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PHYSICAL EXAMINATION AND SIGNS
SIGNS AND SYMPTOMS :
1.Abdominal Pain
- The pain that first occurs is usually at the periumbilical or
epigastric area. This pain develops solely due to the
distention of the appendical lumen, causing firing of the
slow-conducting C-Fibers, which gives of f a poorly localized
pain, that is more dull, and is not always felt.
- The pain will then progress, and move to become more
localized to the Right Lower Quadrant, as the
parietal/peritoneal fast conducting A-fibers starts to gets
involved. The pain also becomes sharper, and more steady.
- The pain is commonly accompanied by
anorexia,nausea,and vomiting.
PHYSICAL EXAMINATION AND SIGNS
2. Rebound Tenderness
- Rebound tenderness is very important in order to be able
to construct a diagnosis of acute appendicitis. But, the
tenderness may not always be present in the early stages, it
is almost always present in the later stages of the disease.
- The tenderness may vary in respect to the location of the
appendix, which may be retrocecal, post-ileal,pelvic,etc.
- But the most common site of tenderness is at McBurney’s
point, which is 1/3 the way from the ASIS towards the
umbilicus.
- But it may be absent there, but be present in the flank
area, or only present in the digital rectal examination
- Abdominal Guarding may also present, where the
musculature of the abdomen is contracted,in an effort to
reduce the pain felt
PSOAS,OBTURATOR,ROVSING SIGN
- These physical signs may only be present in the later
stages of the disease, and hold rather little diagnostic
values.
OTHER IMPORTANT DIAGNOSTIC VALUES
- The temperature is usually normal,or only slightly elvated
(37.2-38), but if the temperature exceeds 38.5, perforation
of the appendix should be suspected.
- Distention is commonly not present initially, and may occur
later when more severe diffuse peritonitis has developed.
- - Leukocytosis is usually mild (10.000-18.000). If
leukocytosis exceeds 20.000 and is accompanied by a shift
to the left, a perforation should be suspected.
- If there is anemia and bloody stool, carcinoma of the cecum
should be suspected as an etiology of the acute
appendicitts.
- Urinalysis MAY show slightly elevated leukocytes and
erythrocyte, if the appendix is in close proximity to the
bladder or ureter ( no bacteria ).But, the urinalysis is most
useful for RULING OUT urinary problems, especially UTIs
DRE(DIGITAL RECTAL EXAMINATION)
- The digital rectal examination is performed by examining
the outer aspects of the anus, also by testing the
neuromuscular integrity of the sphincters by commanding
the patient to contract and relax the muscles, as in
defecating, also evaluating the mucosa, and palpating for
tenderness or masses
- It’s popularity has declined in the diagnosis of acute
appendicitis, eventually in children for whom it is very
uncomfortable.
- If the abdomen physical exam has already shown definitive
signs of acute appendicitis, it is considered unnecessary.
- But in patients for whom the abdomen pe signs are not
defnitive,they may be carried out as an additional diagnostic
tool.
RADIOGRAPHY
- Plain radiographs are rarely of any diagnostic value, and the
most common finding would be a large,opaque,fecalith.
- Ultrasound, especially with an experienced technician,
(compression technique) may be able to demonstrate a
dilated wall of appendix(>6mm diameter). It is also useful in
excluding ovarian cysts, and ectopic pregnancies.
- It is also favored in young patients and pregnant women,
due to the lack of radiation
- - The most important findings would be an outer diameter
>6mm, and hyperechoic periappendicular structures, and
viewing of the appendicoloth
-CT scans especially with contrast are also showing an
increased favoring,It is highly specific and sensitive for
acute appendicits.
- It is also useful in ruling out other causes of abbominal pain.
- The features seen are :
- Thickening of the appendix wall, and diameter >6mm
- Periappendicular inflammation
- Appendicolith
 IS
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PERITONITIS
-Peritonitis is any inflammation of the peritoneal cavity.
- Peritonitis can occur primarily(primary peritonitis) usually
due to liver cirrhosis, or secondary (secondary peritonitis)
commonly due to rupture or perforation of a viscera, a
penetrating abdominal wound, or entry of foreign object
( dialysis catheter)
- Common Signs and Symptoms :
- Abdominal Pain,Guarding,Rebound Tenderness
- Fever
PHYSICAL SIGNS
- Abdominal Pain may be localized or diffused, a localized
abdominal pain is more often a sign of SECONDARY
peritonitis, or a perforated viscus.While a diffuse abdominal
pain,should raise more concern towards primary peritonitis,
most often due to liver cirrhosis.
- Abdominal Guarding and Rebound Tenderness
- Decreased intestinal motility,causing decreased bowel
sounds and distension of the abdomen due to accumulation
of fluids and gasses.
- Signs of shock may appear such as hypotension and
tachycardia
LABORATORY SIGNS
Leukocytosis (>11.000) is marked in Peritonitis
Signs of Dehydration and decrease in pH
Urinalysis(Rule out urinary tract infections)
IMAGING STUDIES
Plain Abdominal Films may be obtained, showing distention of
the small and large intestine, edema of abdominal wall, and
in cases of perforation of gaster and duodenum, there is
usually accumulaton of air under the diaphragm
Ultrasonography may be uncomfortable for the patient, but
may show the accumulation of fluid or peritoneal
abscesses.
Diagnostic Paracentesis may also be performed
-Low pH
-Low glucose
-High protein and Lactate Dehydrogenase
- Culture of peritoneal fluid
Thank You