What are the signs of appendicitis?

Signs of Appendicitis

The classic presentation of appendicitis includes periumbilical pain that migrates to the right lower quadrant, anorexia, nausea or vomiting, and fever with leukocytosis, though this complete triad occurs in only approximately 50% of patients. 1, 2

Classic Clinical Presentation

The typical symptom sequence follows a predictable pattern:

• Initial vague periumbilical or epigastric pain that is poorly localized 3, 2
• Anorexia (loss of appetite) - a nearly universal early finding 3, 2
• Nausea or intermittent vomiting - notably, vomiting that occurs before pain onset makes appendicitis unlikely 1, 4
• Migration of pain to the right lower quadrant - this is one of the strongest discriminators for appendicitis 1, 4
• Low-grade fever - though fever is present in only 30-80% of cases 1
• Leukocytosis - elevated white blood cell count supports the diagnosis 1

Physical Examination Findings

Most Reliable Signs in Adults

• Right lower quadrant tenderness - the most consistent finding 1, 5
• Abdominal rigidity and guarding - indicates peritoneal irritation 5
• Rebound tenderness - suggests peritoneal inflammation 1
• McBurney's point tenderness - located one-third the distance from the anterior superior iliac spine to the umbilicus 6

Specialized Physical Examination Signs

• Positive psoas sign - pain with hip extension or flexion, suggesting retrocecal appendix location; this sign increases likelihood of appendicitis 1, 5, 4
• Positive obturator sign - pain with internal rotation of the flexed hip, suggesting pelvic appendix 6, 5
• Positive Rovsing sign - palpation of the left lower quadrant elicits pain in the right lower quadrant 6

Important Clinical Caveats

Atypical Presentations

In elderly patients, the classic triad is infrequently observed, and many present with signs of ileus or bowel obstruction rather than typical appendicitis symptoms. 1 These patients often have:

• More signs of peritonitis (distension, generalized tenderness, palpable mass) 1
• Delayed presentation to hospital 1
• Higher perforation rates 1

Diagnostic Pitfalls

• The absence of classic pain migration, right lower quadrant pain, guarding, or fever makes appendicitis less likely 4
• Vomiting occurring before pain onset argues against appendicitis 1, 4
• Laboratory tests alone (elevated WBC and CRP) cannot establish the diagnosis, though normal values have high negative predictive value 1

Risk Stratification Tools

Clinical scoring systems help stratify patients:

• Alvarado Score - incorporates symptoms, signs, and laboratory findings 3, 5
• Pediatric Appendicitis Score - for children 3, 5
• Appendicitis Inflammatory Response Score - combines clinical and laboratory data 5

These tools identify low-risk patients who may not need imaging, high-risk patients who can proceed directly to surgery, and intermediate-risk patients requiring diagnostic imaging 3

When Imaging is Needed

Clinical evaluation alone has limitations - approximately 50% of patients lack the complete classic presentation, which historically led to negative appendectomy rates of 14.7%. 1 Modern practice incorporates imaging when:

• Clinical presentation is atypical or equivocal 1, 7
• Patient is obese (ultrasound accuracy decreases significantly) 7
• Patient is elderly with atypical symptoms 1
• Risk stratification scores indicate intermediate probability 3