Appendicitis symptoms and signs

Typically, the appendicitis illness begins with vague midabdominal discomfort followed by nausea, anorexia, and indigestion. The pain is persistent and continuous but not severe, with occasional mild cramps. There may be an episode of vomiting, and within several hours the pain shifts to the right lower quadrant, becoming localized and causing discomfort on moving, walking, or coughing. The patient may feel constipated.

Examination at this point shows localized tenderness to one-finger palpation and perhaps slight muscular guarding. Rebound or percussion tenderness (the latter provides the same information more humanely) may be elicited in the same area. Peristalsis is normal or slightly reduced. Rectal and pelvic examinations are likely to be negative. The temperature is only slightly elevated (eg, 37.8 °C) in the absence of perforation.

Contrary to traditional teaching, tenderness on rectal examination is not a sign of acute appendicitis. If present, it more often points to another cause of the symptoms. Another common misconception is that inflammation in a retrocecal appendix produces an atypical syndrome. This too is incorrect; the clinical findings in this situation are the same as for ordinary (antececal) appendicitis.

Rarely, the cecum may lie on the left side of the abdomen, and appendicitis may be mistaken for sigmoid diverticulitis. An inflamed appendix in the right upper quadrant may mimic acute cholecystitis or perforated ulcer. Even when the cecum is normally situated, a long appendix may reach to other parts of the abdomen, and acute appendicitis in these circumstances may be very confusing indeed.

A couple of general points are worth remembering:

(1) People with early (nonperforated) appendicitis often do not appear ill and may even apologize for taking your time. Finding localized tenderness over McBurney’s point is the cornerstone of diagnosis.

(2) A rule that will help considerably with atypical cases is never to place appendicitis lower than second in the differential diagnosis of acute abdominal pain in a previously healthy person.