EmergencyPedia

ABDOMINAL PAIN CASE 4

‘I can’t keep anything down’ 

Richard is a 26 year old male who presents to ED with vomiting, two episodes of loose stool and abdominal pain for one day. On examination, his heart rate is 100, BP 120/60, RR 20 and his temp 38.0 degrees.

You palpate his abdomen and find he has lower abdominal tenderness worse in the right lower quadrant (RLQ). His region of tenderness makes you suspect he may have appendicitis.

Which of the following is a typical presenting symptom of appendicitis?

Choices:

1. Anorexia
2. Nausea and vomiting
3. Changes in bowel habit
4. All of the above   

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Answer Feedback:- All of the above   

Take Home Message:

Abdominal pain is the most common symptom reported in appendicitis but it is important to remember that other symptoms are common including fever, anorexia and nausea.

Further Explanation:

Appendicitis can present with several symptoms. Abdominal pain is the most common and usually precedes other symptoms. Classic migratory pain (starting in epigastrium and moving to the RLQ) only occurs in half of adult patients.

The location of the pain and tenderness can vary depending on where the tip of the appendix lies. Other clinical signs (of varying sensitivity and specificity) include:

• McBurney’s point tenderness (located between the hip and umbilicus)
• Rovsing’s sign (pain in RLQ on palpation of LLQ)
• Psoas sign (RLQ pain on passive right hip extension, associated with retrocaecal appendix)

As mentioned, symptoms include anorexia, nausea, vomiting, non-specific indigestion, flatulence, bowel changes, diarrhoea and generalised malaise. Investigation findings include leukocytosis and enlarged appendiceal diameter on CT or ultrasound, although imaging is not routinely used.

The Alvarado score (M.A.N.T.R.E.L.S.) provides a mnemonic for the typical symptoms (see link)

Links and References:

1. Alvarado Score – https://www.mdcalc.com/alvarado-score-acute-appendicitis
2. Up To Date provides an extensive explanation of signs and common differentials
3. ACI review https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/abdominal-emergencies/acute-appendicitis/acute-appendicitis-in-non-pregnant-adults