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When obtaining the history, the physician needs to consider other nonsurgical
causes of abdominal pain that may mimic appendicitis (see Chapter 53 Pain:
Abdomen ). Concurrent GI illness in other family members or close contacts
suggests the possibility of an infectious gastroenteritis. Constipation,
streptococcal pharyngitis, urinary tract infection, lower lobe pneumonia,
mesenteric adenitis, and ovarian cyst are common conditions often masquerading
as appendicitis. Although the presentation is generally more rapid and severe,
torsion of the ovary and ectopic pregnancy should be considered in female
patients with sudden onset of severe pain.
Anorexia and nausea are common; vomiting is more common in younger
children. In early stages the patient may complain of pain with motion or
walking, and as peritoneal irritation worsens, the child will prefer to lay
motionless in the bed.
On examination, palpation is usually reliable in demonstrating focal tenderness
at the site of the inflamed appendix. Because the position of the appendix may
vary in children, the localization of the pain and the tenderness on examination
may also vary. An appendix that is located in the lateral gutter may produce flank
pain and lateral abdominal tenderness; an inflamed appendix pointing toward the
left lower quadrant may produce hypogastric tenderness and pain with urination
(from bladder contraction). An inflamed low-lying, pelvic appendix may not
cause significant pain at McBurney point, but instead may cause diarrhea from
direct irritation of the sigmoid colon. When the inflamed appendix is not close to
the anterior abdominal wall, as in the case of retrocecal appendix, tenderness may
be more impressive on deep palpation of the abdomen or by palpating in the
flank. Percussive tenderness, shake tenderness, and pain with coughing or
hopping suggests peritoneal irritation. Rovsing sign, pain in the right lower
quadrant upon palpating the left lower quadrant, is difficult to assess in young
children but when present is highly suggestive of appendicitis. A properly
performed rectal examination can contribute to the clinical impression: the
examining finger should be inserted as fully as possible without touching the area
of presumed tenderness and then, when the child is relaxed and taking deep

breaths, the examiner can indent an area high on the right rectal wall. A sudden
involuntary reaction implies localized tenderness. In a child with a history of
probable appendicitis for more than 2 or 3 days, a boggy, full mass may also be in
this location, suggesting an abscess.
Management