Clinical Features

Migrating abdominal pain: most common and specific symptom

• Typically constant and rapidly worsens

• Most patients present within 48 hours of symptom onset.

• Initial diffuse periumbilical pain: caused by the irritation of the visceral peritoneum (pain is referred to T8–T10 dermatomes) [6]

• Localizes to the RLQ within ∼ 12–24 hours: caused by the irritation of the parietal peritoneum

Nausea

Anorexia

• In up to 80% of cases

• Hamburger sign: If there is no loss of appetite, appendicitis is unlikely. [7]

Vomiting

Low-grade fever

Diarrhea

Constipation

McBurney point tenderness (RLQ tenderness)

• Tenderness at the junction of the lateral third and medial two-thirds of a line drawn from the right anterior superior iliac spine to the umbilicus

• This point corresponds to the location of the base of the appendix.

RLQ guarding and/or rigidity

Rebound tenderness (Blumberg sign), especially in the RLQ

Rovsing sign: RLQ pain elicited on deep palpation of the LLQ [8]

Psoas sign: can be performed in two different ways

• Can be elicited on flexing the right hip with stretched leg against resistance

• RLQ pain may be elicited on passive extension of the right hip when the patient is positioned on their left side.

Obturator sign: RLQ pain on passive internal rotation of the right hip with the hip and knee flexed

Hyperesthesia within Sherren triangle: formed by the anterior superior iliac spine, umbilicus, and symphysis pubis

Lanz point tenderness: at the junction of the right third and left two-thirds of a line connecting both the anterior superior iliac spines

Pain in the Pouch of Douglas: pain elicited by palpating the rectouterine pouch on rectal examination

Baldwin sign: pain in the flank when flexing the right hip (suggests an inflamed retrocecal appendix)