Fast Five Quiz: Appendicitis Diagnosis and Treatment

Richard H. Sinert, DO


March 13, 2019

The most specific physical findings in appendicitis are rebound tenderness, pain on percussion, rigidity, and guarding. Although right lower quadrant (RLQ) tenderness is present in 96% of patients, this is a nonspecific finding. Rarely, left lower quadrant (LLQ) tenderness has been the major manifestation in patients with situs inversus or in patients with a long appendix that extends into the LLQ. Tenderness on palpation in the RLQ over the McBurney point is the most important sign in these patients.

The classic history of anorexia and periumbilical pain followed by nausea, RLQ pain, and vomiting occurs in only 50% of cases. Diarrhea or constipation is noted in as many as 18% of patients and should not be used to discard the possibility of appendicitis. Nausea is present in 61%-92% of patients; anorexia is present in 74%-78% of patients. Neither finding is statistically different from findings in patients who present to the emergency department with other etiologies of abdominal pain. In addition, when vomiting occurs, it nearly always follows the onset of pain. Vomiting that precedes pain is suggestive of intestinal obstruction, and the diagnosis of appendicitis should be reconsidered.

The duration of symptoms is less than 48 hours in approximately 80% of adults but tends to be longer in elderly persons and in those with perforation. Approximately 2% of patients report duration of pain in excess of 2 weeks. A history of similar pain is reported in as many as 23% of cases, but this history of similar pain, in and of itself, should not be used to rule out the possibility of appendicitis.

Read more on the presentation and physical examination of appendicitis.


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