Inflammation of Vermiform Appendix Clinical Presentation

Updated: Oct 19, 2015
  • Author: Steven L Lee, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Presentation

History

Abdominal pain is the most common symptom of appendicitis and is present in nearly every patient with this condition. The classic presentation of a patient with appendicitis includes a history of initial periumbilical or epigastric abdominal pain migrating to the right lower quadrant (RLQ). The pain is gradual in onset and progressively worsens. Anorexia, nausea, and vomiting are typically associated with the disease.

The symptoms of appendicitis vary, depending on the location of the appendix. When the appendix is located anteriorly, the classic migratory pain is expected. In patients with a retrocecal appendix, however, a dull ache is often described. When the tip of the appendix is located in the pelvis, atypical pain is commonly encountered. Patients may report dysuria and urinary frequency due to the inflamed appendix irritating the bladder. Patients may also have diarrhea or tenesmus if the inflamed appendix is adjacent to the rectum. In early appendicitis, the patient is initially afebrile or has a low-grade fever. Higher fevers are associated with a perforated appendix. [3]

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Physical Examination

On physical examination, the patient is usually lying still; movement worsens the pain. Having the patient cough elicits localized pain in the RLQ. Local tenderness to palpation is usually observed. Percussion tenderness is also noted in this area. Children often have localized pain with walking and jumping. The Rovsing sign (pain in the RLQ during palpation of the left lower quadrant [LLQ]) has also been associated with appendicitis. This finding represents indirect tenderness due to peritoneal irritation localized to the RLQ.

Unfortunately, only 55% of patients with appendicitis present with the classic history and physical findings. This is because the early signs and symptoms are primarily dependent on the location of the tip of the appendix, which is highly variable. [7]

When the tip of the appendix is retrocecal, tenderness may be manifested by passive extension of the hip (psoas sign). When it is located in the pelvis, tenderness may be detected during rectal examination or pelvic examination. Thus, in patients with persistent abdominal pain and rectal symptoms (diarrhea or tenesmus), it is important to perform a rectal examination. If the appendix is lying adjacent to the obturator internus, pain may be manifested with flexion of the right hip and internal rotation. Testicular examination findings are typically normal.

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