Rovsing sign

**Definition:** Deep palpation of the left lower quadrant produces pain in the right lower quadrant (referred pain). A positive sign supports a diagnosis of acute appendicitis.

**Mechanism:** Palpation of the LLQ shifts bowel contents and gas retrograde through the colon toward the cecum. This distends the cecum and stretches/irritates the adjacent inflamed parietal peritoneum near the appendix, producing RLQ pain.

**Appendicitis pathophysiology (context):** Luminal obstruction (fecalith in adults; lymphoid hyperplasia in children) leads to increased intraluminal pressure, bacterial overgrowth, venous and then arterial compromise, ischemia, necrosis, and perforation. Early pain is visceral and periumbilical (T10 dermatome, via visceral afferents). Pain then migrates to the RLQ once the parietal peritoneum is inflamed (somatic localization).

**Classic presentation:** Periumbilical pain that migrates to the RLQ, anorexia, nausea and vomiting (typically after the pain starts), and low-grade fever. Leukocytosis is common.

**Related physical exam signs (often tested together):** - **McBurney point tenderness:** one-third of the distance from the ASIS to the umbilicus. - **Psoas sign:** pain on right hip extension or on flexion against resistance. It suggests a retrocecal appendix irritating the iliopsoas. - **Obturator sign:** pain with internal rotation of the flexed right hip. It suggests a pelvic appendix irritating the obturator internus. - **Dunphy sign:** pain with coughing. - **Blumberg sign (rebound tenderness):** pain on sudden release of pressure. It indicates peritoneal irritation.

**Diagnosis and management:** - Clinical diagnosis supported by imaging. CT abdomen/pelvis with contrast is the usual choice in adults. Ultrasound is first line in children and pregnant women, and MRI is used if ultrasound is nondiagnostic in pregnancy. - Treatment is appendectomy (laparoscopic) plus perioperative antibiotics. Nonoperative antibiotic management is an option in select uncomplicated cases. - Complications: perforation, periappendiceal abscess, peritonitis, sepsis, and pylephlebitis (septic thrombophlebitis of the portal vein).

**Test-taking pearls:** - Rovsing = pain in the RLQ when the LLQ is palpated. Don't confuse it with Murphy sign (cholecystitis), Cullen/Grey Turner (hemorrhagic pancreatitis), Kehr sign (splenic injury, left shoulder pain), or Carnett sign (abdominal wall pain). - Rovsing sign is fairly specific but not sensitive. Its absence does not rule out appendicitis. - It is named after Niels Thorkild Rovsing, a Danish surgeon.