What is the likely cause and recommended management for pain that starts around the umbilicus and then localizes to the right lower abdomen?

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Acute Appendicitis: Diagnosis and Management

Most Likely Diagnosis

Pain migrating from the periumbilical region to the right lower abdomen is the classic presentation of acute appendicitis and warrants immediate imaging with CT abdomen and pelvis with IV contrast. 1, 2

Clinical Presentation

  • Periumbilical pain migrating to the right lower quadrant (RLQ) is pathognomonic for acute appendicitis, occurring as visceral pain from luminal obstruction transitions to parietal peritoneal irritation. 1, 2, 3

  • This migration pattern is accompanied by anorexia, nausea, and vomiting in the classic presentation. 2, 3, 4

  • Fever is present in only approximately 50% of appendicitis cases, so its absence does not exclude the diagnosis. 1

  • Right lower quadrant tenderness, guarding, and rebound tenderness develop as inflammation progresses. 3, 4

Immediate Diagnostic Approach

Primary Imaging Recommendation

Order CT abdomen and pelvis with IV contrast (without oral contrast) immediately as the definitive diagnostic test. 1, 2, 5

  • CT achieves 85.7-100% sensitivity and 94.8-100% specificity for acute appendicitis. 1, 2, 5

  • CT without enteral contrast provides equivalent diagnostic accuracy (90-100% sensitivity, 94.8-100% specificity) while avoiding delays from oral contrast administration. 1, 2

  • CT identifies alternative diagnoses in 23-45% of patients presenting with RLQ pain, fundamentally changing management. 1

Alternative Imaging Strategy (Resource-Dependent)

  • In settings where ultrasound-first protocols are preferred, perform graded-compression ultrasound of the RLQ initially. 5

  • If ultrasound is nondiagnostic, equivocal, or limited by body habitus, proceed immediately to CT. 1, 5

  • A staged ultrasound-then-CT algorithm achieves 99% sensitivity and 91% specificity. 1

Critical Diagnostic Pitfalls to Avoid

Do Not Rely on Clinical Assessment Alone

Clinical assessment without imaging misdiagnoses appendicitis in 34-68% of cases, leading to negative appendectomy rates of 14.7-25%. 1, 5

  • Preoperative CT reduces the negative appendectomy rate to 1.7-7.7%. 1, 5

Do Not Exclude Appendicitis Based on Absence of Fever

Fever is absent in approximately 50% of appendicitis cases. 1

Do Not Delay Imaging in Classic Presentations

Even with classic periumbilical-to-RLQ migration, imaging is essential because the classic presentation occurs in only 50% of appendicitis cases. 1

Supportive Laboratory Testing

  • Order complete blood count and C-reactive protein. 2

  • CRP levels are significantly higher in appendicitis versus other etiologies, and normal inflammatory markers have 100% negative predictive value for excluding appendicitis. 2

  • However, laboratory findings have limited diagnostic power (positive likelihood ratio 2.47), emphasizing the primacy of imaging. 1

Key CT Imaging Findings

  • Appendiceal diameter >8.2 mm is highly suggestive of appendicitis. 1

  • Periappendiceal fat stranding is a reliable sign of acute inflammation. 1

  • Appendiceal wall enhancement after IV contrast supports the diagnosis. 1

  • CT also assesses for perforation, abscess formation, and appendicoliths. 1

Management Algorithm Based on CT Results

If CT Confirms Appendicitis

Proceed directly to surgical consultation for appendectomy as standard treatment. 1, 2

  • Laparoscopic appendectomy is preferred over open appendectomy in most cases due to less postoperative pain and shorter hospital stay. 4

If CT Shows Perforated Appendicitis with Abscess

Consider percutaneous drainage followed by interval appendectomy. 1, 2

If CT is Negative but Clinical Suspicion Remains High

Diagnostic laparoscopy is recommended, which has both diagnostic and therapeutic value. 1, 2, 5

Immediate Supportive Care

  • Initiate IV fluid resuscitation for dehydration from vomiting. 2

  • Administer antiemetics (metoclopramide, prochlorperazine, or serotonin antagonists) for nausea and vomiting control. 2

  • Provide pain control with opioids, NSAIDs, or acetaminophen—this does not result in delayed or unnecessary intervention. 3

Special Considerations

Pregnant Patients

  • Use MRI instead of CT, which demonstrates 96% sensitivity and specificity. 1

  • Appendicitis is the most common cause of abdominal pain requiring emergent surgery in pregnant patients. 6, 3

Pediatric Patients

  • Start with ultrasound to avoid radiation exposure, then proceed to CT if ultrasound is nondiagnostic. 1

Reproductive-Age Women

  • Consider transvaginal ultrasound before CT to evaluate for gynecologic pathology. 1

  • CT detects gynecologic pathology in approximately 21.6% of alternative diagnoses. 1

Risk of Perforation

Perforation occurs in 17-32% of patients with acute appendicitis and leads to sepsis. 3

  • Prolonged duration of symptoms before surgical intervention raises the risk of perforation. 3

  • In moderate- to high-risk patients, surgical consultation should be accomplished quickly to reduce morbidity and mortality. 3

References

1
Guideline

Management of Suspected Appendicitis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Diagnostic Approach to Acute Appendicitis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

Acute Appendicitis: Efficient Diagnosis and Management.

American family physician, 2018

4
Research

Acute appendicitis.

Journal of paediatrics and child health, 2017

5
Guideline

Diagnostic Approach for Right Iliac Fossa Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

6
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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