Making the Sneaky Appendicitis Diagnosis

The most common abdominal surgery is for appendicitis. It is a great masquerader. Remember, the history and physical exam of appendicitis are unreliable. Clinically the classic syndrome of periumbilical pain rotating down to McBurney’s point is the expectation – not the norm. My experience in medicine has taught me that a number of times I cognitively said, “there is no way this is appendicitis – no way” that turned out to be CAT scan positive appendicitis diagnosis.

So, when should we think an appendicitis diagnosis?

Well, quite frankly, with anyone with abdominal pain. Diffuse abdominal pain can be appendicitis. RLQ pain makes appendicitis a definite concern. (Remember with a female with RLQ ABD pain, the differential starts with etopic, appendix, PID/STD/abscess, ovarian cyst and adenopathy.)

The classic findings is McBurney’s point pain.

Rovsing sign is palpation of the left lower quadrant with pain in the right lower quadrant and that test is helpful. Psoas sign (extend the leg, and because the psoas muscle is pushing up against the appendix, it hurts) or obturator sign (bend the knee and externally roatate the leg to ilicit pain) is non-specific and not very helpful.


Do they have a surgical abdomen by exam?

Guarding. Ladies, if you want an example what guarding is, sneak up on any guy that you kind of know, but don’t know well, grab their bicep. We, as men, cannot tolerate a woman grabbing our biceps without us going like this. “This is how I roll. This is how I am always like this.” You know we can’t do it, it is just our manliness. That is guarding. It is a voluntary response that happens regularly. So if you push on someone’s belly and they voluntarily clamp down, that is guarding. It is a voluntary response to pushing on their belly. Document it. Rigidity is – they can’t control it. That belly is so clamped down that they cannot relax if they want to. Rebound tenderness, you have a peritoneum here, you have a hot appendix here. If they are not moving they are fine, but if this peritoneum moves at all that hurts like the dickens. If they take a step it hurts. If they bounce in a car, that hurts. I have made the diagnosis of appendicitis by watching someone walk. I’ve said “they have appendicitis and I was right.” If they walk like they are wearing cross country skis, they are walking like this…all they are doing is walking so their appendix does not wiggle. So anybody who has diabetes or is on chronic steroids, won’t have the same inflammatory response. You can have a perforated belly in a diabetic and the physical examination is benign. You can have a patient who is on chronic steroids and have a perforated bowel and they don’t have rebound, rigidity or guarding. So be careful of those two patients. They can throw off your physical examination.

The key to appendicitis diagnosis is time. How long has the patient had the pain? Are they early in the disease process? Do I need to watch this patient? Do I need to insure they are re-examined in a short period of time?

Your patients are concerned about this disease. Everyone knows of appendicitis and it’s on their mind. Have an open conversation about why or why not you feel this is or isn’t cause for an appendicitis diagnosis. Use the terminology because they are going to be thinking it. AND… document this. Always CYA.

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John Bielinski, Jr., MS PAC is a practicing emergency medicine clinician, and has been lecturing nationally for more than ten years, teaching the tactics that have proven invaluable in his career as a medical professional.
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