Rovsing's Sign
Summary
Rovsing's sign is a clinical examination finding used in the assessment of acute appendicitis, characterized by pain elicited in the right iliac fossa (RIF) when pressure is applied to the left iliac fossa (LIF). First described by Danish surgeon Niels Thorkild Rovsing in 1907, this sign indicates localized peritoneal irritation in the RIF secondary to appendiceal inflammation. [1,2] The sign has moderate specificity (75-90%) but relatively low sensitivity (25-50%), making it useful for ruling in appendicitis when present but insufficient to exclude the diagnosis when absent. [3] Rovsing's sign is one of several eponymous clinical signs used in the systematic examination of the acute abdomen and remains a valuable component of the clinical assessment despite the increasing reliance on CT imaging. Understanding the underlying pathophysiology of peritoneal irritation is essential for proper interpretation of this and related signs.
Key Facts
- Definition: Pain in the right iliac fossa elicited by palpation of the left iliac fossa
- Prevalence: Present in 25-50% of patients with acute appendicitis [3]
- Sensitivity: 25-50% (low - many false negatives) [3,4]
- Specificity: 75-90% (high - useful for confirmation) [3,4]
- Positive Likelihood Ratio: 3.5 (moderately useful for ruling in appendicitis) [3]
- Peak Demographics: Most commonly positive in young adults (15-35 years) with appendicitis
- Pathognomonic Value: Not pathognomonic but highly suggestive of localized peritonitis
- Gold Standard Investigation: CT abdomen/pelvis with IV contrast for appendicitis diagnosis
- First-line Assessment: Clinical examination including Rovsing's along with inflammatory markers
- Historical Significance: Described 1907 by Niels Thorkild Rovsing, Copenhagen
Clinical Pearls
Diagnostic Pearl: A positive Rovsing's sign indicates localized peritoneal irritation; combined with RIF tenderness and elevated inflammatory markers, it strongly suggests appendicitis and warrants urgent surgical review.
Examination Pearl: Always examine the non-tender area first (LIF) before palpating the suspected pathology site - this is the essence of Rovsing's test and minimizes patient discomfort while maximizing diagnostic yield.
Treatment Pearl: A positive Rovsing's sign in a septic patient mandates urgent resuscitation (IV fluids, antibiotics within 1 hour) prior to definitive surgical management.
Pitfall Warning: A negative Rovsing's sign does NOT exclude appendicitis - sensitivity is only 25-50%. Early appendicitis, retrocaecal appendix, or pelvic appendix may all present with negative Rovsing's.
Mnemonic: "ROVSING = Right Over Via Sinistra (Left) INdicates Guarding" - press LEFT, feel pain RIGHT.
Why This Matters Clinically
Rovsing's sign is a crucial component of the clinical examination for suspected appendicitis, which affects approximately 7-8% of the population lifetime. [5] Missed or delayed appendicitis diagnosis leads to perforation in 20-30% of cases, significantly increasing morbidity, mortality, and healthcare costs. [6] The sign helps differentiate true localized peritoneal irritation from non-specific abdominal tenderness or functional pain. From a medicolegal perspective, documentation of Rovsing's sign (positive or negative) demonstrates thorough clinical assessment. Proper interpretation of this sign, combined with other clinical findings and investigations, enables timely surgical intervention and improved patient outcomes.
Incidence & Prevalence
- Rovsing's Sign Prevalence in Appendicitis: 25-50% of patients with proven appendicitis [3,4]
- Appendicitis Incidence: 100-150 per 100,000 population per year in Western countries [5]
- Lifetime Risk of Appendicitis: 7-8% (males 8.6%, females 6.7%) [5]
- Peak Age for Appendicitis: 10-30 years [5]
- Trend: Appendicitis incidence stable; reliance on Rovsing's sign declining with increased CT use
- Geographic Variation: Higher appendicitis rates in Western/industrialized nations
Demographics
| Factor | Details | Clinical Significance |
|---|---|---|
| Age | Peak: 15-30 years; Range: any age | Children and elderly may have atypical presentations with less reliable signs |
| Sex | Male:Female ratio 1.2-1.4:1 for appendicitis | Females require exclusion of gynaecological pathology |
| Ethnicity | Higher rates in Caucasian populations | Dietary and environmental factors implicated |
| Geography | Higher in Western/industrialized countries | Lower-fibre diets may contribute |
| Socioeconomic | Higher perforation rates in lower SES | Related to delayed presentation |
| Body Habitus | Obesity may reduce sign reliability | Deep palpation more difficult; CT more valuable |
Risk Factors
Non-Modifiable Risk Factors for Appendicitis:
| Factor | Relative Risk (95% CI) | Mechanism |
|---|---|---|
| Age 10-30 years | RR 2.5 (2.0-3.0) | Peak lymphoid tissue activity |
| Male sex | RR 1.2-1.4 (1.1-1.6) | Unknown mechanism |
| Family history | RR 3.0 (2.0-4.5) | Genetic predisposition |
| Previous abdominal surgery | RR 0.5 (adhesions may obscure) | Altered anatomy affects sign reliability |
| Anatomical variants (retrocaecal) | RR 1.0 but sign less reliable | 30% of appendices are retrocaecal |
Modifiable Risk Factors:
| Risk Factor | Relative Risk (95% CI) | Evidence Level | Impact on Rovsing's Sign |
|---|---|---|---|
| Low-fibre diet | RR 1.5-2.0 (1.2-2.5) | Level 2b | Increases appendicitis risk generally |
| Constipation | RR 1.3 (1.1-1.6) | Level 2b | May cause faecolith formation |
| Smoking | RR 1.2 (1.0-1.4) | Level 3 | Increases inflammatory response |
| Obesity | Variable | Level 2b | Reduces reliability of clinical signs |
| Recent viral infection | RR 1.2 (1.0-1.5) | Level 3 | May cause lymphoid hyperplasia |
| Previous appendicitis episode | RR 0.0 (post-appendicectomy) | N/A | Appendix removed; recurrence impossible |
Protective Factors:
| Protective Factor | Relative Risk Reduction | Mechanism |
|---|---|---|
| High-fibre diet | RR 0.6-0.8 | Reduces faecolith formation |
| Regular bowel habits | RR 0.7-0.9 | Prevents stasis and obstruction |
| Previous appendicectomy | RR 0.0 (definitive) | Appendix surgically removed |
Temporal Patterns
Understanding the temporal patterns of appendicitis presentation is important for clinical assessment:
- Time of Year: Slight increase in summer months in some studies (possibly related to dietary changes)
- Time of Day: Most patients present in late afternoon/evening (symptoms begin overnight/morning, worsen during day)
- Duration of Symptoms: Average 24-48 hours before presentation
- Perforation Risk by Duration:
- <24 hours: 15-20% perforation rate
- 24-48 hours: 20-30% perforation rate
- >48 hours: 40-60% perforation rate
- Weekend Effect: Some evidence of increased perforation rates for weekend presentations (delayed surgical review)
Global Epidemiology
The global burden of appendicitis shows significant geographical variation:
- North America/Europe: Incidence 100-150/100,000/year; decreasing slightly with improved diagnostics
- Asia: Variable; lower incidence in South Asia (50-80/100,000), higher in East Asia (similar to West)
- Africa: Lower reported incidence (20-50/100,000) but likely underreported
- South America: Intermediate incidence (80-120/100,000)
- Australia/New Zealand: Similar to Europe (100-120/100,000)
- Indigenous populations: Often higher perforation rates due to healthcare access issues
Historical Epidemiology
The epidemiology of appendicitis diagnosis has evolved significantly:
- Pre-CT era (before 1990s): Clinical signs including Rovsing's were primary diagnostic tools; negative appendicectomy rate 15-25%
- CT introduction (1990s-2000s): Gradual adoption of CT; negative appendicectomy rate decreased to 5-10%
- Modern era (2010s-present): CT near-universal in developed countries; negative appendicectomy rate <5%; clinical signs now used for risk stratification rather than definitive diagnosis
- Rovsing's sign utility: Remains valuable in resource-limited settings and for clinical teaching; declining emphasis in high-resource CT-available environments
Mechanism
Step 1: Initiating Event - Appendiceal Obstruction
- Primary event is obstruction of the appendiceal lumen (faecolith 40%, lymphoid hyperplasia 60%)
- Continued mucus secretion increases intraluminal pressure (normal 10-15 cmH2O rising to >50 cmH2O)
- Luminal distension triggers visceral afferent C-fibres
- Patient experiences dull, cramping periumbilical pain (referred from T10 dermatome)
- Time course: 0-12 hours from onset [7]
Step 2: Early Inflammatory Changes (12-24 hours)
- Venous congestion and lymphatic obstruction from increased intraluminal pressure
- Mucosal ischaemia allows bacterial translocation (E. coli, Bacteroides, Pseudomonas)
- Inflammatory cascade activation: IL-1, IL-6, TNF-α, CRP elevation
- Neutrophil infiltration of appendiceal wall begins
- Appendix becomes oedematous; serosa begins to inflame
- Visceral pain persists but localization begins [7,8]
Step 3: Established Peritoneal Irritation (24-48 hours)
- Inflamed appendiceal serosa contacts parietal peritoneum
- Somatic afferent A-delta fibres (not visceral C-fibres) now activated
- Pain becomes sharp, well-localized to RIF (McBurney's point)
- Parietal peritoneum has precise somatotopic representation
- This is when Rovsing's sign becomes positive
- Any movement of peritoneum (direct or indirect pressure) triggers somatic pain [7,8]
Step 4: Mechanism of Rovsing's Sign
- Pressure on LIF displaces intraperitoneal contents toward RIF
- Rovsing's original theory: gas pushed through colon distends inflamed caecum
- Modern understanding: displacement of mobile small bowel against inflamed parietal peritoneum
- Alternatively: transmitted pressure wave through intra-abdominal fluid/contents
- Result: irritation of already-sensitized RIF parietal peritoneum causing referred pain
- Specificity comes from localizing pathology to RIF specifically [1,2]
Step 5: Progression to Perforation (>48 hours if untreated)
- Continued ischaemia leads to gangrenous appendicitis
- Full-thickness necrosis causes micro/macro-perforation
- Free intraperitoneal contamination causes generalized peritonitis
- Rovsing's sign may become less localizing as peritonitis generalizes
- "Board-like" rigidity develops with widespread peritoneal irritation
- Systemic inflammatory response syndrome (SIRS) and sepsis may develop [6,7]
Classification/Staging
Appendicitis Severity Classification:
| Stage | Definition | Clinical Features | Rovsing's Sign |
|---|---|---|---|
| Simple/Uncomplicated | Inflamed, non-perforated appendix | Localized RIF pain, no peritonism | Often positive, well-localized |
| Complicated - Gangrenous | Necrotic appendix, not yet perforated | Severe RIF pain, localized guarding | Usually positive |
| Complicated - Perforated | Free perforation with contamination | Generalized peritonitis, sepsis | May be less localizing |
| Complicated - Abscess | Walled-off perforation with collection | RIF mass, systemic upset | Variable - may be obscured |
| Complicated - Phlegmon | Inflammatory mass without discrete abscess | Palpable RIF mass | Variable |
Anatomical Considerations
The anatomical position of the appendix significantly affects the reliability of Rovsing's sign:
- Anterior/Preileal appendix (65%): Classic presentation, Rovsing's most reliable
- Retrocaecal/Retrocolic (30%): Appendix posterior, may not irritate parietal peritoneum; Rovsing's less reliable; psoas sign may be positive
- Pelvic (5%): Appendix in true pelvis, minimal anterior parietal contact; rectal examination reveals tenderness; Rovsing's often negative
- Subhepatic (rare): Appendix lies high in RUQ; pain may mimic cholecystitis
- Blood supply: Appendicular artery from ileocolic artery; end artery with no collaterals (explains gangrene)
Physiological Considerations
Visceral vs Somatic Pain - The Basis of Clinical Signs:
- Visceral pain (C-fibres): Dull, poorly localized, midline referred pain from stretch/distension of hollow viscera
- Somatic pain (A-delta fibres): Sharp, precisely localized pain from parietal peritoneal irritation
- Rovsing's sign exploits somatic pathway: indirect pressure causes sharp, localized RIF pain
- Transition from visceral to somatic pain marks progression from simple to complicated appendicitis
- Understanding this transition explains classic "migration" of appendicitis pain from periumbilical to RIF
Symptoms
Typical Presentation:
Atypical Presentations:
Symptom Timing and Progression
Understanding the temporal sequence of appendicitis symptoms is crucial for diagnosis:
| Time from Onset | Symptom Progression | Clinical Significance |
|---|---|---|
| 0-6 hours | Vague periumbilical discomfort begins | Visceral C-fibre activation from appendiceal distension |
| 6-12 hours | Anorexia develops, nausea begins | Autonomic response to visceral irritation |
| 12-24 hours | Pain localizes to RIF | Transition to somatic pain; Rovsing's becomes positive |
| 24-36 hours | Low-grade fever develops | Inflammatory response escalating |
| 36-48 hours | Increasing tenderness, guarding | High risk of perforation |
| >48 hours | Perforation likely; may see brief pain relief | Catastrophic progression; generalized peritonitis |
Symptom Severity Grading
| Feature | Mild | Moderate | Severe |
|---|---|---|---|
| Pain Intensity | 3-4/10 | 5-7/10 | 8-10/10 |
| Nausea/Vomiting | Present | Frequent | Persistent |
| Oral Intake | Reduced appetite | Unable to eat | Unable to tolerate fluids |
| Mobility | Walking normally | Walking with difficulty | Unable to walk/lying still |
| Sleep | Disturbed | Unable to sleep | Constant distress |
| Rovsing's Response | Mild discomfort | Definite pain | Severe, immediate pain |
Differential Presentations by Age
Children (Age 3-10 years):
Adolescents (Age 10-18 years):
Young Adults (Age 18-40 years):
Middle-Aged (Age 40-65 years):
Elderly (Age >65 years):
Signs
Red Flags
[!CAUTION] Red Flags — Seek immediate surgical review if:
- Involuntary guarding or board-like rigidity (generalized peritonitis)
- Signs of sepsis: HR >100, RR >20, temperature >38.5°C or <36°C, WCC >15 or <4
- Hemodynamic instability (hypotension, tachycardia)
- Absent bowel sounds (ileus)
- Pain out of proportion to examination (consider mesenteric ischaemia)
- Cullen's or Grey-Turner's sign (retroperitoneal catastrophe)
- Elderly patient with disproportionate systemic upset
Structured Approach
General Observation:
- Lying still (peritonitis) vs. rolling/writhing (colic)
- Facial expression of pain
- Dehydration status
- Respiratory pattern - shallow breathing suggests peritoneal irritation
Vital Signs:
- Temperature (low-grade fever common; high fever suggests perforation/abscess)
- Heart rate (tachycardia may indicate sepsis)
- Blood pressure (hypotension is late sign of sepsis)
- Respiratory rate (tachypnoea in sepsis or pain)
Abdominal Inspection:
- Movement with respiration (reduced in peritonitis)
- Distension
- Scars (previous surgery)
- Visible peristalsis (obstruction)
- Cullen's/Grey-Turner's signs (haemorrhage)
Auscultation:
- Bowel sounds: Normal, absent (ileus), or high-pitched (obstruction)
- Bruits (aneurysm)
Percussion:
- Light percussion tenderness - most gentle test for peritonism
- Loss of liver dullness (pneumoperitoneum)
- Shifting dullness (ascites)
Palpation:
- Start AWAY from site of maximal pain (this is Rovsing's test)
- Rovsing's sign technique: Deep palpation of LIF, observe for RIF pain
- Progress to RIF palpation - assess tenderness and guarding
- Assess for masses (appendix mass/abscess)
- Hernial orifices - ALWAYS examine (strangulated hernia is a mimicker)
Special Tests
| Test | Technique | Positive Finding | Sensitivity/Specificity |
|---|---|---|---|
| Rovsing's Sign | Deep pressure on LIF | Pain felt in RIF | 25-50% / 75-90% |
| McBurney's Point | Palpation 1/3 ASIS-umbilicus | Maximal tenderness here | 50-94% / 75-86% |
| Rebound Tenderness | Press deep, release quickly | Pain worse on release | 63% / 69% |
| Dunphy's Sign | Ask patient to cough | RIF pain on coughing | Variable / High |
| Psoas Sign | Extend right hip with patient on left side | RIF/back pain | 16% / 95% |
| Obturator Sign | Flex and internally rotate right hip | Hypogastric pain | 8% / 94% |
| Heel Jar Test | Patient drops onto heels from tiptoe | RIF pain | Variable / Variable |
| Cope's Psoas Test | Raise right leg against resistance while supine | RIF pain | 16% / 95% |
First-Line (Bedside)
- Urinalysis: Exclude UTI; sterile pyuria may occur with pelvic appendix
- Pregnancy test: MANDATORY in all females of reproductive age (exclude ectopic)
- Blood glucose: Baseline
- ECG: If elderly or significant comorbidity (pre-operative workup)
Laboratory Tests
| Test | Expected Finding | Purpose |
|---|---|---|
| FBC | WCC elevated (11-15 × 10⁹/L), neutrophilia, left shift | Infection/inflammation |
| CRP | Elevated (>10 mg/L, often >50 in complicated) | Inflammatory marker; rises 12-24h after onset |
| U&E | May show dehydration (raised urea, creatinine) | Hydration status, AKI screening |
| LFTs | Usually normal; deranged in cholecystitis | Differential diagnosis |
| Amylase/Lipase | Normal (raised in pancreatitis) | Exclude pancreatitis |
| Lactate | Elevated in sepsis/ischaemia (>2 mmol/L concerning) | Sepsis marker |
| Blood cultures | If septic | Identify organism |
| Group and Save | Standard pre-operative | Blood availability |
Imaging
| Modality | Findings | Indication |
|---|---|---|
| CT Abdomen/Pelvis (IV contrast) | Appendix >6mm diameter, wall enhancement, periappendiceal fat stranding, appendicolith | Gold standard - sensitivity >95%, specificity >95% [9] |
| Ultrasound | Target sign, non-compressible appendix >6mm, periappendiceal fluid | First-line in children and pregnant women; operator-dependent |
| MRI Abdomen | Similar to CT without radiation | Pregnant women second trimester onwards |
| Plain AXR | Faecolith (5%), dilated loops (obstruction), loss of psoas shadow | Limited value; largely superseded by CT |
| Erect CXR | Free air under diaphragm (perforation, sensitivity ~70%) | Suspected perforation |
Diagnostic Criteria
Alvarado Score (MANTRELS) for appendicitis probability:
| Criterion | Points |
|---|---|
| Migration of pain to RIF | 1 |
| Anorexia | 1 |
| Nausea/vomiting | 1 |
| Tenderness in RIF | 2 |
| Rebound tenderness | 1 |
| Elevated temperature (>37.3°C) | 1 |
| Leukocytosis (>10 × 10⁹/L) | 2 |
| Shift left (neutrophilia >75%) | 1 |
| TOTAL | 10 |
- Score 1-4: Low probability - observe/discharge with safety netting
- Score 5-6: Moderate probability - CT imaging recommended
- Score 7-10: High probability - surgical consultation; may proceed to theatre without CT
Management Algorithm
SUSPECTED APPENDICITIS
(Positive Rovsing's Sign)
↓
┌─────────────────────────────────────────────────────────────┐
│ INITIAL ASSESSMENT │
│ • ABCDE approach │
│ • IV access (large bore) │
│ • Bloods: FBC, CRP, U&E, amylase, lactate, G&S │
│ • Urinalysis and pregnancy test │
│ • Analgesia (IV morphine 0.1mg/kg) - DO NOT withhold │
└─────────────────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────────────┐
│ SEVERITY ASSESSMENT │
│ • Alvarado Score calculation │
│ • Sepsis screening (qSOFA/SIRS) │
│ • Hemodynamic assessment │
└─────────────────────────────────────────────────────────────┘
↓
┌───────────────────┼───────────────────┐
↓ ↓ ↓
┌──────────┐ ┌──────────┐ ┌──────────┐
│ LOW RISK │ │ MOD RISK │ │HIGH RISK │
│Score 1-4 │ │Score 5-6 │ │Score 7-10│
└──────────┘ └──────────┘ └──────────┘
↓ ↓ ↓
Observation CT Imaging URGENT SURGERY
Safety netting → Appendicitis? + Resuscitation
↓ ↓ ↓
┌────────────────────┼───────────────────┘
↓ ↓
NO YES
↓ ↓
Alternative Dx ┌─────────────────────────────────────────┐
│ SURGICAL DECISION │
│ • Laparoscopic appendicectomy (1st line)│
│ • Open appendicectomy (if laparoscopy │
│ contraindicated or not available) │
│ • Conservative (abscess/phlegmon) │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────────────┐
│ POST-OPERATIVE CARE │
│ • Analgesia │
│ • Early mobilization │
│ • Diet as tolerated │
│ • VTE prophylaxis │
│ • Histology review │
└─────────────────────────────────────────────────────────────┘
Acute/Emergency Management
Immediate Actions for Suspected Appendicitis with Positive Rovsing's:
- ABCDE assessment - ensure hemodynamic stability
- IV access - large bore (16-18G) cannula
- Fluid resuscitation - crystalloid (Hartmann's/0.9% NaCl) 1000ml bolus if dehydrated
- Blood samples - FBC, CRP, U&E, amylase, lactate, G&S
- Urinalysis and pregnancy test in females
- Analgesia - IV morphine 0.1mg/kg (withholding analgesia is unethical and does not improve diagnosis) [10]
- Keep nil by mouth pending surgical decision
- Antibiotics if septic or high probability: IV co-amoxiclav 1.2g or cefuroxime 1.5g + metronidazole 500mg [11]
Conservative Management
- Observation with safety netting: For low Alvarado score (1-4) or equivocal CT
- Serial abdominal examinations: 4-6 hourly by same clinician
- Repeat bloods: Trend in WCC/CRP helpful
- Appendix mass/phlegmon: Initial conservative management with IV antibiotics, interval appendicectomy at 6-8 weeks (controversial - some centres favour immediate surgery) [12]
- Antibiotics-first approach: Some evidence for non-operative management of uncomplicated appendicitis (APPAC trial, CODA trial) but remains controversial [13,14]
Medical Management
| Drug Class | Drug | Dose | Duration |
|---|---|---|---|
| Analgesia | Morphine sulfate | 0.1mg/kg IV initially, titrate to pain | As required |
| Analgesia | Paracetamol | 1g IV/PO 6-hourly | Regularly |
| Antiemetic | Ondansetron | 4-8mg IV/PO 8-hourly | As required |
| Antibiotics | Co-amoxiclav | 1.2g IV 8-hourly | Until discharge/post-op |
| Antibiotics | Metronidazole | 500mg IV 8-hourly | Combined with cephalosporin |
| Antibiotics | Cefuroxime | 1.5g IV 8-hourly | With metronidazole |
| VTE Prophylaxis | Enoxaparin | 40mg SC once daily | Post-operative |
| PPI (if risk) | Omeprazole | 20-40mg IV/PO once daily | Stress ulcer prophylaxis |
Surgical Management
Indications for Surgery:
- Confirmed acute appendicitis on imaging
- High clinical probability (Alvarado ≥7) with positive Rovsing's/peritonism
- Failing conservative management
- Generalized peritonitis
Procedures:
- Laparoscopic appendicectomy (first-line): 3-port technique, mesoappendix divided, appendix base ligated and divided; advantages include reduced wound infection, faster recovery, diagnostic in equivocal cases [15]
- Open appendicectomy: Gridiron or Lanz incision in RIF; reserved for laparoscopy contraindication, extensive adhesions, or resource-limited settings
- Conversion to open: Required in 5-10% of laparoscopic cases (dense adhesions, aberrant anatomy, uncontrolled bleeding)
Disposition
- Admit if: Positive Rovsing's with other peritoneal signs, raised inflammatory markers, hemodynamic instability, elderly or immunocompromised, unable to tolerate oral intake
- Discharge if: Low probability after observation, normal investigations, able to tolerate orally, reliable, with clear safety netting
- Follow-up: Outpatient clinic 2-4 weeks post-surgery for histology review and wound check
Immediate (Minutes-Hours)
| Complication | Incidence | Presentation | Management |
|---|---|---|---|
| Haemorrhage (intra-operative) | 1-2% | Hypotension, tachycardia, falling Hb | Pressure, clip, cautery; conversion to open if needed |
| Anaesthetic complications | Variable | Arrhythmia, hypotension, aspiration | Anaesthetist management |
| Pneumoperitoneum (laparoscopy) | Common but transient | Shoulder tip pain post-op | Resolves spontaneously |
Early (Days)
- Surgical site infection (SSI): 3-5% laparoscopic, 8-15% open; treated with antibiotics ± drainage [15]
- Intra-abdominal abscess: 3-5% after perforated appendicitis; CT-guided drainage or re-laparoscopy
- Ileus: Delayed return of bowel function; conservative management, exclude obstruction
- Urinary retention: Common post-operatively; catheterization if needed
- Stump appendicitis: Rare; incomplete appendicectomy; requires re-operation
Late (Weeks-Months)
- Adhesive small bowel obstruction: 1-3% lifetime risk after any abdominal surgery; may present years later
- Incisional hernia: 1-2% laparoscopic, 2-4% open; surgical repair if symptomatic
- Chronic abdominal pain: Rare; may be related to adhesions or nerve entrapment
- Infertility (females): Slightly increased risk after perforated appendicitis due to pelvic adhesions [16]
- Incidental pathology on histology: Carcinoid tumour (0.3-0.9%), adenocarcinoma (rare); may require oncological follow-up
Natural History
Untreated appendicitis progresses from simple inflammation to gangrene to perforation within 24-72 hours. Perforation rates increase with delay: 20-30% by 36 hours of symptoms. [6] Perforated appendicitis has mortality of 0.1-0.5% in healthy adults but up to 5-15% in elderly or comorbid patients. Spontaneous resolution of appendicitis is rare (<10%) and recurrence is high if not removed.
Outcomes with Treatment
| Variable | Outcome |
|---|---|
| Mortality (simple appendicitis) | <0.1% |
| Mortality (perforated appendicitis) | 0.5-1% (healthy adults), up to 5-15% (elderly/comorbid) |
| Morbidity (laparoscopic) | 5-10% (mostly minor SSI, ileus) |
| Morbidity (open, perforated) | 15-30% |
| Recurrence after non-operative | 25-40% within 1 year [13,14] |
| Hospital stay (uncomplicated) | 1-2 days |
| Return to normal activity | 1-2 weeks (laparoscopic), 2-4 weeks (open) |
Prognostic Factors
Good Prognosis:
- Young, healthy patient
- Simple appendicitis at surgery
- Early presentation (<24 hours of symptoms)
- Laparoscopic approach
- No immunocompromise
Poor Prognosis:
- Elderly (>65 years)
- Significant comorbidities (diabetes, immunosuppression, cardiac disease)
- Delayed presentation with perforation
- Generalized peritonitis at surgery
- Septic shock
Key Guidelines
-
World Society of Emergency Surgery (WSES) Guidelines (2020) — Recommends laparoscopic appendicectomy as gold standard, supports CT imaging in equivocal cases, antibiotics-first approach an acceptable option in uncomplicated appendicitis. PMID: 32295644
-
EAES Consensus (2016) — Laparoscopic appendicectomy preferred over open; diagnostic laparoscopy recommended in fertile women; interval appendicectomy after appendix mass at surgeon's discretion. PMID: 26769648
-
NICE NG14 (2019) — Suspected sepsis guidelines; prompt antibiotic administration within 1 hour if septic appendicitis suspected. NICE
-
Surgical Infection Society/IDSA Guidelines (2010) — Antibiotic recommendations for complicated intra-abdominal infection; duration based on source control adequacy. PMID: 20034345
Landmark Trials
APPAC Trial (2015) — Antibiotics vs Appendicectomy in Non-Complicated Appendicitis
- 530 patients randomized to surgery vs antibiotics (ertapenem followed by levofloxacin/metronidazole)
- Key finding: 73% success at 1 year with antibiotics, 27% required appendicectomy
- Clinical Impact: Demonstrated antibiotics-first is viable but ~1/3 patients need subsequent surgery PMID: 26154088
CODA Trial (2020) — Antibiotics or Surgery for Appendicitis
- 1552 patients in US; largest RCT to date
- Key finding: Antibiotics non-inferior to surgery at 30 days; 29% appendicectomy by 90 days
- Appendicolith presence predicted antibiotic failure
- Clinical Impact: Shared decision-making now recommended for uncomplicated appendicitis PMID: 32955176
Sauerland et al. Cochrane Review (2010) — Laparoscopic vs Open Appendicectomy
- Meta-analysis of 67 RCTs
- Laparoscopic: Fewer wound infections (OR 0.45), less pain, faster recovery
- Laparoscopic: Increased intra-abdominal abscess in some studies (controversial)
- Clinical Impact: Established laparoscopy as gold standard PMID: 20927723
Evidence Strength
| Intervention | Level | Key Evidence |
|---|---|---|
| Laparoscopic appendicectomy for uncomplicated | Level 1a | Cochrane review [PMID: 20927723] |
| CT imaging for diagnosis | Level 1b | Multiple prospective studies [PMID: 24114548] |
| Antibiotics-first for uncomplicated | Level 1b | APPAC, CODA trials |
| Early analgesia (not withholding) | Level 1b | Meta-analyses confirm no adverse diagnostic effect [PMID: 16234459] |
| Interval appendicectomy vs immediate | Level 2a | Observational studies, expert consensus |
What is Rovsing's Sign?
Rovsing's sign is a test that doctors use when they suspect you might have appendicitis (infection of the appendix). During the examination, the doctor presses on the lower left side of your tummy, and if this causes pain on the lower right side, the test is positive. Think of it like pressing on one end of a water balloon and feeling the pressure at the other end — the appendix on the right side is inflamed and sensitive, so any movement or pressure in the tummy irritates it.
Why does it matter?
If Rovsing's sign is positive, it strongly suggests your appendix is inflamed and needs attention. The appendix is a small finger-like pouch attached to the large intestine on the lower right side. When it gets blocked and infected, it can become very painful and, if left untreated, it can burst. A burst appendix can make you very sick and is a medical emergency.
How is it treated?
- Pain relief: You will be given strong painkillers, usually through a drip in your arm.
- Tests and imaging: Blood tests and usually a CT scan to confirm the diagnosis.
- Surgery: The most common treatment is keyhole surgery (laparoscopic appendicectomy) to remove the appendix. This is done under general anaesthetic and usually takes about 30-60 minutes.
- Antibiotics: In some cases, especially if the appendix hasn't burst, doctors may try treating with antibiotics alone, but about 1 in 3 people will still need surgery later.
What to expect
After surgery, most people stay in hospital for 1-2 nights. You can usually eat and drink normally within a day. Recovery at home takes 1-2 weeks, though you should avoid heavy lifting for 4-6 weeks. The small scars from keyhole surgery heal well and fade over time.
When to seek help
If you have been told you might have appendicitis but are being monitored (not having surgery immediately), return immediately or call an ambulance if:
- Your pain suddenly gets much worse
- You develop a fever or feel shivery
- You start vomiting repeatedly
- Your tummy becomes hard and rigid
- You feel faint or very unwell
Primary Guidelines
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Di Saverio S, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg. 2020;15(1):27. PMID: 32295644
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Gorter RR, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016;30(11):4668-4690. PMID: 26769648
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Solomkin JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133-164. PMID: 20034345
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NICE. Sepsis: recognition, diagnosis and early management (NG51). 2016 [Updated 2017]. Link
Landmark Trials
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Salminen P, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340-2348. PMID: 26154088
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CODA Collaborative. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020;383(20):1907-1919. PMID: 32955176
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Sauerland S, et al. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010;(10):CD001546. PMID: 20927723
Systematic Reviews & Meta-Analyses
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Wagner JM, et al. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. PMID: 8918857
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Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91(1):28-37. PMID: 14716790
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Manterola C, et al. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2011;(1):CD005660. PMID: 21249672
Additional References
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Rovsing NT. Indirektes Hervorrufen des typischen Schmerzes an McBurney's Punkt. Zentralbl Chir. 1907;34:1257–1259. (Historical primary source)
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Cope Z. The Early Diagnosis of the Acute Abdomen. 22nd ed. Oxford University Press; 2010.
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McGee S. Evidence-Based Physical Diagnosis. 4th ed. Elsevier; 2018. PMID: 29659024
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Park JS, et al. Value of the Alvarado score in acute appendicitis diagnosis. J Surg Res. 2012;178(2):263-268. PMID: 22341349
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Bhangu A, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278-1287. PMID: 26460662
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Tanaka Y, et al. Assessment of inflammatory markers after appendectomy. Surgery. 2019;165(5):928-934. PMID: 30686499
Further Resources
- Royal College of Surgeons: https://www.rcseng.ac.uk
- Association of Surgeons of Great Britain and Ireland: https://www.asgbi.org.uk
- Patient UK - Appendicitis: https://patient.info/digestive-health/appendicitis-leaflet
Common Exam Questions
Questions that frequently appear in examinations:
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MRCS Part A/B: "A 22-year-old man presents with 12 hours of periumbilical pain that has migrated to the RIF. Examination reveals positive Rovsing's sign. What is the most likely diagnosis and how would you confirm it?"
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MRCS OSCE: "Demonstrate the technique for eliciting Rovsing's sign and explain its clinical significance."
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USMLE Step 2 CK: "Which clinical sign has the highest specificity for acute appendicitis: (a) RIF tenderness, (b) Rebound tenderness, (c) Rovsing's sign, (d) Psoas sign?"
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PLAB 2: "A 25-year-old woman with RIF pain. How would you differentiate appendicitis from gynaecological causes?"
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Medical Finals: "Describe the pathophysiology of pain migration in appendicitis and explain why Rovsing's sign becomes positive."
Viva Points
Opening Statement (How to start your viva answer):
"Rovsing's sign is a clinical finding where palpation of the left iliac fossa elicits pain in the right iliac fossa, indicating localized peritoneal irritation consistent with acute appendicitis. It was first described by the Danish surgeon Niels Thorkild Rovsing in 1907. The sign has moderate specificity (75-90%) but low sensitivity (25-50%), making it useful for ruling in appendicitis when present but insufficient to exclude the diagnosis when absent."
Key Facts to Mention:
- Rovsing's sign indicates somatic pain from parietal peritoneal irritation
- Sensitivity 25-50%, Specificity 75-90%, LR+ 3.5
- CT abdomen/pelvis is gold standard with >95% sensitivity/specificity
- Laparoscopic appendicectomy is first-line surgical treatment
- APPAC and CODA trials demonstrated antibiotics-first is viable for uncomplicated cases
Classification to Quote:
- "The Alvarado score (MANTRELS) is used to risk-stratify patients; score ≥7 indicates high probability of appendicitis"
- "Appendicitis is classified as simple/uncomplicated or complicated (gangrenous, perforated, abscess, or phlegmon)"
Evidence to Cite:
- "The CODA trial (2020, n=1552) showed antibiotics were non-inferior to surgery at 30 days, though 29% required appendicectomy by 90 days"
- "The Cochrane review by Sauerland et al. established laparoscopic appendicectomy as gold standard with fewer wound infections (OR 0.45) versus open"
Structured Answer Framework:
- Definition and Mechanism (30 seconds): Define sign, explain physiological basis
- Sensitivity/Specificity (30 seconds): Quote the numbers, explain clinical utility
- Clinical Context (30 seconds): When to use it, other signs of appendicitis
- Investigation (30 seconds): CT gold standard, Alvarado scoring
- Management (60 seconds): Resuscitation, antibiotics, laparoscopic appendicectomy
- Complications and Evidence (30 seconds): SSI rates, APPAC/CODA trials
Common Mistakes
What fails candidates:
- ❌ Claiming Rovsing's sign rules OUT appendicitis when negative (sensitivity only 25-50%)
- ❌ Not knowing the difference between visceral and somatic pain pathways
- ❌ Forgetting to mention pregnancy test as mandatory investigation in females
- ❌ Recommending withholding analgesia pending surgical review (this is unethical and disproven)
- ❌ Not knowing Alvarado score or its clinical application
- ❌ Failing to mention APPAC or CODA trial when discussing management
Dangerous Errors to Avoid:
- ⚠️ Discharging a patient with positive Rovsing's and raised inflammatory markers without imaging or surgical review
- ⚠️ Failing to consider ectopic pregnancy in females of reproductive age with abdominal pain
Outdated Practices (Do NOT mention):
- Routine rectal examination for appendicitis diagnosis - Now replaced by CT in most cases
- Withholding analgesia until surgical review - Disproven; analgesia does not mask signs
- Routine open appendicectomy - Laparoscopic is now gold standard
Examiner Follow-Up Questions
Expect these follow-up questions:
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"What would you do if the CT was equivocal?"
- Answer: Diagnostic laparoscopy, especially in young females; alternatively, admit for observation with serial clinical examination and repeat inflammatory markers.
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"What is the evidence for antibiotics-first in uncomplicated appendicitis?"
- Answer: APPAC trial (2015, n=530) showed 73% success at 1 year; CODA trial (2020, n=1552) showed non-inferiority at 30 days but 29% needed surgery by 90 days. Appendicolith predicts antibiotic failure. Shared decision-making is now recommended.
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"How would you manage an appendix mass or phlegmon?"
- Answer: Initial conservative management with IV antibiotics, percutaneous drainage if abscess present, interval appendicectomy at 6-8 weeks (though some centres favour immediate surgery).
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"What are the contraindications to laparoscopic appendicectomy?"
- Answer: Absolute: severe cardiopulmonary disease precluding pneumoperitoneum, coagulopathy, massive distension. Relative: extensive previous abdominal surgery, late pregnancy, large appendix mass. Open conversion required in 5-10%.
Last Reviewed: 2025-12-26 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and current guidelines.