Acute appendicitis in adults: Clinical manifestations and differential diagnosis

Author:
Ronald F Martin, MD
Section Editor:
Martin Weiser, MD
Deputy Editor:
Wenliang Chen, MD, PhD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2018. | This topic last updated: Jul 12, 2017.

INTRODUCTION — Appendicitis, an inflammation of the vestigial vermiform appendix, is

one of the most common causes of the acute abdomen and one of the most frequent
indications for an emergent abdominal surgical procedure worldwide [1,2].

The clinical manifestations and differential diagnosis of appendicitis in adults will be

reviewed here. The diagnostic evaluation and management of appendicitis in adults and
appendicitis in pregnancy and children are discussed separately. (See "Acute appendicitis
in adults: Diagnostic evaluation" and "Management of acute appendicitis in
adults" and "Acute appendicitis in pregnancy" and "Acute appendicitis in children: Clinical
manifestations and diagnosis".)

ANATOMY — The vermiform appendix is located at the base of the cecum, near the
ileocecal valve where the taenia coli converge on the cecum (figure 1) [3,4]. The appendix
is a true diverticulum of the cecum. In contrast to acquired diverticular disease, which
consists of a protuberance of a subset of the enteric wall layers, the appendiceal wall
contains all of the layers of the colonic wall: mucosa, submucosa, muscularis (longitudinal
and circular), and the serosal covering [5].

The appendiceal orifice opens into the cecum. Its blood supply, the appendiceal artery, is
a terminal branch of the ileocolic artery, which traverses the length of the mesoappendix
and terminates at the tip of the organ (figure 2) [4].

The attachment of the appendix to the base of the cecum is constant. However, the tip
may migrate to the retrocecal, subcecal, preileal, postileal, and pelvic positions. These
normal anatomic variations can complicate the diagnosis as the site of pain and findings
on the clinical examination will reflect the anatomic position of the appendix.
The presence of B and T lymphoid cells in the mucosa and submucosa of the lamina
propria make the appendix histologically distinct from the cecum [5]. These cells create a
lymphoid pulp that aids immunologic function by increasing lymphoid products such as IgA
and operating as part of the gut-associated lymphoid tissue system [3]. Lymphoid
hyperplasia can cause obstruction of the appendix and lead to appendicitis. The lymphoid
tissue undergoes atrophy with age [6].

EPIDEMIOLOGY — Appendicitis occurs most frequently in the second and third decades
of life. The incidence is approximately 233/100,000 population and is highest in the 10 to
19 year-old age group [7]. It is also higher among men (male to female ratio of 1.4:1), who
have a lifetime incidence of 8.6 percent compared with 6.7 percent for women [7].

PATHOGENESIS — The natural history of appendicitis is similar to that of other

inflammatory processes involving hollow visceral organs. Initial inflammation of the
appendiceal wall is followed by localized ischemia, perforation, and the development of a
contained abscess or generalized peritonitis.

Appendiceal obstruction has been proposed as the primary cause of appendicitis [3,8-11].
Obstruction is frequently implicated but not always identified. A study of patients with
appendicitis showed that there was elevated intraluminal pressure in only one-third of the
patients with nonperforated appendicitis [12].

Appendiceal obstruction may be caused by fecaliths (hard fecal masses), calculi, lymphoid
hyperplasia, infectious processes, and benign or malignant tumors. However, some
patients with a fecalith have a histologically normal appendix and the majority of patients
with appendicitis do not have a fecalith [13,14].

When obstruction of the appendix is the cause of appendicitis, the obstruction leads to an
increase in luminal and intramural pressure, resulting in thrombosis and occlusion of the
small vessels in the appendiceal wall, and stasis of lymphatic flow. As the appendix
becomes engorged, the visceral afferent nerve fibers entering the spinal cord at T8-T10
are stimulated, leading to vague central or periumbilical abdominal pain [8]. Well-localized
pain occurs later in the course when inflammation involves the adjacent parietal
peritoneum.

The mechanism of luminal obstruction varies depending upon the patient's age. In the
young, lymphoid follicular hyperplasia due to infection is thought to be the main cause. In
older patients, luminal obstruction is more likely to be caused by fibrosis, fecaliths, or
neoplasia (carcinoid, adenocarcinoma, or mucocele). In endemic areas, parasites can
cause obstruction in any age group. (See "Cancer of the appendix and pseudomyxoma
peritonei".)

Once obstructed, the lumen becomes filled with mucus and distends, increasing luminal
and intramural pressure. This results in thrombosis and occlusion of the small vessels, and
stasis of lymphatic flow. As lymphatic and vascular compromise progress, the wall of the
appendix becomes ischemic and then necrotic.

Bacterial overgrowth occurs within the diseased appendix. Aerobic organisms predominate
early in the course, while mixed infection is more common in late appendicitis [15].
Common organisms involved in gangrenous and perforated appendicitis include
Escherichia coli, Peptostreptococcus, Bacteroides fragilis, and Pseudomonas species [16].
Intraluminal bacteria subsequently invade the appendiceal wall and further propagate a
neutrophilic exudate. The influx of neutrophils causes a fibropurulent reaction on the
serosal surface, irritating the surrounding parietal peritoneum [6]. This results in stimulation
of somatic nerves, causing pain at the site of peritoneal irritation [5].

During the first 24 hours after symptoms develop, approximately 90 percent of patients
develop inflammation and perhaps necrosis of the appendix, but not perforation. The type
of luminal obstruction may be a predictor of perforation of an acutely inflamed appendix.
Fecaliths were six times more common than true calculi in the appendix, but calculi were
more often associated with perforated appendicitis or periappendiceal abscess (45
percent) than were fecaliths (19 percent). This is presumably due to the rigidity of true
calculi as compared with the softer, more crushable fecaliths [13].

Once significant inflammation and necrosis occur, the appendix is at risk of perforation,
which leads to localized abscess formation or diffuse peritonitis. The time course to
perforation is variable. One study showed that 20 percent of patients developed
perforation less than 24 hours after the onset of symptoms [17]. Sixty-five percent of
patients in whom the appendix perforated had symptoms for longer than 48 hours.

CLINICAL FEATURES

Clinical manifestations

History — Abdominal pain is the most common symptom, and is reported in nearly all
confirmed cases of appendicitis [18,19]. The clinical presentation of acute appendicitis is
described as a constellation of the following classic symptoms:

●Right lower quadrant (right anterior iliac fossa) abdominal pain

●Anorexia

●Nausea and vomiting

In the classic presentation, the patient describes the onset of abdominal pain as the first
symptom. The pain is typically periumbilical in nature with subsequent migration to the
right lower quadrant as the inflammation progresses [18]. Although considered a classic
symptom, migratory pain occurs only in 50 to 60 percent of patients with appendicitis
[8,20]. Nausea and vomiting, if they occur, usually follow the onset of pain. Fever-related
symptoms generally occur later in the course of illness.

In many patients, initial features are atypical or nonspecific, and can include:

●Indigestion

●Flatulence

●Bowel irregularity

●Diarrhea

●Generalized malaise

Because the early symptoms of appendicitis are often subtle, patients and clinicians may
minimize their importance. The symptoms of appendicitis vary depending upon the
location of the tip of the appendix (figure 1) (see 'Anatomy' above). For example, an
inflamed anterior appendix produces marked, localized pain in the right lower quadrant,
while a retrocecal appendix may cause a dull abdominal ache [21]. The location of the pain
may also be atypical in patients who have the tip of the appendix located in the pelvis,
which can cause tenderness below McBurney's point. Such patients may complain of
urinary frequency and dysuria or rectal symptoms, such as tenesmus and diarrhea.

Physical examination — The early signs of appendicitis are often subtle. Low-grade fever
reaching 101.0°F (38.3°C) may be present. The physical examination may be unrevealing
in the very early stages of appendicitis since the visceral organs are not innervated with
somatic pain fibers.

However, as the inflammation progresses, involvement of the overlying parietal

peritoneum causes localized tenderness in the right lower quadrant and can be detected
on the abdominal examination. Rectal examination, although often advocated, has not
been shown to provide additional diagnostic information in cases of appendicitis [22]. In
women, right adnexal area tenderness may be present on pelvic examination, and
differentiating between tenderness of pelvic origin versus that of appendicitis may be
challenging. High-grade fever (>101.0°F/38.3°C) occurs as inflammation progresses.
(See "Causes of abdominal pain in adults".)

Patients with a retrocecal appendix may not exhibit marked localized tenderness in the
right lower quadrant since the appendix does not come into contact with the anterior
parietal peritoneum (figure 1) [21]. The rectal and/or pelvic examination is more likely to
elicit positive signs than the abdominal examination. Tenderness may be more prominent
on pelvic examination, and may be mistaken for adnexal tenderness.

Several findings on physical examination have been described to facilitate diagnosis, but
these findings pre-dated definitive imaging for appendicitis, and the wide variation in their
sensitivity and specificity suggests that they be used with caution to broaden, or narrow, a
differential diagnosis. There are no physical findings, taken alone or in concert, that
definitively confirm a diagnosis of appendicitis.

Commonly described physical signs include:

●McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches

from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the
umbilicus [23] (sensitivity 50 to 94 percent; specificity 75 to 86 percent [24-26]).

●Rovsing's sign refers to pain in the right lower quadrant with palpation of the left
lower quadrant. This sign is also called indirect tenderness and is indicative of right-
sided local peritoneal irritation [27] (sensitivity 22 to 68 percent; specificity 58 to 96
percent [25,28-30]).

●The psoas sign is associated with a retrocecal appendix. This is manifested by right
lower quadrant pain with passive right hip extension. The inflamed appendix may lie
against the right psoas muscle, causing the patient to shorten the muscle by drawing
up the right knee. Passive extension of the iliopsoas muscle with hip extension
causes right lower quadrant pain (sensitivity 13 to 42 percent; specificity 79 to 97
percent [28,31,32]).

●The obturator sign is associated with a pelvic appendix. This test is based on the
principle that the inflamed appendix may lay against the right obturator internus
muscle. When the clinician flexes the patient's right hip and knee followed by internal
rotation of the right hip, this elicits right lower quadrant pain, (sensitivity 8 percent;
specificity 94 percent [31]). The sensitivity is low enough that experienced clinicians
no longer perform this assessment.

Laboratory findings — A mild leukocytosis (white blood cell count

>10,000 cells/microL) is present in most patients with acute appendicitis [33].
Approximately 80 percent of patients have a leukocytosis and a left shift (increase in total
WBC count, bands [immature neutrophils], and neutrophils) in the differential [34-36]. The
sensitivity and specificity of an elevated white blood cell (WBC) count in acute appendicitis
is 80 percent and 55 percent respectively.

Acute appendicitis is unlikely when the WBC count is normal, except in the very early
course of the illness [36,37]. In comparison, mean WBC counts are higher in patients with
a gangrenous (necrotic) or perforated appendix [38]:

●Acute − 14,500±7300 cells/microL

●Gangrenous − 17,100±3900 cells/microL

●Perforated − 17,900±2100 cells/microL (see 'Perforated appendix' below)

Mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been noted to be a
marker for appendiceal perforation with a sensitivity of 70 percent and a specificity of 86
percent [39]. However, the test is not discriminatory and generally not helpful in the
evaluation of patients suspected of acute appendicitis

Imaging exams — The choice of imaging examination for the diagnosis of acute
appendicitis is discussed in detail separately. (See "Acute appendicitis in adults:
Diagnostic evaluation", section on 'Imaging'.)

Computed tomography findings — The following findings suggest acute appendicitis on

standard abdominal computed tomography (CT) scanning with contrast including (image
1 and image 2) [40-42]:

●Enlarged appendiceal diameter >6 mm with an occluded lumen

●Appendiceal wall thickening (>2 mm)

●Periappendiceal fat stranding

●Appendiceal wall enhancement

●Appendicolith (seen in approximately 25 percent of patients)

Ultrasound findings — The most accurate ultrasound finding for acute appendicitis is an
appendiceal diameter of >6 mm (image 3 and image 4) [8,43,44].

Plain radiograph findings — Plain radiographs are usually not helpful for establishing the
diagnosis of appendicitis (image 5).

Magnetic resonance imaging — Magnetic resonance imaging (MRI) can assist with the
evaluation of acute abdominal and pelvic pain during pregnancy (image 6) [45,46]. A
normal appendix is visualized as a tubular structure less than or equal to 6 mm in diameter
and filled with air and/or oral contrast material [47]. An enlarged fluid-filled appendix (>7
mm in diameter) is considered an abnormal finding, while an appendix with a diameter of 6
to 7 mm is considered an inconclusive finding [47]. (See "Approach to acute abdominal
pain in pregnant and postpartum women" and "Acute appendicitis in pregnancy".)

DIFFERENTIAL DIAGNOSIS — A variety of inflammatory and infectious conditions in the

right lower quadrant can mimic the signs and symptoms of acute appendicitis.
(See "Causes of abdominal pain in adults".)

Perforated appendix — During the first 24 hours after the onset of abdominal pain and
associated symptoms, approximately 90 percent of patients develop inflammation and
perhaps necrosis of the appendix, but not perforation. Once significant inflammation and
necrosis occur, the appendix is at risk for perforation, which leads to localized abscess
formation or diffuse peritonitis. The time course to perforation is variable. One study
showed that 20 percent of patients developed perforation less than 24 hours after the
onset of symptoms [17]. Sixty-five percent of patients in whom the appendix perforated
had symptoms for longer than 48 hours.

A perforated appendix must be considered in a patient whose temperature exceeds

103.0°F (39.4°C), the WBC count is greater than 15,000 cells/microL, and imaging studies
reveal a fluid collection in the right lower quadrant. (See 'Pathogenesis' above
and 'Laboratory findings' above and 'Imaging exams' above and "Acute appendicitis in
adults: Diagnostic evaluation".)

Cecal diverticulitis — Cecal diverticulitis usually occurs in young adults and presents with
signs and symptoms that can be virtually identical to those of acute appendicitis. Right-
sided diverticulitis occurs in only 1.5 percent of patients in Western countries, but is more
common in Asian populations (accounting for as many as 75 percent of cases of
diverticulitis). Patients with right-sided diverticulitis tend to be younger than those with left-
sided disease and often are misdiagnosed with acute appendicitis. Computed tomographic
(CT) scanning of the abdomen with IV and oral contrast is the diagnostic test of choice in
patients suspected of having acute diverticulitis. (See "Clinical manifestations and
diagnosis of acute diverticulitis in adults" and "Acute colonic diverticulitis: Medical
management", section on 'Right-sided (cecal) diverticulitis'.)

Meckel's diverticulitis — Meckel's diverticulitis presents in a fashion similar to acute

appendicitis. A Meckel's diverticulum is a congenital remnant of the omphalomesenteric
duct and is located on the small intestine two feet from the ileocecal valve [48,49].
Meckel's diverticulitis should be included in the differential diagnosis, as the small bowel
may migrate into the right lower quadrant and mimic the symptoms of appendicitis. If an
inflamed appendix is not found on abdominal exploration for acute appendicitis, the
surgeon should search for an inflamed Meckel's diverticulum. (See "Meckel's diverticulum",
section on 'Clinical presentations'.)

Acute ileitis — Acute ileitis, due most commonly to an acute self-limited bacterial infection
(Yersinia, Campylobacter, Salmonella, and others), should be considered when acute
diarrhea is a prominent symptom. Other clinical manifestations of acute yersiniosis include
abdominal pain, fever, nausea and/or vomiting. Yersiniosis cannot be readily distinguished
clinically from other causes of acute diarrhea that present with these symptoms. However,
localization of abdominal pain to the right lower quadrant along with acute diarrhea may be
a diagnostic clue for yersiniosis. (See "Clinical manifestations and diagnosis of Yersinia
infections", section on 'Acute yersiniosis'.)

Acute yersiniosis presenting with right lower abdominal pain, fever, vomiting, leukocytosis,
and understated diarrhea may be confused with acute appendicitis. At surgery, findings
include visible inflammation around the appendix and terminal ileum and inflammation of
the mesenteric lymph nodes; the appendix itself is generally normal. Yersinia can be
cultured from the appendix and involved lymph nodes. (See "Clinical manifestations and
diagnosis of Yersinia infections", section on 'Pseudoappendicitis'.)

Crohn's disease — Crohn's disease can present with symptoms similar to appendicitis,
particularly when localized to the distal ileum. Fatigue, prolonged diarrhea with abdominal
pain, weight loss, and fever, with or without gross bleeding, are the hallmarks of Crohn's
disease. An acute exacerbation of Crohn's disease can mimic acute appendicitis and may
be indistinguishable by clinical evaluation and imaging.

Crohn's disease should be suspected in patients who have persistent pain after surgery,
especially if the appendix is histologically normal. (See "Clinical manifestations, diagnosis
and prognosis of Crohn disease in adults".)

Gynecologic and obstetrical conditions — The following gynecologic diseases may

present with symptoms and/or clinical findings that are included in the differential of acute
appendicitis:

Tubo-ovarian abscess — A tubo-ovarian abscess (TOA) is an inflammatory mass

involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs (eg,
bowel, bladder). These abscesses are found most commonly in reproductive age women
and typically result from upper genital tract infection. Tubo-ovarian abscess is usually a
complication of pelvic inflammatory disease. The classic presentation includes acute lower
abdominal pain, fever, chills, and vaginal discharge. However, fever is not present in all
patients, some patients report only low-grade nocturnal fevers or chills, and not all women
present in an acute fashion. Clinical history and CT imaging can help differentiate TOA
from acute appendicitis (picture 1). (See "Epidemiology, clinical manifestations, and
diagnosis of tubo-ovarian abscess", section on 'Clinical presentation'.)

Pelvic inflammatory disease — Lower abdominal pain is the cardinal presenting

symptom in women with pelvic inflammatory disease (PID), although the character of the
pain may be quite subtle. The recent onset of pain that worsens during coitus or with
jarring movement may be the only presenting symptom of PID; the onset of pain during or
shortly after menses is particularly suggestive. On physical examination, only
approximately one-half of patients with PID have fever. Abdominal examination reveals
diffuse tenderness greatest in the lower quadrants, which may or may not be symmetrical.
Rebound tenderness and decreased bowel sounds are common. On pelvic examination,
the finding of a purulent endocervical discharge and/or acute cervical motion and adnexal
tenderness with bimanual examination is strongly suggestive of PID. Clinical history and
CT imaging can help differentiate PID from acute appendicitis. (See "Pelvic inflammatory
disease: Clinical manifestations and diagnosis".)

Ruptured ovarian cyst — Rupture of an ovarian cyst is a common occurrence in women

of reproductive age and may be associated with the sudden onset of unilateral lower
abdominal pain. The right lower quadrant is most commonly affected, possibly because
the rectosigmoid colon protects the left ovary from the effects of abdominal trauma. The
pain often begins during strenuous physical activity, such as exercise or sexual
intercourse, and may be accompanied by light vaginal bleeding due to a drop in secretion
of ovarian hormones and subsequent endometrial sloughing. Blood from the rupture site
may seep into the ovary, which can cause pain from stretching of the ovarian cortex, or it
may flow into the abdomen, which has an irritant effect on the peritoneum. Serous or
mucinous fluid released upon cyst rupture is not very irritating; the patient may remain
asymptomatic despite accumulation of a large volume of intraperitoneal fluid. On the other
hand, spillage of sebaceous material upon rupture of a dermoid cyst causes a marked
granulomatous reaction and chemical peritonitis, which is usually quite painful.
Intraabdominal hemorrhage may be associated with Cullen's sign (ie, periumbilical
ecchymoses). Clinical history and CT imaging can help differentiate a ruptured ovarian
cyst from acute appendicitis (image 7 and image 8). (See "Evaluation and management of
ruptured ovarian cyst".)

Mittelschmerz — Mittelschmerz refers to midcycle pain in an ovulatory woman caused by

normal follicular enlargement just prior to ovulation or to normal follicular bleeding at
ovulation. The pain is typically mild and unilateral; it occurs midway between menstrual
periods and lasts for a few hours to a couple of days. Fluid or blood is released from the
ruptured egg follicle and can cause irritation of the lining of the abdominal wall.
(See "Physiology of the normal menstrual cycle".)

Ovarian and fallopian tube torsion — Ovarian torsion refers to the twisting of the ovary
on its ligamentous supports, often resulting in impedance of its blood supply (picture 2).
Isolated fallopian tube torsion is uncommon (picture 3). Expedient diagnosis is important to
preserve ovarian function and prevent adverse sequelae. However, the diagnosis can be
challenging because the symptoms are relatively nonspecific.

The most common symptom of ovarian torsion is sudden onset lower abdominal pain,
often associated with waves of nausea and vomiting. Fever, although an uncommon
finding in ovarian torsion, may be a marker of necrosis, particularly in the setting of an
increased white blood cell count. Clinical history and CT imaging can help differentiate the
diagnosis from acute appendicitis (picture 4). (See "Ovarian and fallopian tube torsion".)

Endometriosis — Endometriosis is defined as the presence of endometrial glands and

stroma at extrauterine sites. These ectopic endometrial implants are usually located in the
pelvis, but can occur nearly anywhere in the body (picture 5).

Common symptoms of endometriosis include pelvic pain (which is usually chronic and
often more severe during menses or at ovulation), dysmenorrhea, deep dyspareunia,
cyclical bowel or bladder symptoms, abnormal menstrual bleeding, and infertility. There
are often no abnormal findings on physical examination; when findings are present, the
most common is tenderness upon palpation of the posterior fornix. Ultrasound is mostly
useful for diagnosing ovarian endometriomas; it lacks adequate resolution for visualizing
adhesions and superficial peritoneal/ovarianimplants, which are more common than
endometriomas. (See "Endometriosis: Pathogenesis, clinical features, and diagnosis".)

Ovarian hyperstimulation syndrome — Ovarian hyperstimulation syndrome (OHSS) is

an iatrogenic complication of ovulation induction therapy, and may be accompanied by or
mistaken for cyst rupture. Clinical findings include bloating, nausea, vomiting, diarrhea,
lethargy, shortness of breath, and rapid weight gain.

Severe ovarian hyperstimulation syndrome is characterized by large ovarian cysts, ascites,

and, in some patients, pleural and/or pericardial effusion, electrolyte imbalance
(hyponatremia, hyperkalemia), hypovolemia, and hypovolemic shock. Marked
hemoconcentration, increased blood viscosity, and thromboembolic phenomena, including
disseminated intravascular coagulation, occur in the most severe cases.
(See "Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation
syndrome".)

Ectopic pregnancy — Ectopic pregnancy has clinical symptoms and sonographic

features similar to those of a ruptured ovarian cyst. In women with acute pelvic pain or
abnormal vaginal bleeding, a positive pregnancy test strongly suggests the presence of an
ectopic pregnancy if an intrauterine pregnancy cannot be visualized sonographically. If an
intrauterine pregnancy is visualized, then pelvic pain and intraperitoneal fluid could be due
to a ruptured ovarian cyst (eg, corpus luteum cyst, theca lutein cyst) or heterotopic
pregnancy. (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on
'Heterotopic pregnancy'.)

Acute endometritis — Acute endometritis occurs after an obstetrical delivery or, rarely,
after an invasive uterine procedure. The diagnosis is largely based upon the presence of
fever, gradual onset of uterine tenderness, foul uterine discharge, and leukocytosis in an
at-risk setting. (See "Postpartum endometritis" and "Endometritis unrelated to pregnancy".)

Urologic conditions

Renal colic — Pain is the most common symptom and varies from a mild and barely
noticeable ache to discomfort that is so intense that it requires parenteral analgesics. The
pain typically waxes and wanes in severity, and develops in waves or paroxysms that are
related to movement of the stone in the ureter and associated ureteral spasm. Paroxysms
of severe pain usually last 20 to 60 minutes. Pain is thought to occur primarily from urinary
obstruction with distention of the renal capsule. (See "Diagnosis and acute management of
suspected nephrolithiasis in adults" and "Acute management of nephrolithiasis in
children".)

Testicular torsion — Testicular torsion is a urologic emergency that is more common in

neonates and postpubertal boys, although it can occur at any age. Testicular torsion
results from inadequate fixation of the testis to the tunica vaginalis. If fixation of the lower
pole of the testis to the tunica vaginalis is insufficiently broad-based or absent, the testis
may torse (twist) on the spermatic cord, potentially producing ischemia from reduced
arterial inflow and venous outflow obstruction. (See "Causes of scrotal pain in children and
adolescents", section on 'Testicular torsion' and "Evaluation of acute scrotal pain in
adults", section on 'Testicular torsion'.)

Epididymitis — Epididymitis occurs more frequently among late adolescents, but also
occurs in younger boys who deny sexual activity and is the most common cause of scrotal
pain in adults in the outpatient setting. Several factors may predispose postpubertal boys
to develop subacute epididymitis, including sexual activity, heavy physical exertion, and
direct trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in prepubertal boys
is associated with structural anomalies of the urinary tract. In acute infectious epididymitis,
palpation reveals induration and swelling of the involved epididymis with exquisite
tenderness. More advanced cases often present with testicular swelling and pain
(epididymo-orchitis) with scrotal wall erythema and a reactive hydrocele. (See "Causes of
scrotal pain in children and adolescents", section on 'Epididymitis' and "Evaluation of acute
scrotal pain in adults".)

Torsion of the appendix testis or appendix epididymis — The appendix testis is a

small vestigial structure on the anterosuperior aspect of the testis (an embryologic remnant
of the Müllerian duct system). The appendix epididymis is a vestigial remnant of the
Wolffian duct that is located at the head of the epididymis. The pedunculated shape of
these appendages predisposes them to torsion, which can produce scrotal pain that
ranges from mild to severe. Most cases of torsion of the appendix testis occur between the
ages of 7 and 14 years, and rarely occur in adults. (See "Causes of scrotal pain in children
and adolescents", section on 'Torsion of the appendix testis or appendix
epididymis' and "Evaluation of acute scrotal pain in adults", section on 'Torsion of the
appendix testis'.)

TREATMENT — The management of acute appendicitis in children and adults is

discussed in detail separately. (See "Acute appendicitis in children:
Management" and "Management of acute appendicitis in adults".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines

from selected countries and regions around the world are provided separately.
(See "Society guideline links: Appendicitis in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Appendicitis in adults (The Basics)").

SUMMARY AND RECOMMENDATIONS — Appendicitis is one of the most common

causes of the acute abdomen and one of the most frequent indications for an emergent
abdominal surgical procedure worldwide.

●The tip of the appendix can be found in a retrocecal or pelvic location, as well as
medial, lateral, anterior, or posterior to the cecum. Anatomic variability can complicate
the diagnosis, as clinical presentation will reflect the anatomic position of the
appendix. (See 'Anatomy' above.)

●Appendiceal obstruction plays a role in the pathogenesis of appendicitis, but it is not

required for the development of appendicitis. (See 'Pathogenesis' above.)

●The classic symptoms of appendicitis include right lower quadrant abdominal pain,
anorexia, fever, nausea, and vomiting. The abdominal pain is initially periumbilical in
nature with subsequent migration to the right lower quadrant as the inflammation
progresses (see 'Clinical manifestations' above). Patients with appendicitis can also
present with atypical or nonspecific symptoms, such as indigestion, flatulence, bowel
irregularity, and generalized malaise; and not all patients will have migratory
abdominal pain.

●The differential diagnosis of right lower quadrant abdominal pain includes

inflammatory disease processes (eg, Crohn's disease, ruptured cyst), infectious
diseases (eg, acute ileitis, tubo-ovarian abscess), and obstetrical conditions (eg,
ectopic pregnancy). (See 'Differential diagnosis' above.)

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REFERENCES