Epigastric Pain, Periumbilical Pain - Usual Appendicitis Symptoms

The most common symptom of appendicitis is diffuse periumbilical or epigastric pain that subsequently localizes to the right lower quadrant. Focal, reproducible, and constant, the pain affects 95% of patients and increases in severity. The initial symptoms may be nonspecific, e.g., anorexia, nausea, indigestion, distension, bloating, and low-grade fever. Pain usually precedes any nausea and vomiting. If vomiting is the presenting symptom, other diagnoses should be seriously considered.

In 80% of cases, physical examination will reveal right lower- quadrant tenderness with guarding and rebound. Pain is localized at McBurney point , or 1.5-2 inches from the anterior superior iliac spine on a line from the spine to the umbilicus. Other important findings are positive psoas, obturator, and Rovsing signs, present in up to 80%-90% of cases.

Typical signs of appendicitis
Pain localized to the right lower quadrant
Low-grade fever
Positive psoas, obturator, and Rovsing signs
Differential diagnoses of appendicitis
Ileocolitis, e.g., due to inflammatory bowel disease
Enteric infection or parasitic infestation
Colonic adenocarcinoma
Gynecologic pathology
Urinary disease

A psoas or obturator sign is considered positive when contact between the psoas or the obturator muscle and the inflamed appendix elicits pain. Rovsing sign is positive when pain is felt with pressure at a point on the left side of the abdomen corresponding to McBurney point on the right.

Rectal examination will detect tenderness in the right lower quadrant in more than half of patients. When the appendix is retrocecal, the local signs of peritonitis are less common because the bowel may lie over the appendix.

Typical laboratory findings include a leukocytosis. A WBC count >15,000/pL and/or a fever >101°F may signal a ruptured appendix. The urine may contain WBCs, RBCs, or both. All women of childbearing age suspected of having appendicitis should have a serum pregnancy test because pregnancy can affect both presenting signs and treatment.

Radiography has long been a mainstay in confirming or excluding appendicitis. Barium enema has been replaced by ultrasound and the more accurate CT scan. CT findings include peri-appendiceal fat stranding or abscess if perforation has occurred. Air in the appendix excludes appendicitis, but nonvisualization does not confirm appendicitis.

A scoring system of five criteria has been published to improve diagnostic accuracy. Immediate laparotomy is recommended for anyone who presents with four of the following: abdominal pain, vomiting, low-grade fever, WBC count >10,000 /pL, or polymorphonuclear cells >15%.


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