History and exam

Key diagnostic factors

abdominal pain

Constant mid-abdominal pain which later shifts to right lower quadrant. Usually worse on movement.

anorexia

An important symptom almost always associated with acute appendicitis. [22] Without anorexia the diagnosis of acute appendicitis is in question.

right lower quadrant tenderness

A classic sign is right lower quadrant abdominal tenderness (McBurney sign). There may be localized rebound tenderness, especially if the appendix is anterior. Compressing the left lower quadrant may also elicit pain in the right lower quadrant (Rovsing sign). Pain may also be elicited with the patient lying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle (psoas sign) or by internal rotation of the flexed right thigh (obturator sign).

Other diagnostic factors

adolescence or early adulthood

May occur at any age but is most commonly seen in early teens to late 40s.

nausea

Nausea and vomiting are also present in 75% of patients. [22]

fever

Low-grade, usually 1.8°F (1°C) increase in body temperature.

diminished bowel sounds

Bowel sounds may be reduced, particularly on the right side compared with on the left.

tachycardia

Tachycardia may be present, particularly in patients with perforation. [27]

fetor

Fetor may be present. [27]

vomiting

Nausea and vomiting are also present in 75% of patients. [22] Vomiting usually occurs only once or twice.

Rovsing sign

Pressing the left side of the abdominal cavity and eliciting pain in right lower quadrant.

psoas sign

Extending the right thigh on left lateral position elicits pain in right lower quadrant.

obturator sign

Pain is elicited at right lower quadrant of abdomen by internal rotation of the flexed right thigh.

Risk factors

<6 months of breastfeeding

Affects immunologic responses to certain microbial organisms. Children who received <6 months of breastfeeding had a higher incidence of acute appendicitis compared with those who received >6 months of breastfeeding. [13] [14]

low dietary fiber

Known to cause constipation. Children with appendectomies have low fiber in their diet compared with controls. [6] [15] However, this theory is controversial. [16]

improved personal hygiene

A higher incidence of acute appendicitis in Western society may be related to the living conditions and improved personal hygiene. [17]

A balance of gastrointestinal microbial flora is important for prevention of infection, for digestion, and providing important nutrients. [18] Frequent use of antibiotics and improved hygienic conditions lead to decreased exposure and/or imbalance of gastrointestinal microbial flora that may eventually lead to a modified response to viral infection and thereby trigger appendicitis. [19]

smoking

Children exposed to passive smoking have significantly increased incidence of acute appendicitis. [20] There is also an increased incidence of acute appendicitis in adult patients who smoke every day compared with adults who never smoked. [20]

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