- Retrocecal or Retroiliac Appendix: Pain may be dulled by overlying bowel. Isolated rectal tenderness rarely may be the only site of localized pain in patients with a low-lying or retrocecal appendix.
- Elongated Appendix: Pain may be referred to the flank, pelvis, or RUQ.
- Rovsing sign - Tenderness is referred to the RLQ with palpation of the LLQ.
- Psoas sign – Increased pain on hip extension (due to stretching of Psoas)
- Obturator sign - Pain on hip flexion external rotation
- Diagnosing appendicitis in females is a challenge regardless of the conception status. Therefore, use of imaging should be strongly considered in any female with RLQ pain. Nausea and vomiting occur normally in a pregnancy, and the accuracy of the physical exam is compromised because of altered anatomy. Lab values are not useful, because leukocytosis is common during pregnancy.
- Maternal death from appendicitis is extremely rare, spontaneous fetal abortion occurs in up to 15-37% cases. Start with a USG, then MRI if USG is indeterminate. A shielded CT should only be the last resort. If there are potential delays in obtaining imaging, admit them for serial abdominal exams.
- Analgesia: There is robust literature that proves that opioids do not mask physical exam findings or interfere with surgical decision making. If your surgical colleagues like to examine patients prior to that then give them a call the moment you suspect appendicitis and make sure that they put their hand on the patient’s belly within the next few minutes.
- Educate your patients about worsening signs of appendicitis, along with arrangements for immediate re-evaluation if their symptoms worsen, or call them for an abdominal re-examination in 12-24 hours. Document this discussion in the patient’s record.
- Consider admission for those who require significant doses of opiates to control their pain, who cannot follow-up, if patient or family reliability is in question.
- Yes, it is certainly possible to have appendicitis despite having a normal WCC although many surgeons believe otherwise. Approximately 80 to 90% of patients with acute appendicitis will have an elevated white blood cell (WBC) count above 10,000/mm. Unfortunately, the leukocyte count is nonspecific and often is elevated with other causes of abdominal pain.
- Other labs: Mild sterile pyuria may be seen if the appendix is irritating the ureter but significant pyuria (i.e. > 20 WBCs/ HPF) is highly suggestive of urinary tract pathology.
- Use scoring systems such as “MANTRELS score” cautiously especially with female patients.
- Pain Relief always comes first.
- A normal white cell count, a negative USG or even a negative CT cannot rule out appendicitis in a patient with concerning story and physical exam. Therefore, whenever sending them home, discuss reg flags and document that in the patient's chart.
- Pregnancy with RLQ pain, start with USG and then MRI scan if needed. A shielded CT should only be your last option here.
- Have a low threshold to obtain imaging in every female with RLQ pain because appendicitis is "not always" a clinical diagnosis.
Northwick Park Hospital
Department of Emergency Medicine