Diagnosis
History and physical/other
Mimicking features
Inflammatory bowel disease (IBD)
Abdominal pain, severe cramps, weight loss, bloody diarrhea, anemia, enterocutaneous fistula/anal fissures (Crohn’s), toxic megacolon (ulcerative colitis)
Crohn’s can present with RLQ pain due to inflammation limited to the ileocecal region (known as regional enteritis)
Pancreatitis
Epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia, cholelithiasis, gallstones, or alcohol abuse
Predominantly epigastric pain. With severe pancreatitis, ascites forms and may track down the right paracolic gutter (depressions found between the colon and abdominal wall) causing RLQ pain
Cholecystitis
Right upper quadrant (RUQ) pain radiating to back, nausea, vomiting, fever, palpation of RUQ during inspiration stops inspiration secondary to pain (Murphy’s sign)
Though pain is typically RUQ, a large inflamed gallbladder may cause RLQ pain
Appendicitis
Anorexia, vague periumbilical abdominal pain, vomiting, localized right lower quadrant pain (McBurney’s point), Rovsing’s sign, psoas sign
–
Gastroenteritis
Nausea, vomiting, watery diarrhea (viral), bloody diarrhea (certain bacteria), myalgia, fever
May cause diffuse abdominal tenderness and marked leukocytosis
Nephrolithiasis
Colicky flank pain that may radiate to inner thigh or genitals, nausea, vomiting, dysuria, hematuria
Ureteral pain may refer to RLQ
Perforated duodenal ulcer (Valentino’s syndrome)
Sudden onset of epigastric pain, rigid abdomen, history of dyspepsia, NSAID use, recurrent ulcers, H. pylori infection
Initial pain is epigastric, then diffuse, but duodenal perforation may seal, enteric contents may track down right paracolic gutter causing subsequent RLQ pain
Pyelonephritis
Costovertebral angle tenderness, fever, pain on urination, vomiting
Renal and ureteral pain can refer to RLQ
Sigmoid diverticulitis
Pain in LLQ, fever, leukocytosis, nausea, diarrhea, constipation, common in elderly (acquired)
A large, floppy, redundant sigmoid colon may lie in the RLQ, thus presenting with RLQ instead of left lower quadrant (LLQ) pain
Cecal diverticulitis
Congenital solitary diverticulum
Identical to appendicitis
Meckel’s diverticulitis
“Rule of 2’s”: males 2× more common than females, occurs within 2 ft of the ileocecal valve, 2 types of tissue (pancreatic, gastric), found in 2 % of the population, can present at 2 years of age (with painless rectal bleeding)
Identical to appendicitis, in an adult, a Meckel’s diverticulum can become infected (Meckel’s diverticulitis) and present with RLQ pain
What is the Differential Diagnosis of Appendicitis in Women and What Clues on History and Physical Might Direct you Towards a Specific Diagnosis?
Diagnosis | History and physical |
|---|---|
Pelvic inflammatory disease | Neisseria gonorrhoeae or Chlamydia infection, purulent cervical discharge, cervical motion tenderness, adnexal tenderness, dysuria |
Ovarian torsion | Acute onset of severe pelvic pain, adnexal mass, history of ovarian cysts |
Mittelschmerz | Physiologic recurrent mid-cycle pain, mild and unilateral, duration ranges from few hours to few days, normal pelvic exam |
Ruptured ectopic | Typically presents 6–8 weeks after last normal menstrual period, abdominal pain, amenorrhea, vaginal bleeding, breast tenderness, anemia (rarely hemorrhagic shock) |
What is the differential diagnosis of appendicitis in a child and what clues on history and physical might direct you towards a specific diagnosis?
Diagnosis | History and physical |
|---|---|
Mesenteric lymphadenitis | Concomitant or recent URIa; high fever; enlarged, inflamed, and tender lymph nodes in small bowel mesentery; generalized abdominal pain |
Yersinia enterocolitica (pseudoappendicitis) | RLQ pain, fever, vomiting, bloody diarrhea, history of sick contacts (e.g., infected children at daycare) |
Pneumococcal pneumonia | May be associated with nausea, vomiting, and diffuse abdominal pain |
Gastroenteritis | Nausea, vomiting, watery diarrhea (viral), bloody diarrhea (certain bacteria), myalgia, fever |
Intussusception | Nausea, vomiting, crampy abdominal pain, “red currant jelly” stool, “sausage-shaped mass in abdomen (12-month-old infant) |
What Is the Most Likely Diagnosis?
Given the history of initial periumbilical pain that is now localized to the RLQ, associated with tenderness, leukocytosis with increased bands, the most likely diagnosis is acute appendicitis.
Watch Out
Rule out an ectopic pregnancy with a beta-hCG pregnancy test for all women of childbearing age presenting with abdominal pain.
History and Physical
What Is Usually the First Symptom of Appendicitis and What Is the Classic Sequence of Symptoms?
In >95 % of cases of acute appendicitis, anorexia is the first symptom. The classic sequence of symptoms is anorexia, vague periumbilical abdominal pain, vomiting, and then a shift to localized right lower quadrant pain.
What Is the Significance of Absent Bowel Sounds?
Absent bowel sounds indicate a paralytic ileus which in this setting would be secondary to inflamed/infected bowel.
What Is a Hamburger Sign?
The majority of patients with acute appendicitis will have anorexia. If the patient is hungry, acute appendicitis is less likely. Inquire about the patient’s favorite food (e.g., hamburger, pizza), and ask if the patient would like to eat it. Patients with true anorexia will decline their favorite food (positive hamburger sign).
What Are Rovsing’s, Psoas, and Obturator Signs and McBurney’s Point Tenderness?
Appendicitis creates an inflammatory response in the adjacent retroperitoneum and parietal peritoneum. These are signs (Table 20.1) of localized peritonitis in the right lower quadrant due to inflammation. Rovsing’s sign is right lower quadrant pain with palpation of the left lower quadrant. Compression in the LLQ stretches the abdominal wall triggering pain in the inflamed underlying RLQ parietal peritoneum. Appendicitis can also inflame the adjacent psoas or obturator muscles. Psoas sign is right lower quadrant pain on passive extension of the right hip or active flexion of the right hip. Obturator sign is RLQ pain on internal rotation of the hip which can occur with a pelvic appendix. McBurney’s point (Fig. 20.1) is located at one-third of the distance along an imaginary line drawn from the anterior superior iliac spine to the umbilicus and marks the incision site for open appendectomies. McBurney’s sign is maximal tenderness at McBurney’s point.
Table 20.1
Signs of appendicitis
Sign | Description |
|---|---|
Rovsing’s | RLQ pain with palpation of LLQ |
Psoas | RLQ pain on passive extension of the right hip or active flexion of the right hip |
Obturator | RLQ pain on internal rotation of the hip, typical of a pelvic appendix |
McBurney’s | Tenderness to palpation at McBurney’s point |
Fig. 20.1
McBurney’s point. A. McBurney’s point marked for mini incision. B. Incision appearance on postoperative day 4. The procedure began by making a small incision, 1.5–1.8 cm in length, according to the thickness of abdominal wall, at McBurney’s point (With kind permission from Springer Science + Business Media: Surgical Endoscopy, Gasless single-incision laparoscopic appendectomy, 25, 2011, pg 1473, Chen D et al., Fig. 1)
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