This page is for adult patients. For pediatric patients, see: appendicitis (peds)


  • Most common nonobstetric surgical emergency in pregnancy
  • Most commonly caused by luminal obstruction by a fecalith
  • There are no historical or physical exam findings that can definitively rule out appy

Clinical Features


  • Early on primarily malaise, indigestion, anorexia
    • Later patient develops abdominal pain
      • Initially vague, periumbilical (visceral innervation)
      • Later migrates to McBurney point (parietal innervation)
  • Nausea, with or with out emesis, typically follows onset of pain
  • Fever may or not occur
  • Urinary symptoms common given proximity of appendix to urinary tract (sterile pyuria)
  • Sudden improvement suggests perforation
  • 33% of patients have atypical presentation
    • Retrocecal appendix can cause flank or pelvic pain
    • Gravid uterus sometimes displaces appendix superiorly → RUQ pain

Physical Exam

  • Rovsing sign (palpation of LLQ worsens RLQ pain)
  • Psoas sign (extension of right leg at hip while patient lies on left side elicits abdominal pain)
  • Obturator sign (internal and external rotation of thigh at hip elicits pain
  • Peritonitis suggested by:
    • Right heel strike elicits pain
    • Guarding

Clinical Examination Operating Characteristics

Procedure LR+ LR-
RLQ pain 7.3-8.4 0-0.28
Rigidity 3.76 0.82
Migration 3.18 0.50
Pain before vomiting 2.76 NA
Psoas sign 2.38 0.90
Fever 1.94 0.58
Rebound 1.1-6.3 0-0.86
Guarding 1.65-1.78 0-0.54
No similar pain previously 1.5 0.32
Anorexia 1.27 0.64
Nausea 0.69-1.2 0.70-0.84
Vomiting 0.92 1.12

Differential Diagnosis

RLQ Pain



  • CBC
    • Normal WBC does not rule-out appy
  • Urinalysis
    • Sterile pyuria or hematuria consistent with appy
  • Urine pregnancy
  • CRP
    • Normal CRP AND WBC makes appy very unlikely


  • Early surgical consultation should be obtained before imaging in straightforward cases
  • Not universally necessary; consider in:
    • Women of reproductive age
    • Men with equivocal presentation
  • Perforation may result in false negative study
  • Imaging modalities
      • First choice for pregnant women and children
      • Limitations: operator-dependent, difficult to visualize with obesity, gravid uterus, bowel gas, guarding, lack of patient cooperation
      • Findings: noncompressible appendix >6mm in diameter, wall thickness greater or equal to 3 mm
      • Other supportive findings: aperistalsis, distinct wall layers, target appearance in axial view, appendicolith, periappendiceal fluid, prominent echogenic periappendiceal fat
    • CT
      • First choice for adult males and nonpregnant women with equivocal cases
      • Women derive the greatest benefit from preoperative imaging (lower neg appy rate)
      • Contrast (both PO and IV) is unnecessary but typically ordered
    • MRI
      • When unable to identify appendix in children or pregnant women

Clinical Scoring Systems

Alvarado score

Right Lower Quadrant Tenderness+2
Elevated Temperature (37.3°C or 99.1°F)+1
Rebound Tenderness+1
Migration of Pain to the Right Lower Quadrant+1
Nausea or Vomiting+1
Leukocytosis > 10,000+2
Leukocyte Left Shift+1

Clinical scoring system, where a score (Total=10) is composed on presence/absence of 3 signs, 3 symptoms and 2 lab values to help guide in case management.

  • ≤3 = Appendicitis unlikely
  • ≥7 = Surgical consultation
  • 4-6 = Consider CT

MANTRELS Mnemonic: Migration to the right iliac fossa, Anorexia, Nausea/Vomiting, Tenderness in the right iliac fossa, Rebound pain, Elevated temperature (fever), Leukocytosis, and Shift of leukocytes to the left (factors listed in the same order as presented above).


Supportive Management

  1. NPO status
  2. Fluid resuscitation
  3. Analgesia/antiemetics


Coverage should extend to E. coli, Klebsiella, Proteus, and Bacteroides (an anaerobe)

Adult Simple Appendicitis

Antibiotic prophylaxis should be coordinated with surgical consult


Pediatric Simple Appendicitis


Complicated Appendicitis

Defined as perforation, abscess, or phlegmon


Cautious use should be applied to use of fluoroquinolones in complicated pediatric appendicitis due to the risk of tendon injury


  • Open laparotomy or laparoscopy
    • Patients who present <72 hours after the onset of symptoms usually undergo immediate appendectomy
    • Patients who present >72hrs and have perforated appendix may be treated initially with antibiotics, intravenous fluids, and bowel rest


Admission for surgery



  • Either a simple wound infection or an intraabdominal abscess
    • Typically in patients with perforated appendicitis

Recurrent appendicitis

  • Occurs in approximately 1:50,000 appendectomies [2]
  • Typically caused by inflammation of the remaining appendiceal stump
    • Can also be caused by a retained piece of the appendix not removed during surgery [3]
  • Can present similar to primary appendicitis
  • Treatment similar to that of primary appendicitis and likely requires surgical revision of the appendiceal stump or removal of retained tissue
  • Delay in diagnosis and treatment can result in perforation and sepsis

See Also


  2. Hendahewa R. et al. The dilemma of stump appendicitis - a case report and literature review. Int J Surg Case Rep. 2015; 14: 101-3.
  3. Boardman T. et al. Recurrent appendicitis caused by a retained appendiceal tip: A case report. The Journal of Emergency Medicine. 2019; 57: 232-4.
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