Ways to diagnose Appendicitis without tech.

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[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s] He may have been in his second decade of life.
I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

Thank you in advance.


Please add any other signs or symptoms that may aid iin this DX..

Originally Posted by mjl1717

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s]
I'm never going to miss this one!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

Thank you in advance.


Please add any other signs or symptoms that may aid iin this DX..

Guarding, too. Patient preferred to sit up rather than lie flat down.

Sadly, the guy's appendix was perfectly normal when removed... and the pain continued well afterward. I have no idea what happened to him, to this day.

Originally Posted by Morsetlis

Guarding, too. Patient preferred to sit up rather than lie flat down.

Sadly, the guy's appendix was perfectly normal when removed... and the pain continued well afterward. I have no idea what happened to him, to this day.

Good, and officially since the morbidity/mortality rate is so high the surgeon is not liable for that appendectomy.

- Pain is most often very severe
- Touching the localized area will cause greater pain
- Patient increases much greater pain when asked to raise their right leg (while laying down) against slight resistance

in the OR.

i dont think you get sued for taking out a normal appendix just like you dont get sued for delivering a normal baby through a C-section.

Rebound pain.

Unable to hop on right leg without significant pain.

Granny gait: walking hunched over

Markel Sign (aka Heel Jar Test)

Originally Posted by mjl1717

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s]
I'm never going to miss this one!!

Please add any other signs or symptoms that may aid iin this DX..

Never say never. When your see your first atypical presentation it will humble you. Also atypical happens.

The Alvarado score is the most widely used diagnostic aid for the diagnosis of appendicitis and has been modified slightly since it was introduced.

The modified Alvarado scale assigns a score to each of the following diagnostic criteria:

Migratory right iliac fossa pain (1 point)
Anorexia (1 point)
Nausea/vomiting (1 point)
Tenderness in the right iliac fossa (2 points)
Rebound tenderness in the right iliac fossa (1 point)
Fever >37.5 degrees C (1 point)
Leukocytosis (2 points)

The points totals are used to guide management:

A patient with a score of 0 to 3 could be considered to have a low risk of appendicitis and would be discharged with advice to return if there was no improvement in symptoms, subject to social circumstances.

A patient with a score of 4 to 6 would be admitted for observation and re-examination. If the score remains the same after 12 hours, operative intervention is recommended.

A male patient with a score of 7 to 9 would proceed to appendectomy.

In validation studies, the Alvarado score had a sensitivity of 95 percent for appendicitis with a score greater than 7 and overall accuracy of 83 percent.

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):55
Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl. 1994;76(6):418.

"accidentally" bump the bed. If they jump 2.54 cm* off of it with pain, you got yourself a live one.

Pain diffuse -> gradually becomes focal on RLQ

* completely arbitrary height

Originally Posted by myhandsarecold

in the OR.

i dont think you get sued for taking out a normal appendix just like you dont get sued for delivering a normal baby through a C-section.

I don't know anything about lawsuits, but the two examples are different.

In one case, the baby needs to come out, rather that be vaginally or via C-section. The appendix didn't need to come out.

Originally Posted by CaptainSSO

I don't know anything about lawsuits, but the two examples are different.

In one case, the baby needs to come out, rather that be vaginally or via C-section. The appendix didn't need to come out.

Ehh most medical lawsuits are for a permanent disability in some way, shape or form.

Assuming the surgery didn't cause complications there isn't much of a lawsuit on a 3 inch long scar and no permanent problems. Is an attorney really going to spend tens of thousands of dollars for a scar and the patient missing a week off work?

Originally Posted by CaptainSSO

I don't know anything about lawsuits, but the two examples are different.

In one case, the baby needs to come out, rather that be vaginally or via C-section. The appendix didn't need to come out.

it's kind of the same. both can present emergently and have very concerning history but benign or ambiguous physical exam, then what do you do? in this scenario, you dont have access to an US or CT. do you then send home or prophylactically cut?

you get sued for waiting and delivering a dead child or rupturing an appy

you still talk to the patients and most are very reasonable and understand the consequences and most of the time will trust you

Originally Posted by mjl1717

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s]
I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

Thank you in advance.


Please add any other signs or symptoms that may aid iin this DX..

How do people feel about this one? I feel pt's with ruptures look terrible, but I feel I have seen a good amount of mild cases where the pt looks pretty well.

Originally Posted by MiracleforMD

How do people feel about this one? I feel pt's with ruptures look terrible, but I feel I have seen a good amount of mild cases where the pt looks pretty well.

Yeah this is BS. Many people look fine up to the point they perforate. Honestly more people probably have atypical presentations than textbook ones.

Originally Posted by MiracleforMD

How do people feel about this one? I feel pt's with ruptures look terrible, but I feel I have seen a good amount of mild cases where the pt looks pretty well.

Yea my buddy had appendicitis and definitely didn't look "sick," he was just in pain and clutching his side.

Originally Posted by PMPMD

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):55
Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl. 1994;76(6):418.

From experience, and not using the scale, A patient with a high a Alvarado score comes in rarely. Majority of appy's are in the 3-5 range, that I've seen.
I'm a little surprised that migratory pain is scored the same as the other symptoms on that scale.. Migratory pain is the strongest clinical symptom of appy (highest likelihood ratio).

My institution is very imaging happy, and I've only got a surgeon to take two appy's to the OR without imaging. Both male teenagers.

Originally Posted by CaptainSSO

Yea my buddy had appendicitis and definitely didn't look "sick," he was just in pain and clutching his side.

Hmm, clutching one side and being in pain doesnt qualify for looking sick?? (That would not be a healthly looking specimen or person to me)

Perhaps Ill change that and say "many" look sick..
But if there is a perforation they should look toxic..

Originally Posted by sah

Never say never. When your see your first atypical presentation it will humble you. Also atypical happens.

I knew someone would say something like this..

Originally Posted by mjl1717

Hmm, clutching one side and being in pain doesnt qualify for looking sick?? (That would not be a healthly looking specimen or person to me)

There is a very big difference between looking "in pain" and looking "sick"

But if there is a perforation they should look toxic..

Again, often times they don't

If definitely seems like far more are atypical than typical when it comes to appendicitis presentations.

Originally Posted by Rendar5

From experience, and not using the scale, A patient with a high a Alvarado score comes in rarely. Majority of appy's are in the 3-5 range, that I've seen.
I'm a little surprised that migratory pain is scored the same as the other symptoms on that scale.. Migratory pain is the strongest clinical symptom of appy (highest likelihood ratio).

My institution is very imaging happy, and I've only got a surgeon to take two appy's to the OR without imaging. Both male teenagers.

Well migratory pain is only found in around 50% of the cases, so giving it a higher score could lead to underdiagnosing patients.

range [IQR]: 8.5, 14.9 yr); 36% of patients were diagnosed with appendicitis. Among patients with appen-
dicitis, the most common atypical features included absence of pyrexia (83%), absence of Rovsing’s sign
(68%), normal or increased bowel sounds (64%), absence of rebound pain (52%), lack of migration of
pain (50%), lack of guarding (47%), abrupt onset of pain (45%), lack of anorexia (40%), absence of maximal
pain in the right lower quadrant (32%), and absence of percussive tenderness (31%).

https://docs.google.com/viewer?a=v&q...H2DU1nzw&pli=1

Based on those results, percussive tenderness might be more important.

Originally Posted by southernIM

There is a very big difference between looking "in pain" and looking "sick"



Again, often times they don't

Yea, when I think "sick" I think pale, sweating, etc. I don't really care for the term though. It's not really defined and too vague.

this is all well and good and covered in MS1 PDX class..

truth is the number of negative laps over the past 50 years means almost everyone w/ suspected appy gets worked up, and usually a CT. and that's how it should be.

For reasons already mentioned, mere physical exam presentation is not acceptable for determining the urgency of sx in suspected appy. A young patient w/ impending perf/peritonitis can appear very well and suddenly crash. There are classic signs, with sens/spec in the 60-70%, however this isn't good enough. Even in the presence of increased WBCs, surgical abdomen, classic history, fever, +psoas, young patient, etc most of the time surgeons will request CT confirmation, or less often be satisfied w/ U/S (which is quick, painless, cheap and in some patients diagnostic). And imo that's how it should be, to avoid negative laparoscopy.

Originally Posted by CaptainSSO

Yea, when I think "sick" I think pale, sweating, etc. I don't really care for the term though. It's not really defined and too vague.

Good point Captain:

I agree with you..Come to think of it the term sick is a somewhat obscure term...

Eg: 1) Someone called into work "sick".
2) The word sick is really not used in a hospital.
3) Someone saying "Im sick and tired of this" doesnt really say much..

But for what its worth. An attending physician once told me that "sick patients appear sick"..

Originally Posted by mjl1717

Good point Captain:

I agree with you..Come to think of it the term sick is a somewhat obscure term...

Eg: 1) Someone called into work "sick".
2) The word sick is really not used in a hospital.
3) Someone saying "Im sick and tired of this" doesnt really say much..

But for what its worth. An attending physician once told me that "sick patients appear sick"..

"Sick" when used in medical parlance = "at or near the limit of that individual's physiologic reserve". I.e. at risk of crumping in the very near future without intervention.

Originally Posted by southernIM

"Sick" when used in medical parlance = "at or near the limit of that individual's physiologic reserve". I.e. at risk of crumping in the very near future without intervention.

Hmm never thought of it that way, always thought of them as pale, pained, diaphoretic. Thanks!

Originally Posted by mjl1717

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s]
I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Only if you don't see very many patients with it.

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

I rarely see a fever, and the pain should start periumbilical, not epigastric.

Originally Posted by mjl1717

Hmm, clutching one side and being in pain doesnt qualify for looking sick?? (That would not be a healthly looking specimen or person to me)

Perhaps Ill change that and say "many" look sick..
But if there is a perforation they should look toxic..

The vast majority of our appies don't look "sick," as defined by southernIM.

Originally Posted by CaptainSSO

Yea, when I think "sick" I think pale, sweating, etc. I don't really care for the term though. It's not really defined and too vague.

If they look sick, you should be able to recognize it immediately. Sometimes they hide it well though.

Originally Posted by Rendar5

From experience, and not using the scale, A patient with a high a Alvarado score comes in rarely. Majority of appy's are in the 3-5 range, that I've seen.
I'm a little surprised that migratory pain is scored the same as the other symptoms on that scale.. Migratory pain is the strongest clinical symptom of appy (highest likelihood ratio).

My institution is very imaging happy, and I've only got a surgeon to take two appy's to the OR without imaging. Both male teenagers.

Most of my appies are at least a 6. We don't typically take a girl to the OR just on history and physical, but we'll take a younger guy to the OR fairly frequently.

Originally Posted by Law2Doc

Yeah this is BS. Many people look fine up to the point they perforate. Honestly more people probably have atypical presentations than textbook ones.

When the viscus perforates, the patient often feels a lot better for a little while, just like when they dehisce. Relieves the pressure.

Originally Posted by myhandsarecold

in the OR.

i dont think you get sued for taking out a normal appendix just like you dont get sued for delivering a normal baby through a C-section.

As long as you did it for the right reasons, you won't get sued.

Also, it seems like our pathology department will call any appendix "acute appendicitis." I've also done >20 appies, and none of them looked normal when we got in there.

Saturday night:

Thank you everyone for the quick responses especially The Prowler and the Lawyer...

I think there were a few revelations in the thread eg.

1)The nebulousness and obscurity of the word sick.
2)The insight of the Prowler mentioning a relief of pressure for a while with the perforated viscous. /Also the rare fever.
3)Alvarado score
4)Annoying atypical presentations.
5)Numerous hands on maneuvers.
6)SouthernIM gave a definition for that word sick.
7)I'm glad no one ran beserk with a CT scan..

Originally Posted by TheProwler

When the viscus perforates, the patient often feels a lot better for a little while, just like when they dehisce. Relieves the pressure.

ive seen this once. guy perforated possibly a 1 week prior, got better then got super sick. then he came in, we ex lap'ed and his abdomen was all stool. i dont know what happened next as i switched service.

not all get as bad as that guy. some will perforate and the body will just wall it off but why take the chance, just get it out early

Originally Posted by myhandsarecold

ive seen this once. guy perforated possibly a 1 week prior, got better then got super sick. then he came in, we ex lap'ed and his abdomen was all stool. i dont know what happened next as i switched service.

not all get as bad as that guy. some will perforate and the body will just wall it off but why take the chance, just get it out early

Thats a good point also: The greater omentum or lesser omentum could just wall it off!

Originally Posted by myhandsarecold

ive seen this once. guy perforated possibly a 1 week prior, got better then got super sick. then he came in, we ex lap'ed and his abdomen was all stool. i dont know what happened next as i switched service.

not all get as bad as that guy. some will perforate and the body will just wall it off but why take the chance, just get it out early

I don't know the numbers, because we try not to let healthy people sit around with appendicitis, but I have to imagine that an otherwise healthy person can wall off a ruptured appendix more often than not with the omentum or small bowel.

Originally Posted by mjl1717

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s] He may have been in his second decade of life.
I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

Thank you in advance.


Please add any other signs or symptoms that may aid iin this DX..

Uh.........

Let me see if I can help:

RLQ pain for less than 48 hours
Objective RLQ tenderness
Never been seen in the ER before for abdominal pain
Less than 3 prescriptions for narcotics in the last year
No urinary symptoms.
Low squirrel factor

All 6 of those? 98% sensitive and 95% specific.