What are the symptoms of appendicitis?

Symptoms of Appendicitis

Classic appendicitis presents with periumbilical pain that migrates to the right lower quadrant, accompanied by anorexia, nausea or vomiting, and low-grade fever—though this complete presentation occurs in only approximately 50% of patients. 1, 2

Cardinal Symptoms

Pain Pattern

• Periumbilical pain migrating to the right lower quadrant is one of the strongest discriminators for appendicitis in adults and represents the most characteristic symptom pattern 3, 2
• Right lower quadrant pain with localization is the most reliable presenting feature, though the pain may remain diffuse in atypical presentations 1, 4
• The pain typically begins as vague periumbilical discomfort before localizing to McBurney's point (one-third the distance from the anterior superior iliac spine to the umbilicus) 3, 2

Gastrointestinal Symptoms

• Anorexia (loss of appetite) is a classic associated symptom that helps distinguish appendicitis from other causes of abdominal pain 1, 3
• Nausea and intermittent vomiting typically follow the onset of pain, not preceding it 3, 2
• These symptoms occur in the majority of patients but are not universally present 5, 4

Fever and Systemic Signs

• Low-grade fever is present in 30% to 80% of patients, though fever is absent in approximately 50% of cases 1, 3
• The absence of fever does not exclude appendicitis and should not be used as a sole criterion for ruling out the diagnosis 1, 6

Physical Examination Findings

Abdominal Tenderness

• Right lower quadrant tenderness with guarding is the most reliable physical finding for ruling in acute appendicitis in adults 3, 4
• Abdominal rigidity indicates peritoneal irritation and suggests more advanced disease 3, 4
• Rebound tenderness (pain upon release of palpation pressure) indicates peritoneal inflammation 6, 4

Specialized Signs

• Rovsing sign (pain in the right lower quadrant when the left lower quadrant is palpated) suggests peritoneal irritation at the appendix location 3, 4
• Psoas sign (pain with hip extension) indicates a retrocecal appendix irritating the psoas muscle 4
• Obturator sign (pain with internal rotation of the flexed hip) suggests a pelvic appendix 3, 4
• Absent or decreased bowel sounds are reliable findings in children with appendicitis 4

Laboratory Findings

• Leukocytosis (elevated white blood cell count) is common but not diagnostic on its own, occurring in the majority but not all patients 3, 2
• Elevated C-reactive protein (CRP) is frequently present; when two or more inflammatory markers are elevated, appendicitis becomes more likely 3
• Normal inflammatory markers have high negative predictive value (up to 100% in some studies) for excluding appendicitis 3
• A normal WBC count significantly reduces the probability of appendicitis when combined with benign clinical presentation (negative likelihood ratio of 0.25) 6

Age-Related Variations

Pediatric Patients

• Children, particularly those under 5 years of age, more frequently present with atypical symptoms and have higher rates of delayed diagnosis 1
• The classic symptom triad is less reliable in young children, contributing to higher perforation rates in this age group 1

Elderly Patients

• The typical triad of migrating right lower quadrant pain, fever, and leukocytosis is infrequently observed in elderly patients 3
• Signs of peritonitis are more common, including abdominal distension, generalized tenderness and guarding, and palpable abdominal mass 3
• Comorbidities and concurrent medications may mask or complicate the clinical presentation 3
• Elderly patients typically present later with higher perforation rates 3

Women of Childbearing Age

• Female patients have more atypical presentations and broader differential diagnoses including gynecologic conditions 3, 7
• Appendicitis is the most common nonobstetric surgical emergency during pregnancy 4

Critical Clinical Pitfalls

• Approximately 50% of patients present with atypical symptoms, requiring a lower threshold for imaging rather than relying on clinical assessment alone 1
• The complete classic presentation (periumbilical pain migrating to RLQ, anorexia, nausea/vomiting, fever, and leukocytosis) is present in only a minority of patients 3, 2
• Clinical diagnosis alone has historically resulted in negative appendectomy rates of 14.7% to 25%, highlighting the limitations of symptom-based diagnosis 1, 6
• Obesity significantly reduces diagnostic accuracy of physical examination 3
• Delayed presentation increases perforation risk, which occurs in 17% to 32% of patients and leads to increased morbidity 4

When Imaging Is Essential

• Imaging should be obtained rather than proceeding directly to surgery based on clinical symptoms alone, as preoperative imaging reduces negative appendectomy rates from 14.7-25% to 1.7-7.7% 6
• CT abdomen and pelvis with IV contrast demonstrates 85.7-100% sensitivity and 94.8-100% specificity for appendicitis diagnosis 1, 6
• Ultrasound is recommended as first-line imaging in children to avoid radiation exposure, with CT reserved for nondiagnostic or equivocal ultrasound results 6, 3
• Even with classic clinical presentation, imaging identifies alternative diagnoses in 23-45% of patients presenting with right lower quadrant pain 1, 6