History and exam

Key diagnostic factors

common

abdominal pain

Abdominal pain is the most common presenting symptom. Pain typically starts at the mid-abdominal region and 1-12 hours later shifts to the right lower quadrant as the inflammation progresses.[36]​ Pain tends to be constant in nature, with intermittent abdominal cramps, and is usually worse on movement and coughing.

anorexia

An important symptom that is almost always present in patients with acute appendicitis.[12] If the patient is hungry and wants to eat, this is reassuring and makes appendicitis less likely.[37]

nausea and vomiting

Present in 75% of patients with appendicitis.[12]​ Significantly associated with appendicitis in pregnancy.[39]​ Vomiting may also occur in late appendicitis, if there is small bowel obstruction due to an appendiceal abscess.[68]

right lower quadrant tenderness

Common in appendicitis; a classic sign is right lower quadrant abdominal tenderness (McBurney sign).[37]​ There may be localized rebound tenderness, especially if the appendix is anterior. Compressing the left lower quadrant may also elicit pain in the right lower quadrant (Rovsing sign).[35] In retrocecal appendicitis, pain may also be elicited with the patient lying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle (psoas sign) or by internal rotation of the flexed right thigh (obturator sign).[12]​ However, Rovsing and obturator signs are of limited diagnostic value for acute appendicitis.[35]​​[38][43]

In pregnant women, atypical pain such as right upper quadrant or right flank pain may occur after the first trimester due to displacement of the appendix by the gravid uterus.[42]

Localized peritonitis with guarding may be a sign of a perforated appendix and is also strongly associated with appendicitis in pregnant patients.[39]

uncommon

tense rigid abdomen

​A sign of generalized peritonitis that indicates a perforated appendix.[37]

hypotension and tachycardia

Signs of shock or sepsis that indicate a perforated appendix.[2]

palpable mass

Due to a peri-appendiceal abscess caused by a perforation that is contained by the omentum.[7]

Other diagnostic factors

common

age of occurrence

Most commonly occurs between the ages of 10 and 30, with the highest incidence in children and adolescence.[7][13]

fever

Patients may have a low-grade fever.​[2][37]​​​ In patients presenting with a high-grade fever, another diagnosis should be considered.[2]

flushed face and a fetor

May be present in both complicated and uncomplicated appendicitis.[42]

diminished bowel sounds

Bowel sounds may be reduced, particularly on the right side compared with the left. A sign of perforated appendicitis.[37]

tachycardia

Tachycardia may be present, particularly in patients with perforation.[42]

uncommon

loose stool

The patient may pass small volumes of mucus from the rectum if there is a pelvic appendicitis with a collection. The patient may describe this mucus as "diarrhea" (whereas stool volume is increased in true diarrheal illness).[12]

constipation

Sometimes present in appendicitis.[42]

Rovsing sign

Pressing the left side of the abdominal cavity elicits pain in right lower quadrant.[35]​ Of limited diagnostic value for acute appendicitis.[35][38][43]

psoas sign

In retrocecal appendicitis, pain may be elicited in the right lower quadrant with the patient lying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle.[12]

obturator sign

Pain is elicited in the right lower quadrant of abdomen by internal rotation of the flexed right thigh.[35]​ Of limited diagnostic value for acute appendicitis.[35][38][43]

Use of this content is subject to our disclaimer