Differentiation of Acute Appendicitis in the Field

Abdominal pain is common complaint that can arise from many different etiologies.  Here’s some tips to help you differentiate appendicitis from other problems in the field.

Acute appendicitis is the term used to identify inflammation and/or perforation of the vermiform appendix.  Appendicitis is a common surgical emergency that most often affects children, with the average age of occurrence in pediatric patients being 6-10.  Children also have the highest incidence of perforation.  The median age at appendectomy was reported to be 22 years.  However, appendicitis can occur at any age, so providers should always be on the lookout.

Obtaining an accurate patient history is one of the most important steps in identifying a diagnosis of appendicitis.  Most patients report the onset of symptoms within the previous 48 hours, but longer duration may be reported in some populations.  The patient will likely report the following symptoms:

  • Abdominal pain that began in the umbilical or epigastric region and has since migrated to the RLQ.
  • Nausea
  • Anorexia
  • Vomiting (occurs in less than half of patients)

It is important to note that in appendicitis, abdominal pain almost always precedes vomiting.  Vomiting which precedes abdominal pain is indicative of intestinal obstruction.

Pain upon palpation of the RLQ alone does not provide the specificity required for a diagnosis of appendicitis.  Lucky for us, there are many other physical exam findings that can direct you toward a diagnosis.

Physical Exam Findings:

  • Pain upon palpation of the RLQ, specifically at McBurney’s point. (see inset photo below)

surface_projections_of_the_organs_of_the_trunk

  • Pain on percussion of the abdomen
  • Abdominal rigidity
  • Abdominal guarding
  • Positive Markle test
    • Moving a patient to your unit on a stretcher inadvertantly tests this
    • If the patient complains every time there is a bump in the road, they are probably positive
    • To easily test this in children who appear well, get them excited and ask them to jump up and down
    • A patient who walks on the balls of their feet (tiptoe) may be trying to avoid the pain associated with peritoneal inflammation
  • Positive Rovsing Sign
  • Positive Psoas Sign
  • Positive Obturator Sign
  • Temperature >37.3°C (99.1°F)

Take not that not all of the above mentioned findings will always be present, just like many other pathologies.  One way to predict the likelihood of appendicitis based on history and physical exam findings is with the Alvarado Score.  Here’s a link to the score on MDCalcAlvarado Score by MDCalc

The definitive treatment for patients with acute appendicitis is surgery, so keep this in mind when selecting an appropriate treatment destination.  Pre-hospital and pre-surgical care typically involves providing comfort measures for the patient such as analgesics and anti-emetics.  The protocol for these measures varies widely between systems, so check your local protocols.

Thanks for reading!  This is only the tip of the iceberg in terms of identification and treatment of appendicitis, but should provide a good refresher, and just maybe, some new info or skills.  Please take a moment to follow my blog via e-mail so you don’t miss any new content.  You can also follow me on Facebook or Twitter for more tidbits of content and general fun stuff.  Until next time, be safe and stay focused!

-Owen

References

Craig S. Appendicitis Clinical Presentation. [accessed 2017 Jan 10]. http://emedicine.medscape.com/article/773895-clinical#b1

Cover Image Credit: Internet Archive Book Images

Inset Image Credit: Mikael Häggström

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