How to perform an abdominal exam for appendicitis
In addition to knowing the signs and symptoms of an acute abdomen, you should also be aware of a few additional peritoneal signs that can aid you in the diagnosis of a patient’s abdominal pain.
The World Gastroenterology Organization, formerly known as the Organisation Mondiale de Gastro-entérologie (OMGE), published a comprehensive study in 1988 in which they collected survey results from 10320 patients with acute abdominal pain from 200 physicians in 26 centers across 17 countries. The study found that the most common diagnosis for acute abdominal pain is nonspecific abdominal pain in 34% of the patients.
In adults, the most common surgical diagnoses are acute appendicitis, acute cholecystitis, and small bowel obstruction. In this article, we will review appendicitis-related peritoneal signs. But first, it’s important to understand the progression of pain in appendicitis.
Why does the pain location move as appendicitis progresses?
To understand the progression of pain with appendicitis, let’s review some details about the embryologic origin of structures associated with the appendix. The initial discomfort of appendicitis is due to inflammation of the visceral peritoneum and appendix. The visceral peritoneum is a layer of tissue that envelopes the appendix. This type of pain is carried back to the spinal cord by autonomic nerves. The pain gets referred to the midline of the abdomen (e.g., the belly button) due to the embryological origin of those nerves.
Over the disease course, the parietal peritoneum (the lining that covers the inside of the abdomen) eventually becomes inflamed. The pain is carried by somatosensory nerves that have a very specific dermatomal distribution. So, the pain gets localized directly to the location of the appendix—the right lower quadrant (RLQ).
What are the abdominal exam tests for appendicitis?
The psoas sign
The psoas sign involves RLQ pain on passive extension of the hip while the patient is in a left lateral decubitus position. An inflamed appendix that is retroperitoneal will irritate the iliopsoas muscle group of the hip flexors.
Figure 1. Assessing for the psoas sign involves extending the patient’s hip while they are in a left lateral decubitus position. Pain upon passive extension indicates a positive sign of appendicitis.
The obturator sign
The obturator sign involves RLQ pain on passive internal rotation of the hip while the patient is in the supine position. The pain is caused by irritation of the obturator internus muscle from the inflamed appendix.
Figure 2. Assessing for the obturator sign involves internally rotating the patient’s hip while they are in the supine position. Pain upon passive internal rotation indicates a positive sign of appendicitis.
McBurney’s sign involves tenderness with palpation of McBurney’s point, which is located at one-third of the distance from the anterior superior iliac spine to the umbilicus. McBurney’s point is commonly the location of the base of the appendix, so it will be painful when it is inflamed.
Figure 3. Assessing for the McBurney’s sign involves palpation of the point that is one-third the distance from the anterior superior iliac spine to the umbilicus. Tenderness at this point is a positive sign of appendicitis.
Dunphy’s and Rovsing’s signs
Dunphy’s sign involves increased abdominal pain with coughing, and Rovsing’s sign is positive when palpation in the left lower quadrant (LLQ) causes referred pain in the RLQ. Referred pain typically indicates irritation of the entire peritoneum, which can occur with appendicitis.
Figure 4. If a patient has increased abdominal pain with coughing, they have a positive Dunphy’s sign for appendicitis. A positive Rovsing’s sign involves referred pain in the right lower quadrant when palpating the left lower quadrant.
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