What are the symptoms of appendicitis?

Symptoms of Appendicitis

The classic presentation of appendicitis includes periumbilical pain that migrates to the right lower quadrant, accompanied by anorexia, nausea, vomiting, fever, and leukocytosis, though these symptoms are present in only about 50% of patients. 1

Key Clinical Symptoms and Signs

• Periumbilical abdominal pain that migrates to the right lower quadrant (RLQ) is the most characteristic symptom of appendicitis 1
• Anorexia (loss of appetite) commonly precedes other symptoms 1
• Nausea and vomiting typically follow the onset of pain 1, 2
• Low-grade fever is present in 30-80% of cases 1
• Right lower quadrant tenderness is one of the most reliable physical examination findings 2
• Abdominal rigidity or guarding when the abdomen is examined 1

Specific Physical Examination Findings

• Positive psoas sign (pain with extension of the right hip) suggests irritation of the psoas muscle by an inflamed appendix 2
• Positive obturator sign (pain with internal rotation of the flexed right hip) indicates irritation of the obturator muscle 2
• Positive Rovsing sign (pain in the right lower quadrant when pressing on the left lower quadrant) 2
• Rebound tenderness in the right lower quadrant 1
• Diminished or absent bowel sounds may be present 2

Atypical Presentations

• Elderly patients often present atypically with fewer classic symptoms 1
• The typical triad of migrating RLQ pain, fever, and leukocytosis is infrequently observed in elderly patients 1
• Many elderly patients present with signs and symptoms consistent with ileus or bowel obstruction 1
• Children under 5 years of age frequently present with atypical symptoms, leading to delayed diagnosis and higher rates of perforation 1

Laboratory Findings

• Leukocytosis (elevated white blood cell count) is common but not universal 1
• Elevated C-reactive protein (CRP) levels may be present, with higher values potentially indicating perforation 1
• Laboratory tests alone are insufficient for diagnosis but can support clinical suspicion 1
• Normal white blood cell count and CRP values together have a high negative predictive value for appendicitis 1

Warning Signs of Complications

• Diffuse abdominal pain and distension may indicate perforation 1
• Generalized tenderness and guarding suggest peritonitis from a perforated appendix 1
• Palpable abdominal mass may indicate an appendiceal abscess 1
• Prolonged duration of symptoms increases the risk of perforation, which occurs in 17-32% of patients 2

Common Pitfalls in Diagnosis

• Relying solely on clinical signs and symptoms for diagnosis in elderly patients is not recommended due to their atypical presentation 1
• Scoring systems like the Alvarado Score can help exclude appendicitis in patients with low scores but should not be the sole basis for diagnosis 1, 2
• Laboratory tests alone cannot establish the diagnosis of acute appendicitis 1
• Imaging studies (ultrasound, CT, or MRI) are often necessary to confirm the diagnosis, especially in cases with atypical presentation 1

Early recognition of appendicitis symptoms is crucial to prevent complications such as perforation, which can lead to increased morbidity and mortality 2.