Letter to the Editor
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2022; 14(7): 727-730
Published online Jul 27, 2022. doi: 10.4240/wjgs.v14.i7.727
Signs and syndromes in acute appendicitis: A pathophysiologic approach
Steven Howard Yale, Halil Tekiner, Eileen Scott Yale
Steven Howard Yale, Internal Medicine, University of Central Florida, Orlando, FL 32827, United States
Halil Tekiner, Department of the History of Medicine and Ethics, Erciyes University School of Medicine, Melikgazi 38039, Kayseri, Turkey
Eileen Scott Yale, Division of General Internal Medicine, University of Florida, Gainesville, FL 32608, United States
Author contributions: Yale SH, Tekiner H, and Yale ES wrote the manuscript; all authors have read and approved the final manuscript.
Conflict-of-interest statement: The authors declare no conflict of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Steven Howard Yale, MD, Professor, Internal Medicine, University of Central Florida, 6850 Lake Nona Blvd, Orlando, FL 32827, United States. steven.yale.md@gmail.com
Received: February 12, 2022
Peer-review started: February 12, 2022
First decision: April 19, 2022
Revised: April 20, 2022
Accepted: July 5, 2022
Article in press: July 5, 2022
Published online: July 27, 2022

Physical examination signs have not been well studied, and their accuracy and reliability in diagnosis remain unknown. The few studies available are limited in that the method of performing the sign was not stated, the technique used was not standardized, and the position of the appendix was not correlated with imaging or surgical findings. Some appendiceal signs were written in a non-English language and may not have been appropriately translated (e.g., Blumberg-Shchetkin and Rovsing). In other cases, the sign described differs from the original report (e.g., Rovsing, Blumberg-Shchetkin, and Cope sign, Murphy syndrome). Because of these studies limitations, gaps remain regarding the signs’ utility in the bedside diagnosis of acute appendicitis. Based on the few studies available with these limitations in mind, the results suggest that a positive test is more likely to be found in acute appendicitis. However, a negative test does not exclude the diagnosis. Hence, these tests increase the likelihood of ruling in acute appendicitis when positive but are less helpful in ruling out disease when negative. Knowledge about the correct method of performing the sign may be a valuable adjunct to the surgeon in further increasing their pretest probability of disease. Furthermore, it may allow surgeons to study these signs further to better understand their role in clinical practice. In the interim, these signs should continue to be used as a tool to supplement the clinical diagnosis.

Keywords: Appendicitis, Signs and symptoms, Psoas, Rovsing, Signs and symptoms, Syndrome

Core Tip: This paper describes the pathophysiologic mechanism of disease presentation and reports the signs of acute appendicitis as initially reported. Physical examination signs and syndromes have not been well studied in patients with acute appendicitis. Knowledge of how to appropriately perform these bedside maneuvers in diagnosing appendicitis may provide further knowledge about the likelihood of the disease. Understanding the mechanism of disease and these bedside maneuvers may further enhance the ability of surgeons to diagnose acute appendicitis.