The sign Dunphy, or proof of cough, abdominal pain is evidenced when prompted to coughing patient. This test is done in people with suspected acute appendicitis. It is one of the easiest tests to perform as it does not require any special preparation or touch the patient's abdomen.
It can be performed by any trained health personnel and has great sensitivity in the diagnostic approach of acute appendicitis in the patient with abdominal pain.
By https://pixabay.com/nl/users/derneuemann-6406309/ - Pixabay, CC0, There are many tests for the doctor to suspect acute appendicitis in a patient who comes to the emergency room for abdominal pain. It is important to know them, since the diagnosis of this pathology is, basically, clinical. That is, the treating physician may have a high level of suspicion only by evaluating the symptoms and physical examination of the patient.
Although Dunphy's sign is not specific for acute appendicitis, it is a reliable indicator that there is a significant inflammatory process in the abdomen.
What is Dunphy's sign?
Dunphy's sign is also known as a cough test. The idea of the test is to show the pain in the right iliac fossa of the patient at the moment of coughing.
By CFCF - Own work, CC0, Its description is attributed to two surgeons without being clearly established who explained and used this technique for the first time. These professionals were the English doctor Osborne Joby Dunphy (1898-1989) and the American surgeon John Englebert Dunphy (1908-1981).
There is a 1953 publication by Dr. John Dunphy in which he describes the technique of causing pain in the patient's right iliac fossa by asking him to cough.
The doctor should instruct the patient to cough forcefully a couple of times. If the patient manifests pain in the right iliac fossa, brings his hands towards the right iliac fossa indicating discomfort in that place or abruptly interrupts the action due to pain, the sign is considered to be positive.
Coughing triggers pain as it makes the peritoneal layer (sheet that lines the abdominal cavity) rebound causing pain where it is inflamed.
The maneuver to reveal Dunphy's sign is an indirect test, that is, it is not necessary to touch the patient to assess pain. This makes it a more accurate sign and difficult to fake, as the patient does not expect pain.
Although a negative result does not rule out appendicitis, a positive result, together with the rest of the clinical data and laboratory tests, does guide the doctor towards that diagnosis.
Cecal appendix
The vermiform appendix or cecal appendix is an organ that is located on the right side of the abdomen, topographically in the iliac fossa, directly connected to the cecum. The cecum is the first part of the right colon or ascending colon.
By Olek Remesz (wiki-pl: Orem, commons: Orem) - Own work, CC BY-SA 2.5, It is known as a vermiform appendix, due to its elongated shape similar to that of a worm. The word vermiform comes from the Latin vermis = worm.
The appendix is an elongated blind (dead-end) organ, which can be up to 10 cm long. It has an internal lumen a few millimeters in diameter and connects to the lower edge of the cecum. Its function is controversial, but it has been shown to be a lymphatic organ.
It really lacks a significant function and is considered a vestigial organ, in fact in a small percentage of the world population there is an absence of the cecal appendix without interfering with the health of these individuals.
Inflammation of the appendix is the most common cause of acute abdominal pain in young patients. This pathology is known as acute appendicitis.
Acute appendicitis
Inflammation of the cecal appendix is the most common inflammatory process in the abdomen in young patients and is the main trigger for the acute abdominal pathology known as peritonitis.
This condition can occur for many reasons, the most common being obstruction of the appendicular lumen by a small, hard piece of stool called fecalith.
When fecalith blocks the lumen of the appendix, bacteria normally found in the intestine begin to proliferate. Having no outlet, an inflammatory process begins that ends up irritating the appendix and thus begins the first stage of appendicitis.
It is an acute process that is fully established in 6 to 8 hours and can be life-threatening when not treated in a timely manner.
By Davalos - Embryology and Genetics. Second edition. Editorial Ofnin. La Paz. 1990, CC BY-SA 4.0, Its complications are serious and range from the formation of abscesses in the fat around the appendix, to perforation and contamination of the abdominal cavity with feces, sepsis, infection of the blood, and even death.
The diagnosis of acute appendicitis is clinical. This means that the doctor must rely on the questioning, presentation of the disease, symptoms of the patient and pay special attention to the physical examination and laboratory tests.
Within the physical examination that the doctor performs in patients with abdominal pain in whom acute appendicitis is suspected, different clinical maneuvers have been described. These tests are used to reveal pain in the right iliac fossa, typical of acute appendicitis.
Diagnosis
To reach the diagnosis of appendicitis it is important to know that it is an acute process that can take up to 8 hours to fully establish. Therefore at the beginning the patient may present very vague symptoms related to a non-specific digestive process and these become more specific over time.
The triad of abdominal pain that migrates from the navel to the right iliac fossa, the lack of appetite and altered blood tests, guide the doctor to the definitive diagnosis.
By Qwertyytrewqqwerty - Based on Image: Gray1220-en.svg, Public Domain, Abdominal palpation is difficult and requires experience to verify or rule out a diagnosis.
The doctor must know well the anatomy of the intra-abdominal organs, as well as the pathophysiological process of the most common diseases of the abdomen in order to reach a diagnosis.
For this reason, more than twenty maneuvers, most of them easy to perform, have been described to show appendicular pain. The objective of all these maneuvers is to provoke in the patient the typical pain of acute appendicitis, which is a strong pain located in the right iliac fossa of the abdomen.
Although none of these maneuvers is totally specific for appendicitis, it is important to know them and be able to perform them correctly to reach a diagnosis.
References
- Bennett, HD; Tambeur, LJ; Campbell, WB. (1994). Use of coughing test to diagnose peritonitis. Exeter, Great Britain. Taken from: bmj.com
- Hodge, BD; Khorasani-Zadeh A. (2019) Anatomy, Abdomen and Pelvis, Appendix. StatPearls. Treasure Island (FL). Taken from: ncbi.nlm.nih.gov
- Patterson, JW; Dominique E. (2018). Acute Abdomen. StatPearls. Treasure Island (FL). Taken from: ncbi.nlm.nih.gov
- Jones, MW; Zulfiqar, H; Deppen JG. (2019). Appendicitis. StatPearls. Treasure Island (FL). Taken from: ncbi.nlm.nih.gov
- Alvarado A. (2016). How to improve the clinical diagnosis of acute appendicitis in resource limited settings. World journal of emergency surgery: WJES. Taken from: ncbi.nlm.nih.gov