accurate diagnosis of appendicitis remains a challenge. Complications from misdiagnosis of appendicitis include intraabdominal abscess, wound infection, adhesion formation, bowel obstruction, and infertility.

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CLINICAL FEATURES

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The early signs and symptoms of appendicitis are quite nonspecific and progress with time. The most reliable symptom in appendicitis is abdominal pain. Pain commonly begins in the periumbilical or epigastric region. As peritoneal irritation occurs, the pain often localizes to the right lower quadrant. The final location of the pain depends on the location of the appendix. Other symptoms associated with appendicitis include anorexia, nausea, and vomiting, but these symptoms are neither sensitive nor specific. As the pain increases, irritation of the bladder and/or colon may cause dysuria, tenesmus, or other symptoms. Many patients have the “bump” sign, where the patient notes an increase in the abdominal pain associated with bumps in the ride to the hospital. Other physicians will have the patient jump up and down in the examining room to evoke the pain. (Such maneuvers illustrate peritoneal irritation, but are nonspecific for appendicitis.) If the pain suddenly decreases, the examiner should consider appendiceal perforation.

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The classic point of maximal tenderness is in the right lower quadrant just below the middle of a line connecting the umbilicus and the right anterior superior iliac spine (McBurney's point). Patients may also have pain referred to the right lower quadrant when palpating the left lower quadrant (Rovsing's sign), pain elicited by extending the right leg to the hip while lying in the left lateral decubitus position (psoas sign), or pain elicited by passively flexing the right hip and knee and internally rotating the hip (obturator sign). Patients with a pelvic appendix may be quite tender on rectal examination, and patients with a retrocecal appendix may have more prominent flank pain than abdominal pain. No individual physical finding is sensitive or specific enough to rule in or rule out the diagnosis, and all physical findings and maneuvers depend on irritation of the peritoneum.

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Fever is a relatively late finding in appendicitis and rarely exceeds 39°C (102.2°F), unless rupture or other complications occur. Meta-analysis of 42 studies found that fever was the single most useful sign, followed by rebound tenderness and migration of the pain to the right lower quadrant.

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DIAGNOSIS AND DIFFERENTIAL

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Even with that caveat, the diagnosis of acute appendicitis is primarily clinical. Symptoms with high sensitivity for appendicitis include fever, right lower quadrant pain, pain that occurs before vomiting, and absence of prior similar pain. Migration of the pain is thought to be a strong predictor for appendicitis. Physical signs with high specificity include right lower abdominal rigidity and positive psoas sign. In both children and adults, no single historical or physical examination finding is sufficient to make an unequivocal diagnosis ...

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