Rebound tenderness for appendicitis: Nausea, Fever, Abdominal Pain, and More
Nausea, Fever, Abdominal Pain, and More
Your appendix is a small, finger-like pouch that’s located at the lower right side of your abdomen at the junction of your large intestine and small intestine.
Appendicitis occurs when your appendix becomes inflamed and filled with pus, a fluid made up of dead cells and inflammatory debris that often results from an infection. If appendicitis is left untreated, the appendix will swell and eventually burst, leaking its infected contents throughout your abdomen and leading to a potentially life-threatening infection.
There is no way to predict who will get appendicitis, so spotting the signs of appendicitis is vital for early diagnosis. If you have appendicitis, the first symptom you will likely experience is a pain around your belly button.
Over a matter of hours — typically 12 to 24 hours after onset — this pain slowly moves to the lower right part of your belly and tends to settle at a spot called McBurney’s point, which lies directly above the base of your appendix.
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How to recognize an acute abdomen and identify when an urgent sur
Learn how to recognize the signs and symptoms of acute abdomen conditions that require urgent surgical referral.
Olutayo A. Sogunro, DO, FACS, FACOS
3m read
Editors:Shelley Jacobs, PhD
Peer reviewers:Franz Wiesbauer, MD MPH Internist
Last update5th Feb 2021
Severe, acute abdominal pain with an abrupt onset of less than 24 hours is known as an acute abdomen. This is often associated with fever, tachycardia, hypotension, or hypoxia. The initial assessment should be quick and accurate to determine if immediate surgical intervention is needed.
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Signs of an acute abdomen during an abdominal exam
Peritonitis is extremely painful, and during an abdominal exam the patient may present with one or all of the three acute abdomen signs:
- Rigid abdomen
- Guarding of the abdomen
- Rebound tenderness
Figure 1. Three common abdominal exam findings associated with an acute abdomen are a rigid abdomen, guarding of the abdomen, and rebound tenderness.
The pain felt in an acute abdomen is caused by peritonitis (e.g., inflammation of the peritoneum). Peritonitis can be caused by conditions such as a perforated peptic ulcer, small or large bowel obstruction or perforation, diverticular disease, or inflammatory bowel disease (IBD).
Figure 2. The pain associated with an acute abdomen is due to peritonitis which can be caused by conditions such as a perforated peptic ulcer, bowel obstruction or perforation, diverticular disease, or inflammatory bowel disease (IBD).
Rigid abdomen
A rigid abdomen involves involuntary stiffness of the abdominal wall muscles. The patient cannot forcibly relax the muscles.
Guarding of the abdomen
Guarding is the voluntary or involuntary tensing of the abdominal muscles, and tends to be generalized over the entire abdomen.
Voluntary guarding is a conscious contraction of the abdominal wall in anticipation of an exam that will cause pain. Involuntary guarding is a reflex contraction or spasm of the abdominal muscles on palpation due to localized peritoneal inflammation.
With involuntary guarding, the muscles often remain in spasm throughout the respiratory cycle. It is similar to rigidity except that it is associated with palpation, while rigidity is not.
To differentiate between voluntary and involuntary guarding, pay attention to the patient’s nonverbal clues during a conversation while palpating the abdomen. With voluntary guarding, the patient will consciously contract the abdominal muscles in anticipation of the physician laying hands on their abdomen.
Check out this short video from our Abdominal Examination Essentials Course for a demonstration of voluntary guarding:
G57_AbdomExam_Article13_Ch5L1_Video 1
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Rebound tenderness
The third symptom of an acute abdomen is rebound tenderness, which is also known as a Blumberg’s sign. Rebound tenderness involves tenderness with the sudden withdrawal of manual pressure. This causes more pain than the actual application of pressure during an abdominal exam.
To assess for rebound tenderness, deeply palpate a section of the abdomen and hold it down for 5 seconds, then rapidly release the pressure. Ask the patient if pressing down or releasing caused more pain. If the patient experienced more pain when you released the pressure, then the patient is experiencing rebound tenderness.
When to refer a patient with an acute abdomen for an urgent surgical consultation
Conditions involving major blood loss
Some acute abdominal conditions, such as bleeding, require an urgent surgical consultation. There are five sources of massive blood loss that require an urgent referral:
- Ruptured abdominal aortic aneurysm (AAA)
- Gastrointestinal bleed
- Bleeding peptic ulcer
- Trauma
- Bleeding diverticular disease
These conditions may require more than 4–6 units of packed red blood cells within 24 hours. Large blood loss is often associated with hemodynamic instability; patients often present with hypotension and tachycardia.
During the exam, the patient will also appear pale, cool, and clammy.
Perforated viscus
Another urgent condition is a perforated viscus such as a bowel perforation. In this condition bowel contents leak into the abdomen, which is extremely irritating to the peritoneal cavity. These patients present with tachycardia, hypotension, and fever.
Ischemic bowel disease
Ischemic bowel disease is also an urgent condition. These patients tend to have abdominal pain out of proportion to what is found on the exam. The pain is diffuse and constant, and the patient may present with hypotension or hypertension, a rigid abdomen, and tachycardia.
Table 1. Acute abdomen conditions that require an urgent surgical consult along with typical symptoms and possible causes.
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Recommended reading
- de Dombal, FT. 1988. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol Suppl. 144: 35–42. PMID: 3043646
- Jin, XW, Slomka, J, and Blixen, CE. 2002. Cultural and clinical issues in the care of Asian patients. Cleve Clin J Med. 69: 50, 53–54, 56–58. PMID: 11811720
- Tseng, W-S and Streltzer, J. 2008. “Culture and clinical assessment”. In: Cultural Competence in Health Care. Boston: Springer.
- Wong, C. 2020. Liver fire in traditional Chinese medicine. verywellhealth. https://www.verywellhealth.com
About the author
Olutayo A. Sogunro, DO, FACS, FACOS
Olutayo is a Breast Surgical Oncologist at Johns Hopkins Howard County General Hospital and Assistant Professor of Surgery at Johns Hopkins University Hospital, Maryland, USA
Author Profile
Appendicitis – Tbilisi Central District Hospital
- Published: 08/17/2017, 08:59
Appendicitis is an inflammation of the appendix.
Appendicitis is considered to begin when the opening between the appendix and the cecum becomes blocked.
The blockage may be due to thick mucus deposits inside the appendix or due to stool that enters the appendix from the caecum. The mucus or stool hardens, becomes hard as a rock, and clogs the opening.
Such stones are called coprolites (literally – “stones from feces”). In other cases, the lymphoid tissue in the appendix may swell and block the appendix.
The body reacts to this introduction by developing an attack on the bacteria, an attack called inflammation.
Another theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria beyond the appendix.
The reason for this rupture is not clear, but it may be due to changes that occur in the lymphoid tissue lining the wall of the appendix. If inflammation and infection spread through the wall of the appendix, it may rupture.
After rupture, infection may spread to the abdominal cavity; however, the process is usually limited to a small space surrounding the appendix (forming a so-called “periapendicular abscess”).
Sometimes the body successfully “heals” appendicitis without surgery, unless the infection and the inflammation that accompanies it spreads through the abdomen. Inflammation, pain, and other symptoms may disappear.
This situation occurs in some elderly patients and also during antibiotic treatment. Therefore, patients may seek medical attention long after an attack of appendicitis with swelling or infiltrate in the right lower abdomen.
What are the complications of appendicitis?
The most common complication of appendicitis is perforation. Perforation of the appendix can lead to a periappendicular abscess (collection of infected pus) or diffuse peritonitis (infection of the entire abdominal cavity).
The main cause of perforation of the appendix is delay in diagnosis and treatment. A rarer complication is intestinal obstruction.
An obstruction occurs when inflammation around the appendix causes the bowel muscles to stop working, preventing food from passing through the bowel.
If the part of the bowel above the obstruction begins to fill with fluid and gas, the abdomen swells and nausea and vomiting may occur.
A dangerous complication of appendicitis is sepsis (blood poisoning), a condition in which bacteria enter the bloodstream and are carried to other parts of the body.
This is a very serious, life-threatening complication. Luckily, it doesn’t develop very often.
What are the symptoms of appendicitis?
The main symptom of appendicitis is abdominal pain.
At first, the pain is noted throughout the abdomen, especially in its upper part, the patient cannot clearly point with his finger where it hurts.
In medical language, such pain is called indistinctly localized, it is not concentrated at one point. (Indistinctly localized pain is common whenever the problem is in the small intestine or colon, including the appendix.) Pinpointing the exact location of the pain is so difficult that when the patient is asked to point the finger at the location of the pain, most people indicate the location of the pain by moving the hand in a circular motion around the middle of the abdomen.
Then, as the inflammation of the appendix increases, it spreads through the wall of the appendix to its outer shell, and then along the lining of the abdomen, a thin film called the peritoneum. When the peritoneum becomes inflamed, the pain changes and can be clearly defined in one small area. If the appendix ruptures, the infection spreads throughout the abdomen, and the pain becomes widespread again as the lining of the abdomen becomes inflamed. Also, with appendicitis, there may be nausea and vomiting, which may be due to intestinal obstruction. In addition, a common symptom of appendicitis is an increase in temperature, as a reaction of the body in response to inflammation. On the other hand, the absence of temperature does not exclude appendicitis, since in principle this disease can proceed without temperature.
How is appendicitis diagnosed?
Diagnosis begins with a thorough questioning and examination.
Patients often have a high fever and usually have soreness (tolerable to very severe) in the right lower abdomen when the doctor presses there.
If the inflammation has reached the peritoneum, there is often a “rebound” soreness. This means that when the doctor puts pressure on the abdomen and then quickly removes the hand, the pain becomes suddenly, but not for long, worse.
White blood cell count In the presence of an infection, the number of white blood cells in the blood test becomes increased.
In the early stages of appendicitis, before infection develops, it may be normal, but it is more common to see at least a slight rise in white blood cell count early enough.
Unfortunately, appendicitis is not the only condition that causes an increase in white blood cells. Almost any infection or inflammation can lead to an increase in white blood cells.
Therefore, only an increase in the number of white blood cells cannot be considered as direct evidence of appendicitis. Urinary microscopy Urinary microscopy is an examination of the urine under a microscope that can detect red blood cells, white blood cells, and bacteria in the urine.
Urinalysis is usually changed if there is inflammation or stones in the kidneys or bladder, which can sometimes be confused with appendicitis. Therefore, changes in the urine indicate a pathological process in the kidneys or bladder, while normal urine microscopy results are more characteristic of appendicitis.
Abdominal x-ray Abdominal x-ray may reveal coprolite (a hardened and calcified piece of feces the size of a pea that obstructs the exit from the appendix), which may be the cause of appendicitis. This is more typical for children.
Ultrasound An ultrasound is a painless procedure that uses sound waves to see organs inside the body. An ultrasound may reveal an enlarged appendix or abscess.
However, in appendicitis, the appendix is seen in only 50% of patients.
Therefore, the inability to see the appendix on ultrasound does not rule out appendicitis. Ultrasound also helps to exclude the presence of pathological changes in the ovaries, fallopian tubes and uterus, which can simulate appendicitis.
Computed tomography In non-pregnant patients, computed tomography of the appendix is performed to diagnose appendicitis or periappendicular abscess, and to rule out other intra-abdominal and pelvic disorders that mimic appendicitis in symptoms. Laparoscopy Laparoscopy is a surgical procedure in which a thin fiber optic tube with a camera is inserted into the abdominal cavity through a small opening in the abdominal wall.
Laparoscopy allows you to see the appendix and other organs of the abdominal cavity and pelvis. If appendicitis is found, the appendix can be removed immediately.
There is no test other than laparoscopy that can diagnose appendicitis with certainty. Therefore, if appendicitis is suspected, the tactics of action may be as follows: a period of observation, research (see above) or surgery.
Why is appendicitis sometimes difficult to recognize?
Appendicitis is sometimes difficult to diagnose.
The position of the appendix in the abdominal cavity may vary.
Most often, the appendix is located in the right lower abdomen, but the appendix, like other parts of the intestine, has a mesentery.
The mesentery is a sheet-like membrane that attaches the appendix to other structures inside the abdomen. If the mesentery is long, the appendix may move.
In addition, the appendix may be longer than normal. The combination of a long mesentery and a long appendix allows the appendix to descend into the pelvic cavity (and be located between the pelvic organs in women).
The appendix may be located behind the colon (posterior colon appendix). In both cases, the symptoms of inflammation of the appendix may be more similar to those that occur with inflammation of other organs, such as pelvic inflammatory disease in women.
Diagnosis of appendicitis can be difficult if other inflammatory processes give the same symptoms as in appendicitis.
Therefore, the patient is usually observed for some time to see if the condition resolves on its own or if signs appear that are more characteristic of appendicitis or possibly another disease.
What diseases can cause appendicitis-like symptoms?
When treating a patient with suspected appendicitis, the surgeon should not forget about other diseases that have symptoms similar to those of appendicitis.
These disorders include: Meckel’s diverticula Meckel’s diverticulum is a small protrusion of the intestinal wall that is usually located in the right lower abdomen, near the appendix.
A diverticulum may become inflamed or even perforate (rupture). If the diverticulum is inflamed or perforated, it is removed surgically.
Pelvic inflammatory disease The right fallopian tube and ovary are adjacent to the appendix. Sexually active women can contract infectious diseases that affect the fallopian tubes and ovaries.
Antibiotic treatment is usually sufficient and there is no need to remove the fallopian tube and ovary. Inflammatory conditions in the upper right abdomen Fluid from the upper right abdomen may leak into the lower abdomen, where it mimics inflammation and appendicitis.
Fluid may leak from a perforated duodenal ulcer, bladder, or liver abscess. Right-sided diverticulitis Although most diverticula are located on the left side of the colon, they sometimes occur on the right.
If the right-sided diverticulum ruptures, inflammation develops, similar in symptoms to inflammation in appendicitis.
Diseases of the kidneys The right kidney is located so close to the appendix that an inflammatory process, such as an abscess, can also give symptoms, as in appendicitis.
How is appendicitis treated?
If appendicitis is diagnosed, the most common procedure is removal of the appendix (appendectomy).
Antibiotics are started before surgery as soon as the diagnosis is made.
In some patients, the inflammation and infection of appendicitis remain mild and do not spread throughout the abdomen. The human body is able not only to contain inflammation, but also to get rid of it on its own.
These patients feel relatively well and improve after a few days of observation.
Such appendicitis can only be treated with antibiotics. After some time, the appendix can be removed (or not removed).
The difficulty is to distinguish such appendicitis from those prone to complications. Sometimes the patient does not go to the doctor for so long that by the time of the appeal, appendicitis with perforation of the appendix has already existed for many days or even weeks.
In this case, there is usually an already formed abscess, and the perforation in the appendix is closed. If the abscess is small, antibiotic therapy may be given first; however, most often the abscess needs to be drained.
Drainage is usually placed using ultrasound or computed tomography, which can accurately determine the location of the abscess.
The appendix is removed weeks or months after the abscess has been removed.
This is called a delayed appendectomy and is done to prevent a recurrence of an appendicitis attack.
How is the appendix removed?
Two techniques are currently used to remove the appendix: a traditional operation performed through an incision, and an endoscopic operation, which is done through punctures under TV control.
In a through-incision appendectomy, an 8-10 cm long incision is made through the skin and layers of the abdominal wall above the appendix. The surgeon examines the appendix, usually located in the right lower abdomen.
After examining the area around the appendix to ensure there are no other diseases in the area, the appendix is removed. The mesentery of the appendix and the appendix itself are cut, and thus free it from its connection with the intestine; the hole in the intestine is sutured.
If there is an abscess, it can be drained with drains (rubber tubes) that run from the abscess through the incision to the outside.
The incision is then sutured.
A new way to remove the appendix involves the use of a laparoscope. A laparoscope is a thin optical system connected to a video camera that allows the surgeon to look inside the abdomen through a small puncture hole (instead of a large incision).
If appendicitis is found, the appendix is removed using special instruments that are inserted into the abdominal cavity, like a laparoscope, through small holes.
Advantages of using laparoscopy: reduction of post-operative pain (since pain is mainly caused by incisions) and faster recovery, as well as excellent cosmetic results.
Another advantage of laparoscopy is that it allows the surgeon to look into the abdominal cavity and make an accurate diagnosis in cases where the diagnosis of appendicitis is in doubt. For example, laparoscopy has been successfully used in the diagnosis and treatment of ruptured ovarian cysts in women (the symptoms may resemble those of appendicitis).
If the appendix has not been torn (perforated), the patient is discharged from the hospital the next day.
Patients with a perforated appendix feel worse than patients without a rupture.
They stay longer in the hospital (4-7 days), especially if peritonitis has developed.
The hospital gives antibiotics intravenously to fight infection and help clear up abscesses.
Sometimes the surgeon may see an unaltered appendix and find no reason for the patient to complain.
In this case, the surgeon may remove the appendix.
The reason for the removal is as follows: it is better to remove the unaltered appendix than to skip and not cure possibly beginning appendicitis.
What are the complications of appendectomy?
The most common complication of appendicitis is infection of the surgical wound.
These complications can be both severe and mild, ranging from redness and soreness that can only be treated with antibiotics to severe lesions that can be treated with both antibiotics and surgery.
Sometimes the inflammation and infection in appendicitis is so severe that the surgeon does not close the incision completely because the incision made by the surgeon is already contaminated. The incision is sutured only a few days after the infection is suppressed by antibiotics and there is no longer any danger of its development in the incision.
Another complication of appendectomy is an abscess, an accumulation of pus in the area of the appendix.
Although pus is removed surgically from an abscess, there are other methods of treating it (see above).
What are the long-term consequences of the removal of the appendix?
It is still not clear whether the appendix has any important function.
As a rule, after the removal of the appendix, there are no health problems. The most common consequence of the operation is the possible development of an adhesive process.
Fortunately, adhesions develop much less frequently after laparoscopic surgery.
» Appendicitis. Symptoms and treatment
Why does appendicitis get inflamed?
The inflamed appendix most often swells and fills with pus, which is provoked by a complex of reasons:
• First of all, it is the activation of bacteria that get into the appendix from the intestines, as well as viruses or allergens that cause blockage of the lumen of the appendix. This situation is more typical for children and adolescents.
Also, with a mobile lifestyle, when the child moves a lot, blockage of the lumen can occur due to mechanical kinks of the process.
• When the pathogenic flora is activated in adults, blockage of the lumen of the appendix process occurs due to hyperplasia of the lymphoid follicles. In addition, various diseases of the gastrointestinal tract, abdominal trauma, and helminthic infestations cause problems.
• In people suffering from chronic constipation, inflammation of the appendix leads to the formation of fecal stones that interfere with the normal supply of the appendix.
• Less commonly, inflammation of the appendix occurs as a result of the accumulation of large amounts of fluid, which is formed by tumors, foreign bodies or parasites.
Symptoms of appendicitis.
The most obvious symptoms of appendicitis are:
• Abdominal pain. Most often, the patient admits that the pain spreads throughout the abdomen, the patient demonstrates its manifestations in a circular motion around the navel or middle of the abdomen.
This is because it is quite difficult for a person to indicate the source of pain, especially at the very beginning of the inflammatory process. With an increase in inflammation, the pain intensifies and is localized in a certain place, often at the bottom right.
• Nausea and vomiting. It must be borne in mind that these manifestations often accompany the inflammatory process of the appendix, but not all patients occur.
• Temperature increase. More often, this symptom occurs in children. Temperature is the body’s natural response to inflammation. However, many adult patients tolerate the disease without fever.
• Weakness and lack of appetite. The patient may complain that he is “disturbed” and refuse food. Children become moody and whiny.
Diagnosis of appendicitis
The Longevity Clinic performs a successful diagnosis of inflammation of the appendix. The doctor carefully studies the history, clarifies the symptoms that bothered the patient, palpates the abdomen, and measures the temperature.
If inflammation of the appendix occurs, then on palpation of the painful area, the so-called “rebound pain” occurs, which suddenly, but not for a long time, intensifies at the moment when the doctor presses and then quickly removes his hand from the focus of inflammation.
After carrying out all the necessary tests, the patient is sent for surgery. Before the operation is carried out, a mandatory examination is carried out (link to the list of tests).
Treatment of appendicitis. Appendectomy
Unfortunately, apart from surgery, there are no conservative methods in medicine for the treatment of chronic or acute appendicitis. Therefore, at the first signs of this disease, it is necessary to consult a doctor.
After confirming the diagnosis, the patient is scheduled for an appendectomy. An appendectomy is a surgical procedure that removes an inflamed appendix called appendicitis.
Appendectomy can be performed in two ways:
• Laparotomy (strip) surgery.
It is carried out with the help of surgery, during which an incision 8-10 cm long is made on the right side of the abdomen, through which the inflamed process is removed.
• Laparoscopic surgery. The most modern and safe method of removing the inflamed process, in which three small punctures 5-10 mm in size are made in the abdominal cavity, one of which is located in the navel. Through these holes, the surgeon inserts a tiny optical system (laparoscope) inside the abdomen, determines the position and condition of the inflamed process, and then removes it with special surgical instruments that are inserted into the abdominal cavity through the same small holes.
Advantages of laparoscopic appendectomy:
• The operation is performed endoscopically under general anesthesia and takes no more than 15 minutes.
• The patient experiences almost no pain in the puncture area.
• Laparoscopy ensures rapid healing of postoperative sutures.
• Provides a cosmetic effect, sutures from tiny laparoscopic punctures are almost invisible.