Bryan sign

The presumed mechanism is displacement of the uterus towards an inflamed appendix or adjacent sensitive tissues. The diagnostic accuracy of the sign has not been reliably established.

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Historical development

1955 – Williams McIver Bryan Jr (1917–2007) published Surgical emergencies in pregnancy and the puerperium. He described right lower or middle abdominal pain elicited by pressure on the pregnant uterus from the left side as a finding suggestive of appendicitis.

In appendicitis, pressure on a pregnant uterus from the left side will often elicit pain in the right lower or middle quadrant.

Bryan 1955: 1205

1962 – Ruth King and Gail Anderson published Appendicitis and Pregnancy. They reviewed 36 patients clinically diagnosed with appendicitis during pregnancy or the puerperium. Their study described the changing location of abdominal pain during pregnancy and cited Bryan’s earlier results for overall clinical diagnostic accuracy.

1964 – Geza Kurtz et al, retrospectively reviewed 41 cases of appendicitis associated with pregnancy and labour. Displacement of the gravid uterus towards the right elicited pain in 31 of 38 correctly diagnosed cases, with seven additional false-positive responses.

The authors described the manoeuvre as their most reliable physical finding, reporting an accuracy of 83.8% rebound tenderness (68.6%). However, this figure cannot be reproduced from the reported counts and the study does not establish reliable sensitivity or specificity.

1985 – Horowitz et al reviewed 12 appendectomies performed during pregnancy or the puerperium. They cited Kurtz’s findings regarding Bryan sign but did not independently assess its diagnostic performance.

1999 – DeSantis and Lockrow described Bryan sign as persistence of right lower quadrant pain when the uterus is shifted towards the right in a supine patient. Their retrospective series did not provide independent diagnostic accuracy estimates for the manoeuvre.

2018 – Rastogi et al reviewed Bryan sign among historical abdominal examination manoeuvres, repeating the 83.8% accuracy reported by Kurtz et al.

2022 – Yale, Tekiner and Yale reviewed appendiceal examination signs during pregnancy, including Bryan and Alders signs. They highlighted the absence of sufficiently standardised studies establishing their diagnostic accuracy.

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Diagnostic accuracy

The evidence supporting Bryan sign is limited.

Kurtz and colleagues (1964) reported a positive response in 31 of 38 correctly diagnosed cases of appendicitis, together with seven false-positive responses in patients with other conditions. Their stated accuracy of 83.8% does not correspond to the observed positive proportion of 81.6% among the 38 cases.

The study did not provide the complete diagnostic data required to establish reliable sensitivity, specificity or likelihood ratios. Subsequent publications have largely repeated the original findings rather than independently validating the manoeuvre.

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Eponymythology

Bryan’s original description emphasised pain elicited by displacing the gravid uterus from left to right. Later accounts, such as DeSantis and Lockrow (1999), described the persistence of pre-existing right-sided pain during the same movement.

This distinction is clinically relevant. The provocation of new pain and persistence of existing tenderness are not necessarily equivalent examination findings.

Bryan sign should also be distinguished from Alders sign (1951), which involves maintaining pressure over an abdominal tender point while the pregnant patient turns onto the opposite side. Persistence of tenderness suggests an extrauterine source whilst reduction or disappearance suggests a uterine source.

	Alders sign (1951)	Bryan sign (1955)
Action	Patient turns onto the opposite side while the examiner maintains pressure	Examiner displaces the gravid uterus towards the right
Positive finding	Tenderness remains fixed, suggesting extrauterine pathology	Right-sided pain is elicited by uterine displacement
Original purpose	Distinguish uterine from extrauterine causes of pain	Suggest appendicitis in pregnancy

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Associated Persons

• Nicholas Alders (1904–1995)
• Williams McIver Bryan, Jr (1917-2007)

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References

Historical references

• Alders N. Sign for Differentiating Uterine from Extrauterine Complications of Pregnancy and Puerperium. Br Med J. 1951; 2(4741): 1194-5.
• Bryan WM Jr. Surgical emergencies in pregnancy and the puerperium. Am J Obstet Gynecol. 1955; 70(6): 1204-1211. discussion, 1211-1213
• King RM, Anderson GV. Appendicitis and Pregnancy. California medicine 1962; 97(3): 158-162
• Kurtz GR, Davis RS, Sproul JD. Acute appendicitis in pregnancy and labor, a report of 41 cases. Obstetrics & Gynecology. 1964; 23(4): 528-532.
• Horowitz MD et al. Acute appendicitis during pregnancy. Diagnosis and management. Arch Surg. 1985; 120(12): 1362-7.
• DeSantis RA, Lockrow EG. Appendectomy during Pregnancy: A Survey of Two Army Medical Activities. Military Medicine 1999; 164(10): 671-674.
• Rastogi V, Singh D, Tekiner H, Ye F, Mazza JJ, Yale SH. Abdominal Physical Signs and Medical Eponyms: Movements and Compression. Clin Med Res. 2018 Dec;16(3-4):76-82.
• Yale SH, Tekiner H, Yale ES. Signs and syndromes in acute appendicitis: A pathophysiologic approach. World J Gastrointest Surg. 2022 Jul 27;14(7):727-730.