Rovsing Sign in Suspected Appendicitis
Clinical Significance
A positive Rovsing sign increases the likelihood of acute appendicitis but should never be used in isolation—it must be incorporated into validated clinical scoring systems (AIR score, AAS score, or Alvarado score) and combined with imaging to guide management decisions. 1, 2
What is Rovsing Sign
Rovsing sign occurs when palpation of the left lower quadrant elicits pain in the right lower quadrant, based on the principle that pressure in the left colon displaces gas and fluid, causing peritoneal irritation at the inflamed appendix location. 1
Diagnostic Performance
In children: Rovsing sign is among the most reliable physical examination findings for ruling in acute appendicitis, along with absent/decreased bowel sounds, positive psoas sign, and positive obturator sign. 3
In adults: The diagnostic accuracy is more limited—individual clinical signs including Rovsing sign have weak discriminative power with areas under the receiver operating characteristic curve (AUC) ranging from 0.50 to 0.65. 4
Critical limitation: A positive test increases the likelihood of appendicitis when present, but a negative test does not exclude the diagnosis. 5
Integration into Clinical Practice
Use Validated Scoring Systems—Not Individual Signs
The American College of Emergency Physicians recommends using validated clinical scoring systems (AIR score, AAS score, or Alvarado score) rather than relying on individual clinical signs like Rovsing sign alone. 2
The Pediatric Appendicitis Score (PAS) incorporates peritoneal signs and has 80.3% sensitivity for appendicitis in children. 2
These scoring systems stratify patients as low, moderate, or high risk and guide decisions about imaging and surgical consultation. 3
Document Alongside Other Peritoneal Signs
When Rovsing sign is positive, systematically assess and document:
Other peritoneal signs: Rebound tenderness, guarding, psoas sign, obturator sign, and McBurney point tenderness. 1, 2
Laboratory markers: White blood cell count with differential (absolute neutrophil count) and C-reactive protein—when both WBC and left shift are elevated together, the positive likelihood ratio is 9.8. 2
Classic symptom triad: Periumbilical pain migrating to the right lower quadrant, anorexia/nausea/vomiting, and fever (though this complete triad is present in only a minority of patients). 1
Management Algorithm Based on Risk Stratification
Low-Risk Patients (Low Clinical Scores, Negative Peritoneal Signs)
Consider discharge without imaging if validated clinical scores are sufficiently low. 2
Mandatory 24-hour follow-up is essential due to measurable false-negative rates. 6
Provide clear return precautions for worsening symptoms, fever, vomiting, or increasing abdominal tenderness. 6
Intermediate-Risk Patients (Equivocal Findings)
Proceed to ultrasound as first-line imaging regardless of Rovsing sign result. 2
If ultrasound is nondiagnostic or equivocal, proceed directly to CT abdomen and pelvis with IV contrast (sensitivity 90-100%, specificity 94.8-100%). 7
In children, staged ultrasound followed by CT if needed achieves 99% sensitivity and 91% specificity. 6
High-Risk Patients (High Clinical Scores, Positive Peritoneal Signs Including Rovsing)
Proceed directly to CT abdomen and pelvis with IV contrast without enteral contrast for rapid diagnosis. 6
CT identifies alternative diagnoses in 23-45% of cases with right lower quadrant pain, fundamentally changing management. 6
Immediate surgical consultation is warranted when CT confirms appendicitis (appendiceal diameter ≥8.2 mm with periappendiceal infiltration). 6
Critical Pitfalls to Avoid
Never rely on absence of fever to exclude appendicitis—fever is absent in approximately 50% of cases. 6, 1
Never discharge patients based solely on negative Rovsing sign—atypical presentations occur in approximately 50% of patients, especially in elderly patients, pregnant women, and those with retrocecal or pelvic appendix position. 1, 2
Never delay imaging if symptoms worsen during observation—prolonged duration of symptoms before surgical intervention raises perforation risk (occurs in 17-32% of patients). 3
Recognize age-related variations—the typical triad of migrating right lower quadrant pain, fever, and leukocytosis is infrequently observed in elderly patients, who more commonly present with signs of peritonitis including abdominal distension and generalized tenderness. 1
Special Populations
Pregnant patients: Use MRI instead of CT (96% sensitivity and specificity) when imaging is needed after positive peritoneal signs. 6, 2
Children: Ultrasound is first-line imaging to avoid radiation exposure, with CT reserved for nondiagnostic ultrasound results. 6, 2
Elderly patients: Lower threshold for imaging is essential—clinical signs and symptoms alone are unreliable, and delayed presentation increases perforation rates. 1