# Acute Appendicitis (Emergency Referral) - Category: emergency - Review status: reviewed (every claim checked against a document named on this page) - Sources: Appendicitis - StatPearls, Lotfollahzadeh, Lopez & Deppen, updated 12 February 2024 - https://www.ncbi.nlm.nih.gov/books/NBK493193/ · No dose - referral pathway, no medicine given in primary care - Verified date: 2026-08 ## Verified against - Appendicitis - StatPearls, Lotfollahzadeh, Lopez & Deppen, updated 12 February 2024 - https://www.ncbi.nlm.nih.gov/books/NBK493193/ - No dose - referral pathway, no medicine given in primary care ## Treatment metadata - No drug therapy in primary care (Recognition & Referral) ## Complete treatment card ```text ACUTE APPENDICITIS (EMERGENCY REFERRAL) Sources: Appendicitis - StatPearls, Lotfollahzadeh, Lopez & Deppen, updated 12 February 2024 - https://www.ncbi.nlm.nih.gov/books/NBK493193/ · No dose - referral pathway, no medicine given in primary care Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Pain often starts vaguely around the belly button before settling into the right lower abdomen [abdominal pain · right lower quadrant pain] - Pain may wake the patient from sleep or worsen with walking or coughing [cough] - Appetite loss, possible nausea and vomiting, loose stools, feeling unwell, and urinary urgency often go along with the pain [diarrhoea · malaise · nausea · poor appetite · urinary urgency · vomiting] - About 40% of patients have a fever at presentation [fever] - Symptoms usually build up gradually over 12 to 24 hours from onset SIGNS - what you find (5) - Guarding and rebound tenderness localize to McBurney's point, roughly 1.5 to 2 inches from the hip bone toward the navel [abdominal pain · guarding · rebound tenderness · right lower quadrant pain] - Dunphy's sign, pain that worsens with coughing or straining, can support the diagnosis but is not specific [cough] - Rovsing's sign is right-sided pain triggered by pressing on the left lower abdomen [abdominal pain · left lower quadrant pain · right lower quadrant pain] - A positive psoas sign, right lower pain on hip extension or resisted thigh flexion, reflects irritation of the psoas by the inflamed appendix [peritoneal signs] - Early on, physical findings can be subtle before peritoneal signs develop as inflammation progresses [peritoneal signs] TESTS (8) - White count and CRP together help distinguish uncomplicated from complicated disease; both normal has strong negative predictive value - Most patients have a white count over 10,000 cells/mm3, and 17,000 or higher tracks with complicated disease - CT with IV contrast is the preferred imaging test and is over 95% accurate in adults - CT criteria include an appendix wider than 6 to 9 mm, a wall thicker than 2 to 3 mm, fat stranding, wall enhancement, or an appendicolith - Ultrasound is preferred in children and pregnant patients to avoid radiation, though it is less sensitive than CT - On ultrasound, an appendix wider than 6 mm, an appendicolith, or increased fat echogenicity suggest appendicitis, while under 5 mm argues against it - MRI is reserved mainly for pregnant patients, especially after an inconclusive ultrasound - A modified Alvarado score of 7 or higher is strongly linked to acute appendicitis IF NOT THIS - what else fits (7) - Crohn disease can present acutely and mimic appendicitis, sometimes only distinguished at surgery by inflamed ileum - A recent viral illness points toward mesenteric adenitis rather than appendicitis - Gynecologic mimics span mittelschmerz, salpingitis, an ovarian cyst rupture, ectopic pregnancy, a tubo-ovarian abscess, endometriosis, or pelvic inflammatory disease - Marked cervical motion tenderness on bimanual exam points toward pelvic inflammatory disease instead - Testicular or ovarian torsion, epididymitis, and round ligament syndrome are other mimics depending on sex - Gastroenteritis, colitis affecting the right colon, renal colic, kidney stones, and irritable bowel disease can also mimic the presentation - A complicated cecal diverticulum is another differential to keep in mind Score Modified Alvarado score - How strongly does this point to appendicitis? Source StatPearls "Appendicitis" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY IN PRIMARY CARE (RECOGNITION & REFERRAL)[1st line] Adult Same-day surgical referral. Pain that begins diffuse or around the umbilicus and then localises to the right lower quadrant is the classic course; fever is present in about 40%. Do NOT give antibiotics and review tomorrow, and do NOT let a normal temperature or a soft abdomen early on reassure you - the appendix can perforate while the patient is still walking. Analgesia does not mask the diagnosis and should not be withheld. - Refer, with advice Peds Children present less typically and perforate sooner. A child with abdominal pain, vomiting and any right-sided tenderness goes to hospital the same day, not to a review appointment. Source No dose - referral pathway, no medicine given in primary care Caution SURGICAL EMERGENCY. StatPearls puts rupture at roughly 2% of cases by about 36 hours from when symptoms begin, and has that figure climbing a further 5% or so with each 12 hours that go by without proper medical treatment. The primary treatment remains surgical - StatPearls has surgery as the first option for acute appendicitis still, and antibiotics alone are a hospital decision, not a primary- care one. An Alvarado score of 7 or more is significantly associated with appendicitis, but a LOW score does not exclude it and must not be used to send someone home. Pregnancy, the elderly and the immunosuppressed present atypically and are the ones who perforate. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)