History

The primary symptom in acute appendicitis is abdominal pain. In approximately one-half to two-thirds of patients with appendicitis, the pain evolves in a classic pattern. Beginning in the epigastrium or periumbilical region early in the illness, the pain is initially vague and difficult to localize. Patients may describe their discomfort as indigestion or as a feeling of the need to defecate or pass flatus. As the illness progresses, the pain becomes more localized, typically in the right lower quadrant. As described above, however, the location of the patient's pain varies with the anatomic location of the appendix. One meta-analysis, in which approximately half of the studies focused on patients suspected of having acute appendicitis and half were series of patients examined for abdominal pain, provides characteristics of some common clinical findings in acute appendicitis.4 In this analysis, right lower quadrant pain was 81 percent sensitive and 53 percent specific for the diagnosis of acute appendicitis. Similarly, migration of the pain from initial periumbilical pain to the right lower quadrant was 64 percent sensitive and 82 percent specific for the diagnosis of acute appendicitis.4

In addition to abdominal pain, the classic triad of symptoms in appendicitis includes anorexia, nausea, and vomiting. In acute appendicitis, these symptoms typically appear after the onset of vague abdominal pain. Anorexia is the most common of these symptoms, with 68 percent sensitivity and 36 percent specificity.4 Vomiting is more variable in acute appendicitis, occurring in about half of patients with acute appendicitis. 4 The significance of the temporal relationship between abdominal pain and onset of vomiting as a predictor of acute appendicitis has not yet been established. Ta.b.!.e 7.4.-1 provides a summary of the sensitivity and specificity of many symptoms associated with appendicitis.

TABLE 74-1 Summary of Clinical Examination Operating Characteristics for Appendicitis*

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