Learning Objectives
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Learn the clinical presentation of appendicitis pain.
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Learn how to use physical examination to identify appendicitis.
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Develop an understanding of the treatment options for appendicitis.
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Learn the appropriate testing options to help diagnose appendicitis.
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Learn to identify red flags in patients who present with appendicitis pain.
Vivian Zhao
Vivian Zhao is a 32-year-old secretary with the chief complaint of, “My tummy hurts and I feel pretty crappy.” Vivian noted that she woke up last night with a stomachache. She thought is must have been the spicy food she had eaten for dinner. She took some antacids, but the pain really did not get any better. Vivian went on to say that she wouldn’t have bothered coming in, but the pain had changed and she really wasn’t feeling any better. “Doctor, at first the pain was just a dull ache around my belly button, but as the day has progressed, it has moved down over my right ovary. I looked it up on the Internet, and I wonder if I have appendicitis. I haven’t felt like eating anything, and my partner said she thought I was running a temperature. We didn’t have a thermometer, and because I was feeling worse, we just decided to come on over to your office. The ride over was pretty special. Every time we hit a bump, it really hurt. When I got out of the car, it was hard to stand straight up, and walking really hurts.”
I asked Vivian if anything like this has happened before. She shook her head, and said, “Absolutely not. I never get sick, but I really think that something bad is happening! Doctor, do you think I have appendicitis? Jenny, that’s my partner, says it’s probably just an ovarian cyst or something.” Vivian denied any other gynecologic symptoms, blood in her urine, or bowel or bladder symptomatology. Her last menstrual period was about 10 days ago.
I asked Vivian if she had any change in her bowel habits over the last couple of days, and she said she was kind of constipated and now she felt like she needed to throw up. I asked Vivian to point with one finger to show me where it hurt the most. She quickly pointed to McBurney point as if she had read the textbook. I asked her if the pain radiated anywhere else, and she said not really, that over the last couple of hours, the pain seemed to have focused right on that spot.
On physical examination, Vivian was mildly febrile with a temperature of 100.8°F. Her respirations were 18, and her pulse was 84 and regular. Her blood pressure was normal at 122/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed rebound tenderness at McBurney point, as well as positive Rovsing, Blumberg, and obturator signs ( Figs. 14.1 and 14.2 ). There was no costovertebral angle (CVA) tenderness, although percussion over the CVA exacerbated her abdominal pain. There was no peripheral edema. Her low back examination was unremarkable. I did a rectal exam, which revealed tenderness on the right. Visual inspection of the abdomen was unremarkable. “Vivian,” I said, “I think we are going to take a little trip to the hospital and get that appendix out.” She gave me a weak smile and said, “I knew it. I need to call my mom to come be with me.”
Key Clinical Points—What’s Important and What’s Not
The History
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History of acute onset of periumbilical pain that migrated and localized to the right lower quadrant
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History of constipation and anorexia
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History of pain when hitting bumps while riding in the car to come to the office
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Fever was noted
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Last menstrual period 10 days ago
The Physical Examination
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Patient is febrile
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Patient has rebound tenderness at McBurney point
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Tenderness on the right on rectal examination
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Positive Rovsing, Blumberg, and obturator tests for acute appendicitis (see Figs. 14.1 and 14.2 )
Other Findings of Note
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Normal HEENT examination, decreasing the chances of mesenteric adenitis
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Normal cardiovascular examination
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Normal pulmonary examination
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No peripheral edema
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No CVA tenderness
What Tests Would You Like to Order?
The following tests were ordered:
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Computed tomography (CT) scan of the abdomen
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Complete blood count
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Pregnancy test
Test Results
The CT scan of the abdomen revealed a dilated appendix with adjacent fat stranding, suggestive of mild acute appendicitis.
CBC revealed a white count of 12,400 with a shift to left.
Pregnancy test was negative.
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Appendicitis
The Science Behind the Diagnosis
Anatomy
The appendix is a wormlike, pouchlike structure that is located approximately 1 inch inferior to the ileocecal valve ( Fig. 14.3 ). It is 3 to 4 inches long and contains a lumen, which can become obstructed, causing phlegmon formation and the clinical disorder known as appendicitis. The appendix receives its blood supply from the appendicular artery, which is a branch of the ileocolic artery. Innervation of the appendix is from autonomic fibers from the ileocolic branch of the superior mesenteric plexus. The base of the anatomy is located beneath McBurney point (see Fig. 14.2 ).
Clinical Presentation
Acute appendicitis is one of the most common causes of abdominal pain, with an incidence of approximately 8.5% in males and 6.7% in females. The mortality rate is approximately 0.5%. Although acute appendicitis can occur at any age, it most commonly occurs in the second or third decades. Conventional wisdom holds that acute appendicitis is the result of obstruction of the appendicular lumen, with subsequent impairment of the wall leading to perforation and phlegmon formation. More recent thinking posits that mild uncomplicated appendicitis and severe complicated appendicitis are caused by different pathologic processes and are in fact two completely separate diseases requiring very different treatments.
The diagnosis is made on clinical grounds in many countries, and appendectomy has remained the standard of care in the treatment of acute appendicitis for the last century. This is despite that approximately 15% of appendectomies yield a pathologically normal appendix and that appendectomy is not without morbidity and rarely, mortality. The routine use of imaging, including ultrasound and CT as adjuncts to the clinical diagnosis of acute appendicitis, has decreased the number of “normal result” appendectomies to approximately 10%. Recent interest in the nonsurgical management of mild uncomplicated acute appendicitis is also impacting this statistic.
Abdominal pain is a common feature of acute appendicitis ( Fig. 14.4 ). Although the clinical presentation of the pain of acute appendicitis can be variable, its classic clinical presentation begins as mild periumbilical pain that becomes more severe and then migrates to the right lower quadrant at a point that is one-third the distance from the anterior superior iliac spine and the umbilicus, known as McBurney point (see Fig. 14.2 ). The pain becomes more localized and constant, with associated anorexia, nausea, vomiting, and fever. Constipation and diarrhea, as well as urinary tract symptoms, may also occur. Symptoms are usually present for less than 48 hours before the patient seeks medical attention.
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