Which abdominal findings are characteristic of pediatric appendicitis?

Updated: Oct 25, 2018
  • Author: Adam C Alder, MD; Chief Editor: Carmen Cuffari, MD  more...
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Full exposure of the abdomen is key. Before examining the abdomen, ask the child to point with one finger to the site of maximal pain. Begin palpation of the abdomen at a site distant to this, with the most tender area examined last. If the child is particularly anxious, palpation may be performed with a stethoscope.

Distracting questions concerning school and family members may be helpful to relieve anxiety during the examination. Observing the child's facial expressions during this questioning and palpating is critical.

Palpation of the abdomen should be performed with a gentle and light touch, searching for involuntary guarding of the rectus or oblique muscles. In early appendicitis, children may not have significant guarding or peritoneal signs. Younger children are much more likely to present with diffuse abdominal pain and peritonitis, perhaps because their omentum is not well developed and cannot contain the perforation.

Typically, maximal tenderness can be found at the McBurney point in the RLQ. A mass may be palpable in the RLQ if the appendix is perforated.

However, the appendix may lie in many positions. Patients with a medially positioned appendix may present with suprapubic tenderness. Patients with a laterally positioned appendix often have flank tenderness. Patients with a retrocecal appendix may not have any tenderness until appendicitis is advanced or the appendix perforates.

Presence of the Rovsing sign (pain in the RLQ in response to left-sided palpation or percussion) strongly suggests peritoneal irritation.

To assess for the psoas sign, place the child on the left side and hyperextend the right leg at the hip. A positive response suggests an inflammatory mass overlying the psoas muscle (retrocecal appendicitis).

Check for the obturator sign by internally rotating the flexed right thigh. A positive response suggests an inflammatory mass overlying the obturator space (pelvic appendicitis).

During the abdominal examination, try to avoid eliciting rebound tenderness. This is a painful practice and certainly destroys any trust that has been garnered during the examination. Peritonitis can be confirmed with gentle percussion over the right lower quadrant. Involuntary contraction of the abdominal wall musculature (involuntary guarding) and tenderness can be elicited with minimal stress or discomfort to the child.

Other methods can be used to establish that the patient has peritoneal irritation. Asking the patient to sit up in bed, cough, jump up and down, or bounce his or her pelvis off the bed while in the supine position may elicit pain in the presence of peritoneal irritation. Alternatively, other acceptable maneuvers are tapping the patient's soles and shaking the stretcher. A child with advanced appendicitis typically prefers to lie still due to peritoneal irritation.

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