<unk>  as seen on CT imaging Diagnosis is based on a medical history (symptoms) and physical examination, which can be supported by an elevation of neutrophilic white blood cells and imaging studies if needed. Histories fall into two categories, typical and atypical. Typical<unk>  includes several hours of generalized abdominal pain that begins in the region of the umbilicus with associated anorexia, nausea, or vomiting. The pain then "localizes" into the right lower quadrant where the tenderness increases in intensity. It is possible the pain could localize to the left lower quadrant in people with situs inversus totalis. The combination of pain, anorexia, leukocytosis, and fever is classic. Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Irritation of the peritoneum (inside lining of the abdominal wall) can lead to increased pain on movement, or jolting, for example going over speed bumps. Atypical histories often require imaging with ultrasound or CT scanning. Clinical * Aure-Rozanova's sign: Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg's). * Bartomier-Michelson's sign: Increased pain on palpation at the right iliac region as the person being examined lies on their left side compared to when they lie on their back. * Dunphy's sign: Increased pain in the right lower quadrant with coughing. * Hamburger sign: The patient refuses to eat (anorexia is 80% sensitive for<unk>  * Kocher's (Kosher's) sign: From the person's medical history, the start of pain in the umbilical region with a subsequent shift to the right iliac region. * Massouh sign: Developed in and popular in southwest England, the examiner performs a firm swish with his or her index and middle finger across the abdomen from the xiphoid process to the left and the right iliac fossa. A positive Massouh sign is a grimace of the person being examined upon a right sided (and not left) sweep. * Obturator sign: The person being evaluated lies on her or his back with the hip and knee both flexed at ninety degrees. The examiner holds the person's ankle with one hand and knee with the other hand. The examiner rotates the hip by moving the person's ankle away from his or her body while allowing the knee to move only inward. A positive test is pain with internal rotation of the hip. * Psoas sign, also known as "Obraztsova's sign", is right lower-quadrant pain that is produced with either the passive extension of the right hip or by the active flexion of the person's right hip while supine. The pain that is elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and causes pain. * Rovsing's sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon). The thought is there will be increased pressure around the<unk> pendix by pushing bowel contents and air toward the ileocaecal valve provoking right-sided abdominal pain. * Sitkovskiy (Rosenstein)'s sign: Increased pain in the right iliac region as the person is being examined lies on their left side. *Perman's sign: In acute<unk>  palpation in the left iliac fossa may produce pain in the right iliac fossa.Emil Samuel Perman 1856-1946 "About the indications for surgery in<unk>  and an account of cases of Sabbatsberg Hospital in Hygiea 1904 Blood and urine test While there is no laboratory test specific for<unk> , a complete blood count (CBC) is done to check for signs of infection. Although 70–90 percent of people with<unk>  may have an elevated white blood cell (WBC) count, there are many other abdominal and pelvic conditions that can cause the WBC count to be elevated. Due to its low sensitivity and specificity, on its own, WBC is not seen as a good indicator of<unk> . A urinalysis generally does not show infection, but it is important for determining pregnancy status, especially the possibility of an ectopic pregnancy in women of childbearing age. The urinalysis is also important for ruling out a urinary tract infection as the cause of abdominal pain. The presence of more than 20 WBC per high-power field in the urine is more suggestive of a urinary tract disorder. Imaging In children the clinical examination is important to determine which children with abdominal pain should receive immediate surgical consultation and which should receive diagnostic imaging. Because of the health risks of exposing children to radiation, ultrasound is the preferred first choice with CT scan being a legitimate follow-up if the ultrasound is inconclusive. CT scan is more accurate than ultrasound for the diagnosis of<unk>  in adults and adolescents. CT scan has a sensitivity of 94%, specificity of 95%. Ultrasonography had an overall sensitivity of 86%, a specificity of 81%. Ultrasound Ultrasound image of acute<unk>  Abdominal ultrasonography, preferably with doppler sonography, is useful to detect<unk> , especially in children. Ultrasound can show the free fluid collection in the right iliac fossa, along with a visible<unk> pendix with increased blood flow when using color Doppler, and noncompressibility of the<unk> pendix, as it is essentially walled-off abscess. Other secondary sonographic signs of acute<unk>  include the presence of echogenic mesenteric fat surrounding the<unk> pendix and the acoustic shadowing of an<unk> pendicolith. In some cases <unk> proximately 5%), ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of<unk> . This false-negative finding is especially true of early<unk>  before the<unk> pendix has become significantly distended. Also, false-negative findings are more common in adults where larger amounts of fat and bowel gas make visualizing the<unk> pendix technically difficult. Despite these limitations, sonographic imaging with experienced hands can often distinguish between<unk>  and other diseases with similar symptoms. Some of these conditions include inflammation of lymph nodes near the<unk> pendix or pain originating from other pelvic organs such as the ovaries or Fallopian tubes. Ultrasounds may be either done by the radiology department or by the emergency physician. File:UOTW 45 - Ultrasound of the Week 1.Ultrasound showing<unk>  and an<unk> pendicolith File:UOTW 45 - Ultrasound of the Week 3.Ultrasound showing<unk>  and an<unk> pendicolith File:Ultrasonography of a normal<unk> pendix, annotated.Ultrasound of a normal<unk> pendix for comparison File:Ultrasonography of a normal<unk> pendix without and with compression.A normal<unk> pendix without and with compression. Absence of compressibility indicates<unk> . Computed tomography A CT scan demonstrating acute<unk>  (note the<unk> pendix has a diameter of 17.1 mm and there is surrounding fat stranding) A fecalith marked by the arrow that has resulted in acute<unk> . Where it is readily available, computed tomography (CT) has become frequently used, especially in people whose diagnosis is not obvious on history and physical examination. Although some concerns about interpretation are identified, a 2019 Cochrane review found that sensitivity and specificity of CT for the diagnosis of acute<unk>  in adults was high. Concerns about radiation tend to limit use of CT in pregnant women and children, especially with the increasingly widespread usage of MRI. The accurate diagnosis of<unk>  is multi-tiered, with the size of the<unk> pendix having the strongest positive predictive value, while indirect features can either increase or decrease sensitivity and specificity. A size of over 6 mm is both 95% sensitive and specific for<unk> . However, because the<unk> pendix can be filled with fecal material, causing intraluminal distention, this criterion has shown limited utility in more recent meta-analyses. This is as opposed to ultrasound, in which the wall of the<unk> pendix can be more easily distinguished from intraluminal feces. In such scenarios, ancillary features such as increased wall enhancement as compared to adjacent bowel and inflammation of the surrounding fat, or fat stranding, can be supportive of the diagnosis. However, their absence does not preclude it. In severe cases with perforation, an adjacent phlegmon or abscess can be seen. Dense fluid layering in the pelvis can also result, related to either pus or enteric spillage. When patients are thin or younger, the relative absence of fat can make the<unk> pendix and surrounding fat stranding difficult to see. Magnetic resonance imaging Magnetic resonance imaging (MRI) use has become increasingly common for diagnosis of<unk>  in children and pregnant patients due to the radiation dosage that, while of nearly negligible risk in healthy adults, can be harmful to children or the developing baby. In pregnancy, it is more useful during the second and third trimester, particularly as the enlargening uterus displaces the<unk> pendix, making it difficult to find by ultrasound. The periappendiceal stranding that is reflected on CT by fat stranding on MRI<unk> pears as an increased fluid signal on T2 weighted sequences. First trimester pregnancies are usually not candidates for MRI, as the fetus is still undergoing organogenesis, and there are no long-term studies to date regarding its potential risks or side effects. X-ray<unk> pendicolith as seen on plain X-ray In general, plain abdominal
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