What are the signs and symptoms of acute appendicitis in a 31‑year‑old female?

Signs and Symptoms of Acute Appendicitis in a 31-Year-Old Female

In a 31-year-old woman with suspected appendicitis, look for the classic triad of periumbilical pain migrating to the right lower quadrant, anorexia with nausea or vomiting, and fever—though this complete triad appears in only about 50% of cases. 1

Classic Clinical Presentation

The hallmark symptom pattern follows a predictable sequence 2, 3:

• Periumbilical or epigastric pain that begins as vague, colicky discomfort 2, 3, 4
• Pain migration to the right lower quadrant within 12-24 hours, reflecting progression from visceral to parietal peritoneal irritation 2, 3, 5
• Anorexia is a key associated feature and part of the classic triad 2, 3
• Nausea and/or intermittent vomiting typically follow the onset of pain 2, 3, 4
• Low-grade fever (though fever is absent in approximately 50% of cases) 1, 2

The diagnosis is made in approximately 90% of patients who present with this classic sequence. 2

Physical Examination Findings

Most Reliable Signs in Adults

Right lower quadrant tenderness, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant are the best clinical signs for confirming appendicitis in adults. 5

Key examination findings include 6, 5:

• Right lower quadrant tenderness (most common finding) 6
• Rebound tenderness indicating peritoneal irritation 6, 5
• Guarding or involuntary muscle rigidity 6
• McBurney point tenderness (one-third the distance from anterior superior iliac spine to umbilicus) 1
• Rovsing sign (right lower quadrant pain with left lower quadrant palpation) 5
• Psoas sign (pain with right hip extension) 7, 5
• Obturator sign (pain with internal rotation of flexed right hip) 5

Signs of Complicated Appendicitis

In cases of perforation or abscess formation 6:

• Abdominal distension 6
• Generalized tenderness extending beyond the right lower quadrant 6
• Palpable abdominal mass (phlegmon or abscess) 6

Laboratory Findings

Laboratory tests alone cannot confirm or exclude appendicitis but support the clinical picture. 6

• Leukocytosis (WBC >10,000/mm³) is common but has limited diagnostic value alone (positive likelihood ratio only 1.59-2.7) 1, 2
• Elevated C-reactive protein (CRP ≥10 mg/L) has a positive likelihood ratio of 4.24 1
• The combination of WBC >10,000/mm³ AND CRP ≥8 mg/L provides the strongest laboratory prediction (positive likelihood ratio 23.32) 1

Normal white blood cell count and CRP do not exclude appendicitis, especially in early disease. 1

Important Clinical Caveats

Gender-Specific Considerations

In reproductive-age women, appendicitis diagnosis is more challenging because gynecologic conditions (ovarian torsion, ruptured ovarian cyst, ectopic pregnancy, pelvic inflammatory disease) can mimic appendicitis. 1, 8

• Gynecologic pathology accounts for approximately 21.6% of alternative diagnoses in women presenting with right lower quadrant pain 6, 1
• Always obtain a quantitative β-hCG test immediately to exclude ectopic pregnancy before further evaluation 1

Atypical Presentations

Clinical assessment alone misdiagnoses appendicitis in 34-68% of cases, emphasizing the need for imaging confirmation. 1

The classic presentation may be absent or incomplete 6, 3:

• Only a minority of patients present with all typical signs and symptoms together 6
• Fever is absent in approximately 50% of appendicitis cases 1
• Some patients present with symptoms mimicking bowel obstruction (distension, generalized tenderness) 6

Diagnostic Algorithm

Do not rely on clinical signs and symptoms alone to diagnose or exclude appendicitis. 6

Risk Stratification

Use validated scoring systems to guide imaging decisions 1, 7:

• Alvarado score (0-10 points) combines symptoms, signs, and laboratory results
  • Score <5: Low probability
  • Score 5-6: Intermediate probability
  • Score 7-10: High probability
• The Alvarado score is useful for excluding appendicitis but lacks sufficient specificity to confirm it 1, 7

Imaging Recommendations

For a 31-year-old woman with suspected appendicitis, the American College of Radiology recommends starting with transvaginal ultrasound (if available) followed by CT abdomen/pelvis with IV contrast if ultrasound is inconclusive. 1

• CT with IV contrast provides 85.7-100% sensitivity and 94.8-100% specificity for appendicitis 6, 1
• CT identifies alternative diagnoses in 23-45% of patients with right lower quadrant pain 6, 1
• Ultrasound first-line in women avoids radiation while allowing assessment of gynecologic emergencies 1

Key Clinical Pitfalls to Avoid

• Never exclude appendicitis based solely on absence of fever or normal inflammatory markers 1
• Do not delay imaging in patients with persistent symptoms, even if initial clinical assessment seems reassuring 1
• Recognize that NSAIDs can mask evolving symptoms and delay diagnosis 1
• In women of childbearing age, always consider and exclude gynecologic emergencies before attributing symptoms to appendicitis 1, 8