Appendicitis Presentation

Perhaps the most common surgically correctable cause of abdominal pain, the diagnosis of acute appendicitis remains difficult in many instances. Some of the signs and symptoms can be subtle to both the clinician and the patient and may not be present in all instances. Arriving at the correct diagnosis is essential, however, as a delay in diagnosis may allow progression to perforation and significantly increased morbidity and mortality. Incorrectly diagnosing a patient with appendicitis, although not catastrophic, often subjects the patient to an unnecessary operation.

The classic presentation of acute appendicitis begins with crampy, intermittent abdominal pain, thought to be due to obstruction of the appendiceal lumen. The pain may be either periumbilical or diffuse and difficult to localize. This is typically followed shortly thereafter with nausea; vomiting may or may not be present. If nausea and vomiting precede the pain, patients are likely to have another cause for their abdominal pain, such as gastroenteritis. Classically, the pain migrates to the right lower quadrant as transmural inflammation of the appendix leads to inflammation of the peritoneal lining of the right lower abdomen. This usually occurs within 12–24 hours of the onset of symptoms. The character of the pain also changes from dull and colicky to sharp and constant. Movement or Valsalva maneuver often worsens this pain, so that the patient typically desires to lie still; some patients describe pain with every bump in the car or ambulance ride to the hospital. Patients may report low-grade fever up to 101°F (38.3°C). Higher temperatures and shaking chills should again alert the surgeon to other diagnoses, including appendiceal perforation or nonappendiceal sources. When questioned, patients who have appendicitis commonly report anorexia; appendicitis is unlikely in those with a normal appetite.

The surgeon is constantly reminded that in practice, the classic presentation of acute appendicitis is not present in all patients. Patients may have none or only a few of the symptoms just described. For instance, they may not notice or recall the initial colicky pain. When the pain becomes constant, it may localize to other quadrants of the abdomen due to an alteration in appendiceal anatomy as in late pregnancy or malrotation. In patients with a retrocecal appendix, the pain may never localize until generalized peritonitis from perforated appendicitis occurs. Urinary or bowel frequency may be present due to appendiceal inflammation irritating the adjacent bladder or rectum. Because appendicitis is so common, a high index of suspicion for appendicitis is warranted in all patients with abdominal pain.