What is the significance of a positive Rovsing sign in diagnosing appendicitis?

Rovsing Sign in Appendicitis Diagnosis

Rovsing sign is a valuable clinical indicator that increases the likelihood of appendicitis when positive, with a positive likelihood ratio of 3.52, making it one of the more reliable physical examination findings for diagnosing appendicitis.

Definition and Technique

• Rovsing sign refers to pain in the right lower quadrant (RLQ) when palpating the left lower quadrant of the abdomen 1
• Named after Danish surgeon Niels Thorkild Rovsing (1862-1927), who first described this clinical finding 2
• The sign is elicited by applying pressure to the left lower quadrant, causing pain in the right lower quadrant 3

Diagnostic Value

• Rovsing sign has a positive likelihood ratio of 3.52 (95% CI = 2.65-4.68) for appendicitis, making it one of the more reliable physical examination findings 4
• It is most useful as a rule-in test - a positive result increases the likelihood of appendicitis, but a negative result does not exclude the diagnosis 1
• The sign is based on the principle that inflammation in one area of the peritoneum can cause pain when a distant area of the peritoneum is manipulated 3

Clinical Context

• Rovsing sign should be evaluated alongside other clinical signs and symptoms of appendicitis, including:

  • Right lower quadrant pain 5
  • Periumbilical pain radiating to the right lower quadrant 6
  • Abdominal rigidity 5
  • Fever and leukocytosis 5

• Other valuable clinical signs in appendicitis include:

  • Psoas sign (pain with extension of the right hip) 6
  • Obturator sign (pain with internal rotation of the flexed right hip) 6
  • Cough/hop pain (pain in RLQ when patient coughs or hops) 4

Limitations and Considerations

• Physical examination signs including Rovsing sign have not been well studied with standardized techniques 1
• The accuracy and reliability of Rovsing sign may vary depending on:
  • The position of the appendix (retrocecal, pelvic, etc.) 1
  • The experience of the examiner 1
  • The stage of appendicitis (early vs. perforated) 5

Role in Diagnostic Algorithm

• Rovsing sign should be incorporated into a comprehensive evaluation that includes:

  1. Clinical assessment using validated scoring systems like Alvarado Score or Pediatric Appendicitis Score 6
  2. Laboratory studies (particularly white blood cell count) 5
  3. Imaging studies when indicated 7

• Despite its utility, Rovsing sign alone is insufficient to rule in or rule out appendicitis definitively 4

• When Rovsing sign is positive in a patient with suspected appendicitis, imaging studies are still recommended to confirm the diagnosis 7

Imaging Considerations

• Ultrasound is recommended as first-line imaging for suspected appendicitis 7
• CT scan without oral contrast has high sensitivity (90-100%) and specificity (94.8-100%) for appendicitis diagnosis 7
• MRI shows excellent diagnostic performance with sensitivity and specificity of 96% (95% CI: 95%-97%) 7

Clinical Pitfalls

• Over-reliance on any single physical examination finding, including Rovsing sign, may lead to diagnostic errors 1
• The sign may be less reliable in patients with atypical presentations, such as those with pelvic appendicitis 5
• Interpretation of Rovsing sign should be cautious in patients with other causes of peritoneal irritation 1