McBurney’s point and diagnosing appendicitis in children

Date First Published:
June 13, 2007
Last Updated:
December 21, 2007
Report by:
Clare Lamont, Medical Student (MRI)
Search checked by:
Katherine Potier, MRI
Three-Part Question:
In [young children with abdominal pain] how [useful is tenderness at McBurney's point] at [ruling in appendicitis]
Clinical Scenario:
You are examining a 4 year old child with abdominal pain - with appendicitis at the top of your differential diagnosis. If the child is tender at McBurney's point is that enough to confirm your suspicion of appendicitis and prompt surgical referral?
Search Strategy:
MEDLINE 1950 – Nov week 1 2007 using the OVID interface AND EMBASE 1980 to 2007 week 23
Search Details:
[{paediatric filter 2003 updated version for MEDLINE OVID interface} AND {exp Abdominal Pain/ OR exp Abdomen, Acute/ OR abdo$ pain.mp} AND {mcburney$ point.mp OR right iliac fossa tenderness.mp OR right iliac fossa.mp OR right lower quadrant tenderness.mp OR right lower quadrant.mp} AND {exp Physical Examination/ OR specific tenderness.mp OR localised tenderness.mp OR guarding.mp OR rebound tenderness.mp} AND {exp Appendicitis/ OR exp Appendix/ OR append$.mp}] LIMIT to human AND English
Outcome:
MEDLINE:24 papers were found of which 18 were irrelevant or of insufficient quality.
EMBASE: 27 papers were found of which 26 were irrelevant or of insufficient quality (excluding duplicates)
The remaining 7 papers are shown in the table.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
A Practical Score for the Early Diagnosis of Acute Appendicitis Alvardo, A. 1985 USA 305 patients (4-80) admitted with abdominal pain suggestive of acute appendicitis.
227 confirmed acute appendicitis at appendicectomy.		 Retrospective review Tenderness in right lower quadrant in acute appendicitis Sens 100% No subset analysis for children
No power calculation
Spec 12%
Predicitive value 100%
Observation Versus Operation for Abdominal Pain in the Right Lower Quadrant. Roles of the Clinical Examination and the Leukocyte Count Nauta RJ. Magnant C. 1986 USA 97 patients (2.5-91) admitted with pre-operative diagnosis of appendicitis.
Histological diagnosis of appendicitis confirmed in 81%.		 Cohort Rebound tenderness in appendicitis 67% No subset analysis for children.
No power calculation
'Rebound tenderness' not specified at McBurney's point.
Study type unclear - retrospective or prospective
No data on sensiticity or specificity
Rebound tenderness in non-appendicitis 39%
Significant (95% CI 0.19 and 0.59)
Assessment of peritonism in appendicitis Golledge J et al 1996 UK 100 patients (4-81) presented with right iliac fossa pain, with a provisional diagnosis of appendicitis. Prospective cohort Right iliac fossa tenderness sens 100% spec 7% ppv 46% No subset analysis for children.
Small number in study - no power calculation
Percussion tenderness over McBurney's pt sens 57% spec 86% ppv 76%
A useful sign for the diagnosis of peritoneal irritation in the right iliac fossa Lane, R and Grabham, J 1997 UK 83 patients (7-80) admitted to surgical ward with tenderness in the right iliac fossa.
Gold standard: histological diagnosis of appendicitis made in 59%		 Prospective diagnostic test study Modified sign - 1 min pressure on McBurney's point to illicit peritoneal irriation sens 94% No subset analysis for children
Small study - no power calculation
One difference of opinion between clinicians
spec 71 %
A clinical decision rule to identify children at low risk for appendicitis Kharbanda, AB et al. 2005 USA 601 patients (3-18) presenting to paediatric Emergency Department with symptoms and signs of appendicitis.
Post-surgery diagnosis of appendicitis 35%		 Prospective cohort study Maximal tenderness in right lower quadrant sens 79.9% spec 40.7% No power calculation
Was part of creation of clinical decision rule to predict those children at low risk of appendicitis
npv 77.9%
Does this child have appendicitis? Bundy DG. Byerley JS. Liles EA. Perrin EM. Katznelson J. Rice HE. 2007 USA Children with suspected appendicitis-which signs and symptoms increased likely diagnosis Review of literature-42 studies met inclusion criteria, of which 25 were assigned quality level of 3 or above Presence of fever increases likelihood of appendicits (LR 3.4, CI 2.4-4.8) Review article-meta-analysis not performed
States that signs and symptoms are most useful in combination.
Rebound tenderness LR 3, CI 2.3-3.9
Mid-abdominal pain migrating to RIF LR range 1.9-3.1
WCC <10 Decreases likelihood (LR 0.22, CI 0.17-0.30)
Author Commentary:
Across the papers there was consistently high sensitivity - 79.9 - 100%. This implies that when there is no tenderness at McBurney's point appendicitis can be ruled out. The papers did not agree on specificity (7-100%) hence it must be concluded that positive tenderness does not rule in a diagnosis of appendicitis - simply peritonism which has many causes. A number of different methods used to elicit tenderness at McBurneys point (palpation, 1 minutes pressure, percussion) are proven to be comparable.
Bottom Line:
Eliciting tenderness at McBurney's point is a valuable part of the abdominal examination - if negative appendicitis is a less likely diagnosis. However symptoms and signs are needed in combination.
References:
  1. Alvardo, A.. A Practical Score for the Early Diagnosis of Acute Appendicitis
  2. Nauta RJ. Magnant C.. Observation Versus Operation for Abdominal Pain in the Right Lower Quadrant. Roles of the Clinical Examination and the Leukocyte Count
  3. Golledge J et al. Assessment of peritonism in appendicitis
  4. Lane, R and Grabham, J. A useful sign for the diagnosis of peritoneal irritation in the right iliac fossa
  5. Kharbanda, AB et al.. A clinical decision rule to identify children at low risk for appendicitis
  6. Bundy DG. Byerley JS. Liles EA. Perrin EM. Katznelson J. Rice HE.. Does this child have appendicitis?