Rovsing's Sign in a Post-Appendectomy Patient
In a patient with prior appendectomy presenting with left upper quadrant pain elicited by right lower quadrant palpation (positive Rovsing's sign), obtain CT abdomen and pelvis with IV contrast immediately to evaluate for alternative pathology causing referred pain or peritoneal irritation.
Diagnostic Approach
This clinical scenario represents a diagnostic paradox—Rovsing's sign (LUQ pain on RLQ palpation) classically suggests appendicitis, but the appendix has already been removed. The positive peritoneal sign indicates genuine intra-abdominal pathology requiring urgent investigation.
Immediate Imaging: CT with IV Contrast
CT abdomen and pelvis with IV contrast is the definitive initial imaging modality 1. This provides:
- Rapid, high-resolution cross-sectional evaluation of all abdominal structures
- Superior anatomical delineation for detecting complications, fluid collections, abscesses, and inflammatory processes 1
- Evaluation of the surgical bed for post-operative complications (abscess, adhesions causing referred pain)
- Assessment of LUQ structures: spleen, stomach, pancreas, left kidney, and bowel 1
Why This Matters
The referred peritoneal irritation suggests either:
- Diffuse peritonitis from any source causing generalized peritoneal inflammation
- Adhesive disease from prior surgery creating traction or obstruction
- Primary LUQ pathology (splenic infarct, gastric perforation, pancreatitis) with peritoneal irritation extending to involve the entire peritoneum
- Post-operative complications in the appendectomy bed (abscess, stump leak—though rare)
Alternative Imaging Considerations
Ultrasound is inadequate in this scenario. While useful for initial evaluation of some LUQ pathology, it cannot provide the comprehensive assessment needed when peritoneal signs are present 1.
MRI without and with contrast achieves 96% sensitivity and 93% specificity for acute abdominal pathology 1, but is reserved for pregnant patients or when CT is contraindicated—not appropriate for urgent evaluation in a standard adult patient.
CT without contrast limits vascular evaluation and diminishes conspicuity of small lesions, infarcts, and inflammatory changes 1—unacceptable when peritoneal signs demand complete assessment.
Critical Pitfalls to Avoid
- Do not dismiss the physical finding simply because the appendix is absent. Rovsing's sign indicates peritoneal irritation, not necessarily appendiceal pathology.
- Do not delay imaging for serial examinations when focal peritoneal signs are present 2.
- Do not order ultrasound first—it will likely be non-diagnostic and delay definitive imaging.
- Do not forget post-operative complications: stump appendicitis (extremely rare but reported), abscess formation, or adhesive disease can occur months to years after appendectomy.
What to Look For on CT
The radiologist should specifically evaluate:
- Surgical bed: fluid collections, abscesses, inflammatory stranding
- LUQ structures: splenic size, infarction, hematoma, perisplenic collections 1
- Bowel: obstruction, perforation, diverticulitis, inflammatory bowel disease
- Pancreas: pancreatitis with extension to LUQ
- Free fluid and pneumoperitoneum: suggesting perforation
Surgical Consultation Threshold
Obtain immediate surgical consultation if CT demonstrates:
- Abscess requiring drainage
- Bowel perforation or obstruction
- Any finding requiring operative intervention
Even with negative or equivocal imaging, persistent focal peritoneal signs warrant surgical evaluation 2, as physical examination retains diagnostic value even when imaging is unrevealing.