Ans. c (Cullen's sign) (Ref. Bailey and Love 26th/pg. 1203; box 71.4)Signs to elicit in appendicitisClinical signs of Acute Pancreatitis# Pointing sign# Cullen's sign# Rovsing's sign# Grey Turner's sign# Psoas sign# Fox sign# Obturator sign ACUTE APPENDICITIS# Acute appendicitis is relatively rare in infants, and becomes increasingly common in childhood and early adult life, reaching a peak incidence in the teens and early 20s.# The incidence of appendicitis is equal amongst males and females before puberty. In teenagers and young adults the male: female ratio increases to 3:2 at the age of 25 years; thereafter the greater incidence in males declines.# Aetiology- Some form of luminal obstruction by either a faecolith or stricture is found in the majority of cases.- The incidental finding of a faecolith is a relative indication for prophylactic appendicectomy.- Intestinal parasites, particularly Oxyuris vermicularis (syn. pinworm), can proliferate in the appendix and occlude the lumen.Clinical signs --Clinical examination{best for diagnosis)The diagnosis of appendicitis rests more on thorough clinical examination of the abdomen than on any aspect of the history or laboratory investigation.Cardinal features# unwell patient with low grade pyrexia, localised tenderness, guarding and rebound tenderness.The pointing sign# The patient is then asked to point to where the pain began and to where it moved.McBurney's tenderness# Muscle guarding over the point of maximum tenderness, classically McBurney point.Rebound tenderness# Palpation in LTF causes pain in RIFRovsing's sign# Deep palpation of the left iliac fossa may cause pain in the right iliac fossa.Psoas sign# Occasionally an inflamed appendix lies on the psoas muscle and the patient, often a young adult, will lie with the right hip flexed for pain relief.Obturator test(Zachary Cope)# Spasm of the obturator internus is sometimes demonstrable when hip is flexed and internally rotated. If inflamed appendix is in contact with obturator internus, this maneuvre will cause pain in hypogastrium.Cutaneous hyperaesthesia# Cutaneous hyperesthesia may be demo in the right iliac fossa, but is rarely of diagnostic value.Special features. according to ageInfants# Appendicitis is relatively rare in infants under 36 months of age.# diagnosis is often delayed and thus the incidence of perforation and post-op morbidity is considerably higher.# Diffuse peritonitis can develop rapidly due to the underdeveloped greater omentum.Children# It is rare to find a child with appendicitis who has not vomited.# Children with appendicitis usually have complete aversion to food.# In addition, they do not sleep and bowel sounds are completely absent in early stages.The elderly# Gangrene and perforation occur much more frequently in elderly patients.# Elderly patients with lax abdominal walls or obesity may harbour a gangrenous appendix with little evidence of it, and the clinical picture may simulate subacute intestinal obstruction.# These features with coincident medical conditions produce a much higher mortality for acute appendicitis in elderly.The obese# Obesity can obscure and diminish all the local signs of acute appendicitis.# Delay in diagnosis coupled with the technical difficulty of operating in the obese make it wiser to consider operating through a midline abdominal incision.Pregnancy# Appendicitis is the most common extrauterine acute abdominal condition in pregnancv with a frequency of from one in 1500 to one in 2000 pregnancies.# As pregnancy develops during the second and third trimesters, the caecum and appendix are progressively pushed to the right upper quadrant of the abdomen.# Foetal loss occurs in 3-5% of cases, increasing to 20% if perforation is found at operation.