Diagnosis of acute Appendicitis
Appendicitis is usually diagnosed through clinical signs and symptoms. Murphy’s triad (pain, vomiting and temperature) is diagnostic of appendicitis.
Signs and Symptoms of acute Appendicitis
1. Temperature – appendicitis may cause rise in temperature, but higher temperature is unusual with uncomplicated appendicitis. Temperature elevation is restricted to 99 to 100 degree fahrenheit. Pulse rate is usually normal or slightly elevated.
2. Palpation – presence of peritoneal inflammation can be suspected if cough or percussion on the abdominal wall elicits pain.
- Systemic gentle palpation will detect an area of maximum tenderness that corresponds to the position of the appendix and is usually located in the right lower quadrant at or near McBurney’s point.
- The classic method of demonstrating peritoneal inflammation is rebound tenderness. In this case gentle pressure is exerted on the inflamed area and sudden release of the hand will cause extreme pain of the patient at the inflamed area. This is called rebound tenderness.
- Pain in the right lower quadrant is complained of when palpation pressure is exerted in the left lower quadrant. It is also called as ‘referred rebound tenderness’ and when present is quite helpful in supporting the diagnosis. This is called as Rovsing’s sign.
- Psoas sign – this test is performed by having the patient lie on his left side. The examiner then slowly extends the patient’s right thigh. This will produce pain to make the sign positive. This indicates presence of irritative inflamed appendix in close proximity to the psoas muscle.
Other special investigations are:
- It will reveal moderate rise in white blood cell count (leucocytosis) ranging from about 10,000 to 18,000 per cubic mm. In case of normal total and differential leucocytosis, the diagnosis of appendicitis should be questioned. In case of perforated appendicitis the total white cell count may rise above 18,000.
- Except for high specific gravity due to dehydration, routine urine examination will usually reveal normal result in case of appendicitis. Only when the inflamed appendix lies near the ureter or bladder, white cells and even red cells may be seen in the urine.
- There is no diagnostic sign found of appendicitis in X-ray examination.
- Plain films may show a faecolith (fecal particles) at the appendicular region. A distended loop of small bowel in the right lower quadrant may be seen. Less often a distended caecum or gas-filled appendix may be detected.
- In late complicated appendicitis straight X-ray may reveal absence of small bowl gas in the right lower quadrant.
Barium enema examination
- This procedure is obviously unnecessary in most cases of appendicitis in which the diagnosis is reasonably clear on clinical grounds.
- The positive findings to be sought during barium enema examination are non-filling or partial filling of the appendix and extrinsic pressure defect on the caecum producing a picture of ‘reverse 3’ on the caecum and mucosal irregularities of the terminal ileum.