What are the symptoms of appendicitis?

The typical symptoms of appendicitis can be different in some groups of people, especially young children, pregnant people and older adults.

The Common symptoms of appendicitis are:

• Tummy (abdominal) pain - that usually starts in the middle of your tummy around the belly button and later moves to the lower right side.

• Feeling sick (nausea).

• Vomiting.

• Loss of appetite.

• Fever.

If you think you may have appendicitis find out what to do here.

In this series of articles centred around appendicitis you can read about symptoms of appendicitis, treatment for appendicitis, and causes of appendicitis - all written by one of our expert GPs.

The rest of this feature will take an in-depth look at the symptoms appendicitis as, at Patient, we know our readers sometimes want to have a deep dive into certain topics.

What are the symptoms of appendicitis?

Tummy (abdominal) pain

Depiction of a person with appendicitis symptoms

By myupchar.com/en, CC BY-SA 4.0, via Wikimedia Commons

Tummy pain is the main symptom of appendicitis. Typically, pain from appendicitis starts in the middle of the tummy (abdomen), around the belly button, and might come and go. Over hours, the pain travels or spreads across your tummy to the lower right-hand side, and usually becomes constant and severe.

This doesn't always happen though - some people with appendicitis just have pain in the right lower side from the beginning.

The reason the pain moves is because of the way the body's nerves are connected. When appendicitis starts, the brain interprets the pain signals from the appendix as coming from the middle of the tummy. Later, the inflammation from the appendix causes the lining of the tummy to become irritated and inflamed, and the brain starts to feel pain from where the appendix is actually located.

People with appendicitis often find that coughing or walking makes the pain worse. Research found that people with appendicitis had pain that got worse when driving over speed bumps on the way to the hospital.

Abdominal tenderness

In appendicitis, the area over the appendix - the lower right side of the tummy - is usually tender when pressed. This is something that healthcare professionals check for when looking for signs of appendicitis. Some people get pain when the tummy is pressed, that gets worse when pressure is released - rebound tenderness.

Nausea, vomiting, and loss of appetite

As well as having pain, people with appendicitis can feel sick (nauseous) and vomit. People with appendicitis often lose their appetite and don't want to eat anything.

Constipation and diarrhoea

People with appendicitis can have constipation or diarrhoea. In the early stages, some people's symptoms can be difficult to tell apart from simply feeling uncomfortable due to constipation. In people with diarrhoea, the symptoms can be mistaken for gastroenteritis.

Fever

A fever can occur in some people with appendicitis.

Urine symptoms

Some people have to pee (pass urine) a lot, or suddenly feel the need to use the toilet. This can occur if inflammation from the appendix spreads to cause irritation in the bladder or ureters - the tubes connecting the kidneys to the bladder.

Symptoms in young children

Appendicitis is rare in infants less than 1 year old and young children. However, when it does happen, the symptoms tend not to follow the typical pattern. Very young children can't express what they are feeling, but those who can might describe general stomach pain.

The symptoms can be quite vague and include feeling and looking unwell, not eating, and having vomiting and/or diarrhoea. In severe cases, children tend to lie still with their knees bent - straightening and movement make the pain worse.

If they have vomiting and diarrhoea, it's easy to mistake the symptoms for gastroenteritis, which is more common in children. Appendicitis is often particularly difficult for doctors to diagnose in young children, because it's rare and because the symptoms are often difficult to tell apart from other problems, especially early on in the illness.

See gastroenteritis in children for more details on symptoms that indicate when children with diarrhoea and vomiting should be taken to see a doctor.

Symptoms in pregnancy

Appendicitis is rare in pregnancy - occurring in around one in 1000 pregnancies - but it is the most common non-pregnancy-related reason for emergency surgery in pregnancy.

Appendicitis in pregnancy causes similar symptoms to those in people who aren't pregnant, such as right-sided abdominal pain that gradually gets worse over hours or days, and nausea and vomiting. However, symptoms such as mild abdominal pain and nausea and vomiting are very common in pregnancy, and sometimes symptoms of appendicitis can be mistakenly put down to normal pregnancy-related issues, particularly in the early stages.

In the later stages of pregnancy, the womb and baby have grown a lot, and can push the appendix further up in the tummy. Appendicitis pain can therefore be felt in the middle or upper part of the tummy, rather than in the lower right side.

Symptoms in older people

Appendicitis is relatively rare in older people. When it does occur, it can be difficult to diagnose, because the symptoms can be caused by many different conditions, not just appendicitis. Pain, worse in the lower right side of the tummy, does occur, but sometimes it can be quite mild, or not located in one specific part of the tummy. Nausea and vomiting might occur. Sometimes, the symptoms are vague - such as suddenly becoming confused, or becoming very unwell with signs of sepsis. As a result, it can be difficult to diagnose appendicitis early in older people, and diagnoses are often made quite late into the course of the illness.

What does appendicitis feel like?

Appendicitis symptoms can feel different from person to person. Appendicitis typically starts with a mild or vague pain, that might come and go, in the middle of the tummy near the belly button. Over hours, or sometimes days, this spreads across your tummy to the lower right side. The pain usually becomes continuous, and worse and worse. Some people say that the pain in the middle feels dull, and then becomes sharp when it moves to the lower right-hand side. In some people, the pain starts in the lower right side of the tummy, without starting in the middle.

Appendicitis occurs suddenly. People usually develop symptoms and then feel progressively worse over the course of hours or days. Pain that has lasted for longer - weeks or months - is unlikely to be appendicitis.

As appendicitis develops, the pain typically gets worse. The pain is often unlike anything that has been felt before. It might wake someone up from sleep - which is unusual with less serious causes of stomach pains. Coughing or walking may make the pain worse. If the appendix has burst, people often want to lie very still, as any movement can worsen their abdominal pain.

It's common for people with appendicitis to lose their appetite for food, and have nausea or vomiting.

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Gastritis

Gastritis is very common. It occurs when the lining of your stomach becomes swollen (inflamed). Gastritis is usually mild and resolves without any treatment. However, gastritis can cause pain in the upper part of your tummy (abdomen) and may lead to a stomach ulcer. Some simple changes to your lifestyle and using over-the-counter antacid medicines are often all that is required. Other medicines to reduce the acid in your stomach are sometimes needed. Gastritis usually resolves without any problems. However, if not treated properly, gastritis can last for a long time or may lead to a stomach ulcer or cause anaemia.

by Dr Colin Tidy, MRCGP

What side is appendicitis?

Appendicitis causes pain in the lower right side of the tummy, because this is the side where the appendix is. Often, the pain starts in the middle of the tummy but then moves to the lower right side later.

There are some extremely rare cases where appendicitis can cause pain elsewhere. For example, around one in 10,000 people have situs inversus, where their internal organs are found on the opposite side to most people. So their appendix is found on the left-hand side, and would cause left-sided pain.

Can appendicitis pain come and go?

In the early stages of appendicitis, some people find that the vague pain in the middle of the tummy can come and go, and feel more like a normal stomach ache. However, over time, the pain tends to become more severe, continuous, and move to the lower right side of the tummy.

How quickly does appendicitis progress?

The speed at which appendicitis progresses differs from person to person. Typically, though, the early symptoms last a few hours, and then get worse - such as developing continuous, severe pain in the lower right side. People usually have signs of early appendicitis by around 12 to 24 hours after the first symptoms have started. Studies suggest that around three out of four people with appendicitis see a doctor within 24 hours of symptoms starting.

The risk of the appendix bursting (rupturing) increases from two days (48 hours) after symptoms have started, although it can happen earlier than that, in rare cases.

Generally, appendicitis progresses over hours to days. It's therefore important that, if appendicitis is suspected, it's detected and treated as soon as possible.

When to see a doctor for appendicitis symptoms

How to diagnose appendicitis

Sometimes, appendicitis produces typical symptoms and signs on a physical exam. If this is the case, a surgeon might feel confident to make the diagnosis of appendicitis without needing tests, and may recommend going straight for an operation.

Some tests are usually requested anyway - mostly, to look for other problems. Other tests can be useful if the diagnosis is not clear, or to help rule out appendicitis as a possibility.

These include:

• Blood tests - usually shows signs of infection and inflammation in people with appendicitis. The white blood cells, which fight off infection, are usually raised and other blood tests that show inflammation, like C-reactive protein, tend to be raised too.

• A pregnancy test - for anyone who has any possibility of being pregnant. This is important to rule out an ectopic pregnancy, which can also cause pain in the lower right of the tummy - or the left side.

• Other urine tests - to look for signs of a urine infection, which can sometimes cause abdominal pain.

• Sometimes, if the diagnosis isn't clear, a period of observation and re-assessment can be helpful.

• Imaging tests (scans) can be useful to look for appendicitis in people where the diagnosis isn't certain:

• An ultrasound scan - can show signs of appendicitis. However, it can be difficult to see the appendix in some cases. It's also difficult to see the appendix on ultrasound if people have a thick layer of fat in their tummy. This is often done as a first test in young people, especially children, because it doesn't require any exposure to radiation.

• A CT scan - best at spotting signs of appendicitis, and can also pick up some other causes of abdominal pain. However, CT scans involve exposure to radiation from X-rays, which has a small increased risk of causing cancer later in life. CT scans are very useful in older people, and may be done in younger people particularly if ultrasound is not suitable. They are avoided in pregnancy unless absolutely necessary, and likewise rarely done in children unless definitely needed.

• An MRI scan - sometimes used in pregnant women with suspected appendicitis, usually if an ultrasound scan hasn't helped. It's not as good as a CT scan for picking up appendicitis, but avoids exposing the unborn baby to radiation, which is potentially harmful.