Acute appendicitis is one of the most common conditions leading to emergency abdominal surgery. As an emergency physician, I’ve seen countless patients with appendicitis and the symptoms can vary greatly — sometimes it seems as though no two cases are exactly alike.
This condition is typically caused by obstruction of the appendix, a small tubular structure that extends from the first part of your large intestine (cecum) into the right lower part of your abdomen. Appendicitis can occur at any age. Although rare in infants, the condition increases in frequency throughout childhood and most commonly affects teens and young adults.
The classic symptoms of appendicitis include loss of appetite (anorexia), abdominal pain starting around the belly button (umbilicus) and migrating to the right lower quadrant followed by vomiting and fever. However, variations from this “classic” presentation are quite common. For example, sometimes the appendix is positioned differently and can cause upper abdominal pain or back pain instead. In my experience, the level of pain and the associated symptoms can vary significantly based on patient age, the position of the appendix, and the timing of when they come to the emergency department. History is only one piece of the puzzle when I’m trying to make this diagnosis.
When I examine a patient, a careful evaluation of the location and character of abdominal pain is critical to helping me assess the likelihood of appendicitis and make a decision about performing imaging. There are many alternative diagnoses I am weighing when I see a patient with abdominal pain, including bowel infections (colitis or diverticulitis) or obstruction, problems with the ovaries (such as cysts, or torsion, twisting of the ovary) in women, testicular problems in men (torsion or epididymitis), kidney stones and bladder infections, among many others. Certain conditions including mesenteric adenitis (inflamed abdominal lymph nodes) and epiploic appendagitis (twisting or inflammation of fatty tissue around the appendix or colon) can cause pain that mimics appendicitis. In patients presenting with right lower abdominal pain, the list of possible diagnoses — what clinicians refer to as the differential — is a long one!
When performing the physical exam, I look for a few key signs in addition to right lower quadrant pain. Classically, in appendicitis, right lower quadrant tenderness is present, specifically at McBurney’s point, which is located two thirds of the way from the belly button to the right hip.
Rovsing’s sign, right-sided pain that occurs when I press or tap on the left lower quadrant, indicates irritation of the lining of the abdomen (peritoneum). Rebound tenderness (pain when I release pressure on the abdomen) or guarding (tensing up of muscles due to the pain) can also suggest the presence of this irritation (peritonitis).
The psoas sign is evaluated by placing the patient on their left side and extending the right leg at the hip. A positive psoas sign can suggest a retrocecal location of the appendix, meaning that it faces towards the back. To test for the obturator sign, the patient’s flexed right thigh should be internally rotated. Pain can be present when the appendix is located lower down towards the pelvic region. When positive, both of these tests indicate the likely presence of appendicitis.
In adolescent or adult females, a pelvic examination should be considered if the patient is sexually active. In males, performing a testicular examination to assess for torsion may be appropriate. After all, it’s important not to zero in too early on appendicitis as your diagnosis. There are so many things that can cause abdominal pain, some of them dangerous and others quite benign. I always maintain a large list of possible diagnoses when I’m working up a patient with acute abdominal pain.
Sometimes the diagnosis of appendicitis can be made based on history and physical examination alone. However, most patients require testing to establish a diagnosis. A complete blood count (CBC) with differential, basic metabolic panel and pregnancy test in females of child-bearing status should be ordered. The white blood cell (WBC) count is elevated in approximately 75% of cases but this finding doesn’t necessarily help you rule in or rule out appendicitis. Some use inflammatory markers, such as C-reactive protein (CRP) and procalcitonin, to help evaluate patients, although, like the WBC, these markers cannot confirm appendicitis on their own. Since the appendix is close to the ureters, inflammatory cells can appear in a urinalysis test, even when a urinary tract infection isn’t present.
Most of the time, when appendicitis is high on your differential, imaging is needed to make the diagnosis. In pediatric patients, ultrasound can be used to diagnose appendicitis in some patients and the lack of radiation makes ultrasound the first choice for imaging in children. However, ultrasound is significantly less sensitive for appendicitis in adults and thus the standard mode of evaluation is a CT (computerized tomography) scan of the abdomen and pelvis. MRI (magnetic resonance imaging) can also be used but is typically reserved for pediatric patients and pregnant patients to avoid radiation. These practices may vary depending on the availability of different types of imaging where you practice.
Once the diagnosis is confirmed, you should consult with a general surgeon to evaluate the patient. The typical standard treatment in the US is emergent removal of the appendix via laparoscopic surgery. Depending on where you practice, patients may also be managed with antibiotics alone. Don’t forget, you should also address the patient’s pain, nausea or other symptoms; give them fluids if they appear dehydrated (as they won’t be able to eat or drink for a while); and give them antibiotics to help prevent infection.
Are you ready to diagnose and treat a case of suspected appendicitis? Practice and perfect your case management using Full Code Medical virtual simulation. Try a case now on Full Code to determine whether or not the patient has appendicitis.
Kwan KYI, Nager AL. “Diagnosing pediatric appendicitis: usefulness of laboratory markers.” The American Journal of Emergency Medicine.
Jones MW, Lopez RA, Deppend JG. “Appendicitis.” StatPearls. National Library of Medicine.
Rentea RM, St Peter SD. “Pediatric Appendicitis.” Surgical Clinics of North America.