What are the signs and symptoms of appendicitis?

Signs and Symptoms of Appendicitis

The classic presentation of appendicitis includes periumbilical pain migrating to the right lower quadrant (RLQ), loss of appetite, nausea or vomiting, with fever and leukocytosis present in approximately 50% of patients. 1 However, this classic presentation is not always observed, particularly in elderly patients and children, leading to potential diagnostic challenges.

Key Clinical Signs and Symptoms

Common Presentations

• Abdominal Pain

  • Initially periumbilical pain that migrates to the RLQ
  • Right lower quadrant tenderness (strongest discriminator) 1
  • Pain may be constant and progressive

• Gastrointestinal Symptoms

  • Anorexia (loss of appetite)
  • Nausea and vomiting (common but not universal) 1, 2
  • Altered bowel habits (constipation or diarrhea)

• Systemic Symptoms

  • Fever (present in 30-80% of cases) 1
  • Leukocytosis (elevated white blood cell count) 1

Physical Examination Findings

• Right lower quadrant tenderness (McBurney's point)
• Guarding and rigidity of the abdominal wall
• Rebound tenderness
• Rovsing sign (pain in RLQ when pressing the left lower quadrant)
• Psoas sign (pain with extension of right hip)
• Obturator sign (pain with internal rotation of flexed right hip)

Age-Specific Considerations

Elderly Patients

Elderly patients often present atypically, making diagnosis challenging:

• Lower rate of correct pre-operative diagnosis compared to younger patients 1
• Longer time from symptom onset to admission and from admission to surgery 1
• Classic triad (migrating RLQ pain, fever, leukocytosis) is infrequently observed 1
• May present with signs of ileus or bowel obstruction 1
• More likely to show signs of peritonitis (abdominal distension, generalized tenderness, guarding, rebound tenderness) 1
• Higher risk of perforation due to delayed diagnosis 1

Children

Children may also present differently:

• Less reliable symptoms, particularly in those under 5 years of age 1
• Higher rate of perforated appendicitis due to delayed diagnosis 1
• Right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the RLQ are the best signs 2
• Absent or decreased bowel sounds, positive psoas sign, positive obturator sign, and positive Rovsing sign are most reliable in children 2

Atypical Presentations

• Pregnancy: Location of pain may shift upward as pregnancy progresses, with pain in the right upper quadrant or entire right side in later stages 3
• Anatomical variations: Left lower quadrant pain can occur with an unusually long appendix projecting into the left side or with situs inversus totalis 4
• Post-trauma: Though rare, appendicitis can occur following blunt abdominal trauma 5

Diagnostic Pitfalls

• Relying solely on clinical signs and symptoms is not recommended, especially in elderly patients 1
• Laboratory tests alone (leukocyte count and CRP) are insufficient for diagnosis but normal values may help exclude appendicitis 1
• Delayed diagnosis increases risk of perforation, which occurs in 17-32% of patients 2

Diagnostic Approach

When appendicitis is suspected based on clinical presentation:

1. Laboratory tests: Complete blood count, C-reactive protein (though not diagnostic alone) 1
2. Imaging:
   • Ultrasound as first-line imaging, especially in children and pregnant women 1
   • CT scan has become the primary diagnostic imaging modality for adults due to high diagnostic yield (sensitivity 85.7-100%, specificity 94.8-100%) 1

Warning Signs of Complications

• Diffuse abdominal pain and rigidity (suggesting perforation)
• Signs of peritonitis (abdominal distension, generalized tenderness and guarding)
• High fever and tachycardia (suggesting sepsis)
• Palpable abdominal mass (suggesting abscess formation)

Early diagnosis and prompt treatment are essential to reduce morbidity and mortality associated with appendicitis, particularly in high-risk populations such as the elderly and young children.