Approach to the Patient with Acute Abdomen – Part I

All of these signs are indicative of an appendicitis. Rovsing's sign: Palpation of left iliac fossa causes right iliac fossa pain Aaron's sign: Referred pain to the epigastrium upon continuous pressure placed on right iliac fossa Blumberg sign: Pain upon removal of pressure in the right iliac fossa McBurney's sign: Deep tenderness at McBurney's point (Right iliac fossa, one-third of the distance from the anterior superior iliac spine to the umbilicus) Psoas sign: Pain on right hip flexion or extension

In a typical presentation of appendicitis the pain starts peri-umbilically and then migrates to the right iliac fossa. This represents the inflammation stretching the visceral wall transforming into localised parietal peritoneal inflammation. In younger children this inflammation irritates the psoas muscle making walking very painful. Those who have a long appendix that is situated posterior to the caecum may conversely have lumbar back pain. If the appendix has ruptured gas and/or blood enters the abdominal cavity leading to irritation of the diaphragm. The diaphragm is innervated by the phrenic nerve C3-5 which can cause referred shoulder tip pain.

It is most likely that a female of the age presenting with acute right iliac fossa pain and vomiting is suffering from an appendicitis. Although all the above will be needed to diagnose an appendicitis, it is very important to rule out an ectopic pregnancy in any females of child baring ages as this could be life threatening.

Immediate surgical management is required to remove the inflamed appendix prior to its rupture. Most appendectomies occur within 24 hours of pain onset and are done by a laparoscopic approach.

Both Lanz and Gridiron give access to the appendix. However many surgeons prefer to use the Lanz incision as it follows Langer’s lines and therefore leads to better healing and reduced scarring

Although presenting similar to the appendicitis patient, the higher temperature, diffuse tenderness and cervical lymphadenopathy all point to a diagnosis of mesenteric adenitis. This usually occurs after a recent upper respiratory tract infection. Consequently it is important to ask about a recent cough or soar throat.

FBC and CRP is recommended in all patients to assess severity of infection or inflammation and are helpful to monitor the disease process.

Typically the pain goes away within a few days after the lymph tissue inflammation subsides. Therefore no treatment is usually required other than pain relief and encouraging water consumption.

Mesenteric adenitis is distinctly uncommon in those older than 20 years.

Mesenteric adenitis is more likely to present in the first decade of like while appendicitis most commonly presents within the second decade.