What is the clinical significance of Robson's sign in an adult patient with abdominal pain, weight loss, or jaundice, and how should it be further evaluated and managed?

Rovsing Sign: Clinical Significance and Management

Rovsing sign is a physical examination finding for acute appendicitis, not pancreatic or biliary disease, and has no role in evaluating patients with abdominal pain, weight loss, or jaundice when pancreatic cancer is suspected. 1, 2

What Rovsing Sign Actually Is

• Rovsing sign refers to pain in the right lower quadrant when palpating the left lower quadrant in patients with suspected acute appendicitis 1, 2
• The sign is named after Danish surgeon Niels Thorkild Rovsing (1862-1927), who described it in 1907 1
• Critical caveat: The sign is widely described incorrectly in English medical literature and textbooks, with no included studies providing an accurate description of how to properly elicit it 2
• German medical texts describe the sign correctly, but English sources have propagated an erroneous translation that has corrupted medical teaching and research 2

Why This Sign Is Irrelevant to Your Clinical Question

The clinical context you're asking about—abdominal pain, weight loss, and jaundice—points toward pancreatic or biliary pathology, not appendicitis. For these presentations, you need different physical examination findings:

Relevant Physical Signs for Pancreatic/Biliary Disease

• Courvoisier's sign (palpable gallbladder with painless jaundice) indicates malignant biliary obstruction, typically from pancreatic head tumors 3, 4
• Virchow's node (enlarged supraclavicular lymph node) indicates metastatic pancreatic cancer and inoperability 3, 5, 6
• Palpable fixed epigastric mass indicates locally advanced pancreatic cancer and unresectability 3, 5, 6
• Ascites indicates advanced pancreatic disease 3, 5, 6

Proper Evaluation of Suspected Pancreatic Cancer

When a patient presents with the triad of abdominal pain, weight loss, and jaundice, immediately obtain a triphasic contrast-enhanced CT scan of the pancreas to diagnose and stage potential pancreatic adenocarcinoma. 3, 6, 4

Initial Diagnostic Approach

• Abdominal ultrasonography can rapidly identify pancreatic tumors, dilated bile ducts, and liver metastases, saving time if metastases are present 6, 4
• CT scan with pancreas protocol (arterial, late arterial, and venous phases) is the preferred imaging modality for diagnosis and staging, with 80-90% accuracy for predicting resectability 3, 6, 4
• Do not delay imaging for patients with jaundice, as this may indicate either resectable head tumors or unresectable body/tail tumors with hepatic metastases 3, 6

Red Flag Symptoms Requiring Urgent Evaluation

• Persistent back pain indicates retroperitoneal nerve infiltration and usually incurability 3, 5, 6, 4
• Severe and rapid weight loss is associated with unresectability 3, 5
• New-onset diabetes in patients over 50 years without predisposing factors strongly suggests pancreatic cancer (5% develop diabetes within two years before diagnosis) 3, 6, 4
• Painless jaundice with palpable gallbladder (Courvoisier's sign) indicates malignant obstruction 3, 4

Time-Sensitive Management Decisions

• Endoscopic biliary stenting with self-expanding metal stents should be performed urgently (not emergently) to relieve jaundice, normalize bilirubin for potential chemotherapy, and prevent cholangitis 6
• Pathological proof is mandatory for unresectable cases or when preoperative treatment is planned 3, 6
• For surgical candidates, avoid preoperative percutaneous biopsy to prevent tumor seeding 6

Signs of Inoperability

• Jaundice in body/tail tumors usually indicates hepatic or hilar metastases and inoperability 3, 6
• Marked weight loss, palpable fixed epigastric mass, ascites, or Virchow's node all indicate unresectable disease 3, 5, 6

Bottom line: Rovsing sign has zero relevance to pancreatic or biliary pathology. Focus instead on Courvoisier's sign, imaging with CT, and recognizing red flags for advanced disease.