What is the difference between Murphy's sign, McBurney's sign, and Rovsing's sign in diagnosing appendicitis?

Murphy's Sign vs McBurney's Sign vs Rovsing's Sign

These are three distinct physical examination signs used to diagnose different abdominal conditions: Murphy's sign is specific for cholecystitis (gallbladder inflammation), McBurney's sign indicates appendicitis through direct tenderness at a specific anatomical point, and Rovsing's sign suggests appendicitis through referred pain elicited by palpating the left lower quadrant.

Murphy's Sign

Purpose: Diagnostic for acute cholecystitis, NOT appendicitis 1

Technique and Interpretation:

• Characterized by inspiratory arrest during deep palpation of the right upper quadrant 1
• The examiner places their hand below the right costal margin and asks the patient to take a deep breath
• A positive sign occurs when the descending inflamed gallbladder contacts the examiner's hand, causing sudden pain and cessation of inspiration
• This sign is specific for cholecystitis and helps distinguish it from appendicitis 1

McBurney's Sign

Purpose: Direct assessment for appendicitis 1, 2

Anatomical Location:

• McBurney's point is located approximately one-third the distance from the anterior superior iliac spine to the umbilicus 2
• This represents the typical anatomical location of the appendix

Technique and Interpretation:

• Direct palpation at McBurney's point elicits maximal tenderness in acute appendicitis 1, 2
• Right lower quadrant pain at this specific point is one of the best signs for ruling in acute appendicitis in adults 3
• Tenderness at McBurney's point remains a key finding despite advances in imaging and laboratory diagnostics 2

Rovsing's Sign

Purpose: Indirect assessment for appendicitis through referred peritoneal irritation 1, 3, 4

Technique and Interpretation:

• The examiner palpates the left lower quadrant of the abdomen 4
• A positive Rovsing's sign occurs when this left-sided palpation elicits pain in the right lower quadrant 4
• Based on the principle that pressure in the left colon displaces gas and fluid, causing peritoneal irritation at the inflamed appendix location
• A positive Rovsing sign is most reliable for ruling in acute appendicitis in children 3

Clinical Application in Appendicitis Diagnosis

Comprehensive Physical Examination Approach:

While these individual signs are helpful, no single clinical finding is unequivocal in identifying appendicitis; a constellation of findings including characteristic abdominal pain, localized abdominal tenderness, and laboratory evidence of acute inflammation will generally identify most patients 5

Key Clinical Findings for Appendicitis:

• Classic presentation includes periumbilical pain migrating to the right lower quadrant, anorexia/nausea/vomiting, and low-grade fever 6
• The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests increased likelihood of appendicitis 7
• Abdominal rigidity and periumbilical pain radiating to the right lower quadrant are among the best signs for ruling in appendicitis 3
• Additional supportive signs include positive obturator sign (pain with internal rotation of flexed hip, suggesting pelvic appendix location) 1

Critical Pitfall to Avoid: Do not rely on physical examination alone. Clinical findings should be used to risk-stratify patients and guide decisions about further testing (laboratory tests and/or imaging studies) and management 5. The diagnosis of appendicitis made on clinical grounds alone historically resulted in unacceptably high negative appendectomy rates of up to 25% 5.

Recommended Diagnostic Algorithm:

• Use clinical signs (McBurney's sign, Rovsing's sign, psoas sign, obturator sign) combined with laboratory studies (WBC count, C-reactive protein) for initial risk stratification 5, 3
• For adults with suspected appendicitis, helical CT of the abdomen and pelvis with intravenous contrast (without oral or rectal contrast) is the recommended imaging procedure, with sensitivity of 85.7-100% and specificity of 94.8-100% 5, 1
• Ultrasound may be used as first-line imaging but has lower sensitivity compared to CT 1, 8
• MRI shows excellent diagnostic performance (96% sensitivity and specificity) and is particularly useful in pregnant patients 5, 1