Give me all the signs of appendicitis
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I now have comprehensive, high-quality data from Harrison's Principles of Internal Medicine 22E and Current Surgical Therapy 14E. Here is the full breakdown:
Signs of Appendicitis
Symptoms (What the Patient Reports)
| Symptom | Frequency |
|---|---|
| Abdominal pain | >95% |
| Anorexia | >70% |
| Nausea | >65% |
| Vomiting | 50-75% |
| Migration of pain to right lower quadrant | 50-60% |
| Fever | 10-20% |
| Constipation or diarrhea | 4-16% each |
Classic pain sequence: Vague periumbilical or diffuse pain first (from visceral afferent stretch due to appendiceal distension), then migration to the right lower quadrant (RLQ) as parietal peritoneum becomes involved. This migration pattern occurs in about 50-60% of patients and is one of the most specific features.
Physical Signs (What the Examiner Finds)
| Sign | Frequency |
|---|---|
| Abdominal tenderness | >95% |
| Right lower quadrant tenderness | >90% |
| Rebound tenderness | 30-70% |
| Rectal tenderness | 30-40% |
| Cervical motion tenderness | ~30% |
| Rigidity / guarding | ~10% |
| Obturator sign | 5-10% |
| Psoas sign | 3-5% |
| Rovsing's sign | ~5% |
| Palpable mass | <5% |
Named Classic Signs
1. McBurney's Point Tenderness
Maximal tenderness at McBurney's point - approximately one-third of the way along a line from the right anterior iliac spine to the umbilicus. This is the most common location for direct tenderness.
2. Rovsing's Sign
Palpating the left lower quadrant causes pain in the right lower quadrant. Indicates peritoneal irritation around the appendix.
3. Psoas Sign (Iliopsoas Sign)
Extending the right hip causes pain along the posterolateral back and hip. Suggests a retrocecal appendix lying against the psoas muscle.
4. Obturator Sign
Internal rotation of the flexed right hip causes pelvic or RLQ pain. Suggests an inflamed appendix lying in the pelvis (pelvic appendix).
5. Rebound Tenderness (Blumberg's Sign)
Pain worsens when deep pressure is suddenly released. Indicates parietal peritoneal irritation.
6. Dunphy's Sign (Cough Sign)
Pain in the RLQ with coughing or any sudden increase in intra-abdominal pressure (sneezing, Valsalva maneuver, bumpy car ride). Reflects peritoneal irritation.
7. Heel Drop / Jump Sign
The patient is asked to stand on tiptoes and drop to their heels - this reproduces RLQ pain by jarring the peritoneum.
Patients Lie Still
A characteristic behavioral sign: patients with appendicitis tend to lie very still to minimize peritoneal irritation caused by movement. This contrasts with renal colic, where patients are restless and writhing.
General Examination Findings
- Low-grade fever - temperature is usually only mildly elevated. A temperature >38.3°C (101°F) with rigors suggests perforation, abscess, or phlegmon.
- Mild tachycardia in simple appendicitis
- Appears mildly ill in uncomplicated cases
Laboratory Correlates (Supporting the Diagnosis)
- Leukocytosis (WBC 10,000-18,000 cells/µL) in ~70% of simple appendicitis
- Left shift (>75% neutrophilia) in >95% of cases
- Elevated CRP
- Sterile pyuria/hematuria may occur if the inflamed appendix abuts the ureter or bladder (don't mistake for UTI)
Atypical Presentations
- Elderly: Pain may be minimal, predominantly presenting with nausea/anorexia/emesis. RLQ tenderness may be absent or subtle.
- Children: Dramatic response to stimulation; smaller omentum means less ability to wall off perforation - higher risk.
- Pregnant women: Appendix is less displaced than traditionally thought; signs of peritoneal irritation may be diminished due to the abdominal wall being pushed away from viscera.
- Pelvic appendix: May cause dysuria, urinary frequency, diarrhea, tenesmus, and suprapubic pain rather than RLQ pain.
- Retrocecal appendix: Anterior abdominal wall tenderness may be minimal; psoas sign becomes prominent.
Alvarado Scoring System (Clinical Aid)
| Feature | Score |
|---|---|
| Migration of pain to RLQ | 1 |
| Anorexia | 1 |
| Nausea / Vomiting | 1 |
| RLQ tenderness | 2 |
| Tenderness with hopping/coughing/percussion | 2 |
| Fever ≥38.0°C | 1 |
| Leukocytosis (WBC >10,000) | 1 |
| Neutrophilia (>75%) | 1 |
| Total | 10 |
Score ≥7 is highly suggestive of appendicitis.
Sources: Harrison's Principles of Internal Medicine 22E (Tables 342-3 and 342-4); Current Surgical Therapy 14E (Mahdi & Pegoli)
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