Appendicitis is one of the most common surgical emergencies and one of the most frequently missed early. The pain starts in a place that does not point to the appendix, which is exactly why it gets attributed to indigestion or gastritis.
Understanding how the pain moves is the most useful thing to know.
The Classic Pattern of Pain
Appendicitis has a characteristic sequence, and recognising it is more useful than any single symptom.
- Pain begins around the navel, vague and colicky
- Loss of appetite, which is almost universal and often the first sign
- Nausea, and sometimes vomiting after the pain begins
- Over six to twenty four hours, the pain shifts to the lower right abdomen and becomes sharp and constant
- Pain worsens on movement, coughing or going over a speed bump
- Low grade fever
- Tenderness at a point in the lower right abdomen
The migration of the pain is the key feature. Vomiting before pain begins points away from appendicitis and toward gastroenteritis. Loss of appetite in someone who normally eats well is a genuinely useful early clue.
Why It Presents Differently in Some People
The classic picture appears in only about half of patients, and several groups deviate from it.
Children: often cannot localise pain, may present with vomiting, refusal to walk, or simply lying very still. Rupture occurs faster in young children.
Older adults: may have minimal pain and little fever, and the diagnosis is frequently delayed, resulting in higher rupture rates.
Pregnant women: the appendix is displaced upward by the growing uterus, so pain may be in the upper right abdomen and is easily attributed to pregnancy. Appendicitis is the most common non obstetric surgical emergency in pregnancy.
Retrocaecal appendix: when it sits behind the caecum, pain may be in the flank or back rather than the classic point.
Conditions That Mimic It
Several conditions produce similar pain, which is why examination and sometimes imaging are needed.
- Mesenteric adenitis, common in children after a viral illness
- Ovarian cyst rupture or torsion
- Ectopic pregnancy, which must be excluded in any woman of reproductive age
- Pelvic inflammatory disease
- Urinary tract infection or a ureteric stone
- Crohn disease
- Right sided diverticulitis
A pregnancy test is mandatory in any woman of reproductive age with lower abdominal pain, because a ruptured ectopic pregnancy is immediately life threatening and can present identically.
How It Is Diagnosed
Diagnosis rests on the history and examination, supported by tests.
- Clinical examination: localised tenderness and guarding, which remains the most important element
- Blood tests: raised white cell count and inflammatory markers, though these can be normal early
- Urine test: to exclude infection
- Ultrasound: first choice in children and pregnancy, avoiding radiation, though it cannot always visualise the appendix
- CT scan: most accurate in adults, particularly where the picture is unclear
A normal white cell count does not exclude early appendicitis. Where the diagnosis is uncertain and the patient is stable, a period of observation with repeat examination is a legitimate and often better approach than immediate surgery.
What Not to Do While Waiting
Several common actions make the situation worse or obscure the diagnosis.
- Do not take laxatives or have an enema, which can precipitate rupture
- Do not apply a heating pad to the abdomen, which increases inflammation
- Do not eat or drink once appendicitis is suspected, since surgery may be needed
- Do not take antibiotics obtained without prescription, which can partially treat and mask the picture
- Avoid strong painkillers before assessment where possible, though modern practice accepts analgesia as it does not prevent accurate diagnosis
Taking a laxative for what is assumed to be constipation is a common and dangerous error in early appendicitis.
Surgery and the Alternative
Appendectomy remains the standard treatment and is usually performed laparoscopically through three small incisions.
The operation takes thirty to sixty minutes under general anaesthetic. For uncomplicated appendicitis, most patients go home within one to two days.
Antibiotic treatment alone is an alternative in selected patients with uncomplicated appendicitis and no appendicolith. It avoids surgery initially, but a meaningful proportion of patients have a recurrence within a year and eventually need the operation. It is a reasonable option for patients who cannot undergo surgery, and a genuine choice to discuss where circumstances allow.
If It Ruptures
Rupture typically occurs after around forty eight to seventy two hours of symptoms, though it can be earlier in children.
It changes the illness substantially. Infection spreads through the abdominal cavity, causing peritonitis, and the operation becomes more complex with washout of the abdomen required. Hospital stay extends to five to seven days, intravenous antibiotics are needed for longer, and complications such as abscess formation and wound infection become more likely.
Sometimes a contained abscess forms rather than free rupture. This may be treated initially with antibiotics and drainage, with surgery deferred for several weeks once inflammation has settled.
Our general surgery and critical care teams manage complicated appendicitis.
Recovery
Recovery after uncomplicated laparoscopic appendectomy is straightforward.
- Day 1: walking, eating light food, usually home the next day
- Week 1: light activity, simple painkillers, wound care
- Weeks 2 to 3: return to school or desk work
- Weeks 4 to 6: return to sport and heavy lifting
Contact your surgeon for fever, increasing abdominal pain, wound redness or discharge, persistent vomiting, or failure to pass wind or stool. An abscess can develop a week or two after surgery, particularly following a ruptured appendix.
Removal of the appendix has no long term consequences for digestion or immunity.
Pain that starts around the navel, moves to the lower right abdomen, and comes with loss of appetite should be assessed the same day rather than treated as gastritis. Do not take a laxative, and do not wait overnight to see if it settles.
Our emergency department at T. Nagar assesses acute abdominal pain around the clock.
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