APPENDICITIS(Revised)

Important ConceptsAppendicitis 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 twice) and mild pyrexia. Classically, symptoms of obstruction are also present in early appendix i.e. colicky pain. With development of the inflammation, parietal peritoneum is involved which leads to a more intense pain localized to right iliac fossa (the area overlying appendix). Unlike the colicky pain of early appendicitis, this pain is continuous in nature and may cause the patient to scream. When perforation occurs, generalized peritonitis ensues due to insufficient walling of the inflammation. Signs of peritonitis (board-like rigidity of the abdominal wall, intense pain involving the whole abdomen, high grade fever, rapid pulse, absence of bowel sounds, absence of abdominal breathing movements, rebound tenderness) can be observed in such patients.

Summary of Abdominal Examination

Introduction Consent Positioning of the Patient Proper Exposure Inspection of the Abdomen (shape,

symmetry, visible distension or lumps, scars, visible veins)

Superficial Palpation (pain, mass and tenderness)

Deep Palpation (deep masses and tenderness)

Palpation of masses(site, position, size, surface, edge, consistency, fluid thrill, resonance, pulsatility)

Visceral Palpation (liver, spleen, urinary bladder, aorta)

Supraclavicular lymph nodes Hernial orifices Femoral pulses Genitalia Percussion of Abdomen (Masses and

Areas of tenderness) Auscultation of Abdomen (Bowel

sounds, Aortic bruit, Renal bruit, 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.

HistoryHistory 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 SignsThe 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 ExaminationThe 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 ExaminationA 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 SignWhen 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 SignContinuous 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 SignPsoas 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 SignIf an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internal rotation of the hip. This maneuver will cause pain in the vagina hypogastrium.

Dunphy’ SignWhen asked to cough (patient may be asked to look to the left

The Alvarado (MANTRELS) Score

Migratory RIF pain (1)

Anorexia (1)

Nausea and Vomiting (1)

Tenderness (2)

Rebound Tenderness (2)

Elevated Temperature (1)

Leucocytosis (2)

Shift of Leucocytes to left (1)

and cough), there will be pain in the right lower quadrant. This is the Dunphy’s sign.

Kocher (Kosher)’s SignFrom the history given, the appearance of pain in the epigastric region or around the stomach at the beginning of disease with a subsequent shift to the right iliac region is positive Kocher’s sign.

Sitkovskiy (Rosenstein)'s signIncreased pain in the right iliac region as patient lies on his/her left side.

Bartomier-Michelson's signIncreased pain on palpation at the right iliac region as patient lays on his/her left side compared to when patient was on supine position.

Aure-Rozanova's signThere is increase pain on palpation with finger in right Petit triangle (the inferior lumbar triangle, formed medially by the lattissmus dorsi muscle, laterally by the external abdominal oblique muscle and inferiorly by the iliac crest) - typical in retrocecal position of the appendix.

Blumberg signIt is also referred to as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes the severe pain on the site indicating positive Blumberg's sign and peritonitis.

For clinical diagnosis of appendix, a scoring system most widely used is the Alvarado score. It has been given in the test box. A score of 7 or more is highly predictive of acute appendix. In patients with an equivocal score (5 – 6), abdominal ultrasound or contrast-enhanced CT examination further reduces the rate of negative appendicectomy.

Real – Life Scenarios

Scenario IA female patient of 12 years age presented to the emergency with exacerbation of her right iliac fossa pain. She had visited

Summary of Appendix Examination

Introduction Consent Positioning (for

abdominal examination) Exposure (for abdominal

examination) Inspection of abdomen

(Distension, Flexion of right hip, Abdominal movements)

Dunphy’s Sign Pointing Sign Palpation (Tenderness,

Muscle rigidity, Rovsing’s sign, Blumberg sign)

Percussion (Rebound tenderness, Appendiceal mass)

Obturator Sign

Ask patient to lie on his left side

Rosentein’s sign Bartomier Michelson’s

sign Psoas sign Aure – Rozanova’s sign

(when ileocaecal appendix is suspected)

Ask patient to lie supine again

Auscultate abdomen (Bowel sounds)

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/mm3.

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

Scenario IIA 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.