Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!!

Three Stages of Appendicitis

* Stage 1: ~12 hours of “gastroenteritis” like symptoms* Stage 2: Direct somatic irritation* This is when pain over McBurney’s develops!* Stage 3: Perforation* Patient is now sick and septic

Approach to Appendicitis

* Step 1: Consider getting labs* Always remember “The white blood cell count is the last refuge of the intellectually destitute”* The WBC count has both low sensitivity and low specificity for acute appendicitis* Step 2: Get a detailed history* When did the pain start? * How many HOURS into their syndrome are they (remember stages of appendicitis)* Is the pain migrating?* Objective fever?* Did the pain start before the vomiting started?* Does the patient have decreased appetite?* Step 3: Perform a physical exam* Pain over McBurney’s point* Right lower quadrant* 1/3 the distance from the ASIS to the umbilicus* Peritoneal signs (Rigidity, Rebound, Guarding)* Psoas sign* Lie patient on left side with legs extended* Extend their hip behind them* Pain = Suspected retroperitoneal inflammation* Obturator sign* Have patient lie on back with hip/knee flexed at 90 degrees* Internally rotate hip (move ankle away from body)* Pain = Suspected obturator internus inflammation* Step 4: Imaging* Most adults* CT scan +/- IV contrast* Pregnant women* MRI abdomen* Pediatric patients* RLQ ultrasound* Step 5: Disposition* Perform a repeat abdominal exam* Even if CT is negative, consider followup in ED in 12-24 hours

Additional Reading

* McBurney’s Point (Wikipedia)* Psoas Sign (Wikipedia)* Obturator Sign (Wikipedia)