Appendicitis Symptoms & Diagnosis: Recognizing the Warning Signs
Appendicitis: Recognizing Symptoms & Understanding Diagnosis
The appendix is a 5-10 cm finger-like pouch extending from the cecum. While you can't palpate your own appendix, recognizing the classic symptom progression is critical for timely intervention.
Classic Symptom Progression
- Visceral pain (0-12h): Periumbilical/epigastric, dull, aching, poorly localized (T10 referral)
- Anorexia: Often precedes or accompanies pain onset
- Nausea/vomiting: Follows pain (not before - differentiates from gastroenteritis)
- Somatic pain (12-24h): Migrates to RLQ (McBurney's point: 2/3 from umbilicus to ASIS)
- Low-grade fever: 99-101°F (37.2-38.3°C)
- Local signs: Guarding, rebound tenderness, Rovsing's sign (LLQ pressure → RLQ pain)
Atypical Presentations (Up to 40%)
| Population | Variation |
|---|
| Pregnancy | Appendix displaced upward; RUQ/flank pain |
| Children | Rapid progression; diffuse pain; high rupture risk |
| Elderly | Muted symptoms; confusion; delayed presentation |
| Retrocecal appendix | Flank/back pain; psoas sign (hip extension pain) |
| Pelvic appendix | Suprapubic pain; urinary frequency; rectal tenderness |
| Immunocompromised | Blunted response; sepsis may precede pain |
Key Physical Exam Signs
- McBurney's point tenderness: Maximal at 1.5-2" from ASIS toward umbilicus
- Rebound tenderness (Blumberg's): Pain on quick release > compression
- Rovsing's sign: LLQ palpation → RLQ pain (specific for peritoneal irritation)
- Psoas sign: Passive hip extension → RLQ pain (retrocecal)
- Obturator sign: Flexed hip + internal rotation → hypogastric pain (pelvic)
- Dunphy's sign: Coughing → RLQ pain
Diagnostic Workup
- Clinical scores: Alvarado (MANTRELS), Appendicitis Inflammatory Response (AIR), Pediatric Appendicitis Score (PAS)
- Labs: CBC (↑WBC, ↑neutrophils, ↑bands), CRP, urinalysis (rule out UTI/stone)
- Imaging (if equivocal):
- Ultrasound: First-line (children, pregnant); non-radiating; operator-dependent
- CT abdomen/pelvis with contrast: Gold standard (sens 95%, spec 95%)
- MRI: Pregnancy (2nd/3rd choice after US); no radiation
Treatment & Urgency
- Uncomplicated: Laparoscopic appendectomy (preferred); antibiotics alone option (CODA trial)
- Perforated: Surgery + drainage; IV antibiotics; possible interval appendectomy
- Time critical: Rupture risk ↑ significantly after 24-48h symptoms
Red Flags: Seek ER Immediately
- RLQ pain + fever + vomiting
- Pain worsening over hours
- Inability to walk upright (psoas irritation)
- Rigid abdomen, severe tenderness
Bottom Line
Appendicitis is a clinical diagnosis supported by labs/imaging. Classic migration from periumbilical to RLQ pain + anorexia is highly suggestive. When in doubt, surgical evaluation - negative appendectomy rate 5-15% is acceptable vs. missing perforation.
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