What is the management approach for a patient with a positive Rovsing's sign suggesting possible appendicitis?

Management of Positive Rovsing's Sign in Suspected Appendicitis

A positive Rovsing's sign indicates increased likelihood of appendicitis and should trigger immediate diagnostic imaging (ultrasound first-line or CT scan) followed by surgical consultation, antibiotic administration, and timely appendectomy as the standard of care. 1, 2

Initial Clinical Assessment

When Rovsing's sign is positive, this finding should be integrated with other clinical indicators to risk-stratify the patient:

• Key clinical findings that increase appendicitis likelihood include: right lower quadrant pain, migratory periumbilical pain to the right lower quadrant, fever, abdominal rigidity, positive psoas sign, and positive obturator sign 3, 4
• Laboratory evaluation should include: complete blood count looking for leukocytosis with left shift (>75% segmented neutrophils) and C-reactive protein 3, 2
• In children specifically: absent or decreased bowel sounds, positive psoas sign, positive obturator sign, and positive Rovsing's sign are the most reliable clinical indicators 4

Diagnostic Imaging Algorithm

Use a step-up approach starting with clinical and laboratory examination, then progressing to imaging: 3

• Adults: Helical CT of abdomen/pelvis with intravenous contrast is the recommended imaging (sensitivity 90-100%, specificity 94.8-100%) 1, 2, 5
• Women of childbearing age: Obtain pregnancy test first; if pregnant (first trimester), use ultrasound or MRI instead of CT to avoid ionizing radiation 3, 1
• Children: Ultrasound is reasonable first-line imaging to avoid radiation exposure (sensitivity 87.1%, specificity 89.2%), though CT has slightly higher accuracy 3, 1, 6
• If ultrasound is inconclusive: Proceed to CT scan 3
• MRI alternative: When available, MRI shows excellent diagnostic performance (sensitivity 94%, specificity 96%) and is particularly useful in pregnant patients 3, 2

Immediate Management Steps

Once appendicitis is suspected with positive Rovsing's sign:

1. Notify surgical consultant early - do not delay surgical consultation while awaiting imaging if clinical suspicion is high 3
2. Initiate broad-spectrum antibiotics immediately covering aerobic gram-negative organisms and anaerobes (e.g., piperacillin-tazobactam monotherapy, or cephalosporin/fluoroquinolone plus metronidazole) 3, 1, 5
3. Provide adequate pain control with opioids, NSAIDs, or acetaminophen - this does not delay diagnosis or cause unnecessary intervention 4

Surgical Decision-Making

Appendectomy (laparoscopic or open) remains the standard treatment for acute appendicitis: 3, 1

• Timing: Perform surgery as soon as reasonably feasible for non-perforated appendicitis; within 24 hours for uncomplicated cases, within 8 hours for complicated appendicitis 1
• Approach: Both laparoscopic and open appendectomy are acceptable, with laparoscopic preferred in children and offering benefits of shorter hospital stay and less postoperative pain in adults 3, 1
• High-risk CT findings: If imaging shows appendicolith, mass effect, or appendiceal diameter >13mm, surgical management is strongly recommended as antibiotic-first approach has ~40% failure rate 5

Special Populations

• Pregnant patients: Require timely surgical intervention to decrease complication risk; use ultrasound or MRI for diagnosis 1, 7
• Immunosuppressed patients: Should undergo timely surgical intervention rather than conservative management 7
• Elderly patients: Have higher perforation rates (55-70%) and mortality risk with perforation (~5% vs <0.1% in non-perforated), requiring urgent evaluation 8
• Very young children (<5 years): May have atypical presentation leading to delayed diagnosis and higher perforation rates 1

Antibiotic-Only Management Consideration

Antibiotics alone may be considered only in highly selected patients with uncomplicated appendicitis: 3, 1, 5

• Requirements: CT-confirmed uncomplicated appendicitis without appendicolith, no mass effect, appendiceal diameter <13mm, and patient fit for surgery if antibiotics fail 5
• Limitation: 27% recurrence rate at 1 year and need for CT confirmation limits widespread application 3
• Recommendation: Given high recurrence rates and antimicrobial stewardship concerns, appendectomy remains preferred first-line therapy 3

Critical Pitfalls to Avoid

• Do not delay imaging in women of childbearing age - all female patients should undergo diagnostic imaging with pregnancy testing prior 1
• Do not rely solely on clinical findings without imaging when diagnosis is uncertain - this leads to missed diagnoses or unnecessary surgeries 1
• Do not delay antibiotics once appendicitis is confirmed or strongly suspected - this increases complication risk 1
• Do not discharge patients with negative imaging without 24-hour follow-up - false-negative imaging rates are measurable 3
• Recognize that perforation risk increases with symptom duration - perforation occurs in 17-32% of cases and significantly increases mortality 8, 4