Acute appendicitis: Clinical anatomy of the new palpation sign

Abstract

Introduction Currently, diagnosis of acute appendicitis (AA) is challenging. Here, we aim to propose using the new palpation sign to diagnose AA and establish the effectiveness of clinical examination using a proprietary diagnostic palpation procedure. Materials and Methods We retrospectively analyzed 2,883 patients of all ages who were examined for suspected AA, of whom 532 patients required surgical intervention, using the new palpation sign. Patients were divided into three age categories. Based on the correlation between clinical data and histological findings, clinical examination finding was defined as false negative, false positive, and positive. Pearson correlation analysis was performed to assess the correlation between patients' sex and age distribution and clinical and histological findings. Results There was a strong correlation (r > .95) for distribution of total number of examined patients (distributed in groups by sex and age) versus false‐positive clinical findings, total number of examined patients (distributed in groups by sex and age) versus positive clinical findings, and total number of examined patients (distributed in groups by age) versus histology in phlegmonous and gangrenous appendicitis. Correlations (r = .94 and .90) were observed for distribution of total number of examined patients (distributed in groups by age) versus negative histological findings and Byron's obliterating appendicopathy. Pearson's chi‐squared test showed no significant difference between expected and observed frequencies of both clinical and histologic findings. Conclusions The new palpation sign can be used to diagnose early and later stage appendicitis, especially in children and young women, and is very effective in indicating surgery for AA.

A New Palpation Sign for the Diagnosis of Atypical Forms of Acute Appendicitis (Children and Women of Childbearing Age)

“…The advantage of the new palpation sign is its viscerosomatic character. Thanks to the visceral re ex arc, the sign enables the diagnosis of AA even before the onset of somatic pain with peritoneal symptoms, thus eliminating one of the important factors that contributes to diagnostic mistakes in women of childbearing age [24].…”

“…If a deep palpation induces a contracture of the abdominal wall which does not allow the pulsation of the iliac arteries to be felt, even when the child is exhaling, the sign is considered positive, i.e., there is a high probability of acute appendicitis (Fig. 1)" [24].…”

About a New Palpation Sign in the Diagnosis of Acute Appendicitis in Children and Women of Childbearing Age

“…If we notice pulsation of the iliac artery, the sign is considered negative, i.e., this sign excludes AA. If a deep palpation induces a contracture of the abdominal wall (abdominal guarding) which does not allow the pulsation of the iliac arteries to be felt, even when the child is exhaling, the sign is considered positive, i.e., there is a high probability of acute appendicitis (Figure 1)" [8,9].…”

Physical Examination and Appendiceal Signs During Pregnancy

“…Different descriptions and locations of the pain in acute appendicitis can be explained by whether the splanchnic (visceral) and/or cerebrospinal (somatic) nerve pathways are involved [7][8]. In acute appendicitis early in the disease course, Pacinian mechanoreceptors and splanchnic afferent nerve fibers within the appendix are activated in response to stretching, spasms, or compression [7]. The pain fibers travel with splanchnic sympathetic nerves (superior mesenteric, gastric, and hepatic plexus) to the dorsal root ganglion.…”

“…Hence, the location of this pain in early appendicitis is fixed regardless of the position of the appendix. What is not frequently recognized is that in some cases, when the pain is abrupt and severe, there is "spill-over" of splanchnic to somatic afferent neurons given their close anatomical proximity in the dorsal root of the spinal cord [7][8]. Because of this phenomenon, severe visceral appendiceal pain may also directly activate alpha motor neurons and efferent nerve pathways in intercostal nerves that innervate the abdominal wall muscles producing involuntary abdominal spasm (guarding) and pain at the right T10-T11 dermatome in the absence of inflammatory involvement of the parietal peritoneum.…”