What are the signs of appendicitis?

Signs of Appendicitis

The classic presentation of appendicitis includes periumbilical abdominal 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

Cardinal Signs and Symptoms

Pain Characteristics

• Initial periumbilical pain that migrates to the RLQ (McBurney's point)
• Pain that precedes vomiting (vomiting before pain makes appendicitis less likely) 2
• Steady, dull pain that becomes sharp and localized

Physical Examination Findings

• RLQ tenderness on palpation
• Guarding and rigidity over the RLQ
• Positive psoas sign (pain with extension of right hip) 2
• Rebound tenderness
• In elderly patients: may present with more signs of peritonitis (abdominal distension, generalized tenderness) 1

Associated Symptoms

• Anorexia (loss of appetite)
• Nausea and vomiting (following onset of pain)
• Low-grade fever
• Malaise

Laboratory Findings

• Leukocytosis (elevated white blood cell count)
• Elevated C-reactive protein (CRP)
• Note: Laboratory tests alone are insufficient for diagnosis 1
• High CRP values in elderly patients may indicate perforation (AUC 0.811 with cut-off of 101.9 mg/l) 1

Atypical Presentations

Elderly Patients

• Less likely to present with classic triad of symptoms
• May have signs consistent with ileus or bowel obstruction 1
• Higher rate of perforation due to delayed diagnosis
• More likely to have peritoneal signs (abdominal distension, generalized tenderness) 1

Children

• May have more diffuse abdominal pain
• Difficulty articulating symptoms

Diagnostic Accuracy

It's important to note that only about 50% of patients present with the characteristic symptoms 3. The diagnosis of appendicitis is made in approximately 90% of patients presenting with the classic symptoms 4.

Imaging Findings

When clinical diagnosis is uncertain, imaging is often utilized:

• CT findings suggestive of appendicitis:

  • Appendiceal dilatation (≥7 mm diameter)
  • Presence of appendicoliths
  • Wall thickening
  • Periappendiceal fat stranding 1

• Ultrasound findings:

  • Non-compressible appendix
  • Diameter >6 mm
  • Wall thickening
  • Periappendiceal fluid 1

Diagnostic Pitfalls

• Relying solely on clinical signs and symptoms, especially in elderly patients 1
• Atypical presentations may lead to delayed diagnosis
• Absence of fever or leukocytosis does not rule out appendicitis
• Over-reliance on a single diagnostic test rather than considering the entire clinical picture

Clinical Decision Making

When evaluating a patient with suspected appendicitis:

1. Assess for classic migration of pain from periumbilical to RLQ
2. Check for RLQ tenderness, guarding, and rebound tenderness
3. Note the presence of anorexia, nausea, or vomiting (after pain onset)
4. Evaluate for fever and leukocytosis
5. Consider imaging when the diagnosis remains uncertain

Remember that prompt diagnosis is critical as delayed treatment increases the risk of perforation, abscess formation, and peritonitis, significantly increasing morbidity and mortality.