What is Positive Rovsing’s Sign – Acute Appendicitis
Acute appendicitis refers to acute inflammation of the appendix, typically due to an obstruction of the appendiceal lumen. In both children and adults, it is the most common cause of acute abdomen requiring emergency surgical intervention.
The characteristic features of acute appendicitis are:
- Periumbilical abdominal pain that migrates to the right lower quadrant (RLQ)
- Anorexia (loss of appetite)
- Hamburger sign: If there is no loss of appetite, appendicitis is unlikely.
- Nausea
- Fever
- RLQ abdominal tenderness.
Positive Rovsing’s Sign
Clinical signs of appendicitis
- McBurney point tenderness (RLQ tenderness)
- Tenderness at the junction of the lateral third and medial two-thirds of a line drawn from the right anterior superior iliac spine to the umbilicus
- This point corresponds to the location of the base of the appendix.
- RLQ guarding and/or rigidity
- Rebound tenderness (Blumberg sign), especially in the RLQ
- Rovsing’s sign: RLQ pain elicited on deep palpation of the LLQ
- Psoas sign
- Can be elicited on flexing the right hip against resistance
- RLQ pain may be elicited on passive extension of the right hip
- Obturator sign: RLQ pain on passive internal rotation of the right hip with the hip and knee flexed
- Hyperesthesia within Sherren triangle: formed by the anterior superior iliac spine, umbilicus, and symphysis pubis
- Lanz point tenderness: at the junction of the right third and left two-thirds of a line connecting both the anterior superior iliac spines
- Pain in the Pouch of Douglas: pain elicited by palpating the rectouterine pouch on rectal examination
- Baldwin sign: pain in the flank when flexing the right hip (suggests an inflamed retrocecal appendix)
Positive Rovsing’s Sign
Diagnosis
Laboratory testing:
Although limited in their ability to differentiate appendicitis from other causes of abdominal pain, the following studies are typically obtained in children suspected to have appendicitis:
- White blood cell count (WBC): Will be elevated
- Differential with calculation of the absolute neutrophil count (ANC): Will be elevated
- C-reactive protein (CRP): Will be elevated
- Urinalysis: mild pyuria may be present. Also to rule out urinary tract infection
Imaging studies:
- Abdominal ultrasonography: is inexpensive, safe, and widely available. Diagnostic accuracy, reported to range from 71 to 97% and is highly dependent on operator skill. Ultrasonography is especially useful in women who are pregnant or of childbearing age, and in children. Major advantages to ultrasonography include non-invasiveness, short acquisition time, lack of radiation exposure, and potential for discovering other causes of abdominal pain (e.g., ovarian cysts, ectopic pregnancy, tubo-ovarian abscess).
- Abdominal CT with IV contrast: is more precise than ultrasonography and more reproducible from hospital to hospital. It has a diagnostic accuracy rate for acute appendicitis of 93 to 98%.
Positive Rovsing’s Sign
Management
Conservative management, which includes bowel rest, antibiotics, and analgesics, is indicated in patients with an inflammatory appendiceal mass (phlegmon) or an appendiceal abscess because surgical intervention is associated with a higher risk of complications in these patient groups.
The current standard of management of acute appendicitis is emergency appendectomy (open or laparoscopic) and broad-spectrum antibiotics.
Interval appendectomy 6–12 weeks after resolution of the acute episode can be performed in these patients to prevent a recurrence.
Positive Rovsing’s Sign
How to look for Rovsing’s sign
If palpation of the left lower quadrant of a person’s abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing’s sign and may have appendicitis. In acute appendicitis, palpation in the left iliac fossa may produce pain in the right iliac fossa.
A Rovsing sign is elicited by pushing on the abdomen far away from the appendix in the left lower quadrant as in most people the appendix is in the right lower quadrant. While this maneuver stretches the entire peritoneal lining, it only causes pain in any location where the peritoneum is irritating the muscle. In the case of appendicitis, the pain is felt in the right lower quadrant despite pressure being placed elsewhere.
Most practitioners push on the left lower quadrant to see where the patient complains of pain. If pain is felt in the right lower quadrant, then there may be an inflamed organ or piece of tissue in the right lower quadrant. The appendix is generally the prime suspect, although other pathology can also give a “positive” Rovsing’s sign. If left lower quadrant pressure by the examiner leads only to left-sided pain or pain on both the left and right sides, then there may be some other pathologic etiology. This may include causes relating to the bladder, uterus, ascending (right) colon, fallopian tubes, ovaries, or other structures.
Positive Rovsing’s Sign
Other physical examinations that helps in diagnosing acute appendicitis are Obturator’s sign and Psoas sign.
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Positive Rovsing’s Sign