- Home
- General Surgery
- Appendicitis
Appendicitis
Classic in the textbook, atypical in real life — always do a pregnancy test. Take the story (central pain moving to the RIF, anorexia, nausea), examine carefully, use a score to guide imaging, and don't miss the gynaecological mimics or the perforated appendix in the very young and the very old. Built for revision, not live patient decisions.
Settle them, and check the basics
resuscitate · analgesiaRed flags — what each should make you think
Give proper analgesia; it doesn't mask appendicitis, and a comfortable patient is easier to examine. And in any woman of childbearing age with RIF pain, do a pregnancy test before anything else: a ruptured ectopic can look exactly like this.
First actions
- 🧪Pregnancy test
- 💊Analgesia + antiemetic
- IVIV access, bloods
- NBMNil by mouth
- 🔢Score it
- ☎Surgical review
Understand the patient
story · signs · scoreThe story and signs
- Central/periumbilical pain migrating to the RIF, anorexia, nausea/vomiting, low-grade fever
- Tenderness at McBurney's point, guarding, rebound/percussion tenderness
- Rovsing's sign (RIF pain on LIF pressure), psoas sign (retrocaecal), obturator sign (pelvic)
- Atypical: pelvic appendix (urinary symptoms, diarrhoea), retrocaecal (flank pain), pregnancy (pain higher up), elderly and very young (vague, perforate early)
Imaging choice
- Children and young women — ultrasound first
- Adults — CT abdomen/pelvis when diagnosis uncertain (especially over 40: caecal cancer, diverticulitis)
- Pregnancy — ultrasound, then MRI
- High-probability young men — may go straight to laparoscopy on clinical grounds (surgeon's decision)
Treatment
- Laparoscopic appendicectomy is the standard
- IV antibiotics per local policy once diagnosed (and before theatre)
- Non-operative management with antibiotics is an option for selected uncomplicated appendicitis (CT-confirmed, no appendicolith) — shared decision, higher recurrence
- Appendix mass/abscess — antibiotics ± radiological drainage, interval review
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Generalised peritonism, high fever, tachycardia, sepsis; more common in children under 5 and the elderly.
Clinical ± CT.
Sepsis bundle, IV antibiotics, urgent surgery.
Woman of childbearing age, pain ± PV bleeding, shoulder tip pain, collapse.
Pregnancy test, TVUSS.
See the ectopic pregnancy page.
Sudden severe unilateral pelvic pain, vomiting, adnexal mass.
USS with Doppler.
See the ovarian torsion page.
Lower abdominal pain and vomiting in a teenage boy.
Testicular exam.
See the testicular torsion page.
Investigate — what to order, when, and what it tells you
test with a question in mindUrine
Bloods
Imaging
How the plan comes together
disposition · handoverhome
Low-probability score, well, tolerating oral, pain controlled: safety-net strongly (worsening pain, fever, vomiting → return) or arrange review within 24 h.
admit / theatre
Intermediate/high probability, peritonism, raised markers, or confirmed on imaging.
Hand over: score, pregnancy test, imaging, antibiotics given, consent.
Pregnancy test, proper analgesia, a score to guide imaging, and a careful exam that includes the hernial orifices and testes. The very young and very old perforate early. Nicely done getting here.
Clerking template
copy or downloadAppendicitis — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for appendicitis?
- Generalised peritonism, rigid abdomen — think perforated appendicitis
- Septic, high lactate — think perforation / abscess
- Positive pregnancy test — think ectopic pregnancy
- Sudden unilateral pelvic pain + vomiting — think ovarian torsion
- Elderly with RIF mass, weight loss — think caecal cancer
- Young child, vomiting, irritable — think perforates early — senior review
What is the initial management of appendicitis?
- Pregnancy test — every woman of childbearing age
- Analgesia + antiemetic — IV paracetamol, opioids as needed
- IV access, bloods — FBC, CRP, U&E, G&S
- Nil by mouth — if surgery likely
- Score it — e.g. Adult Appendicitis Score or AIR score; Alvarado/PAS in children
- Surgical review — —
Always alongside senior support and your local guideline.
What diagnoses must you not miss in appendicitis?
- Perforated appendicitis — peritonitis · sepsis
- Ectopic pregnancy — positive hCG
- Ovarian torsion — sudden · vomiting
- Testicular torsion (boys) — examine the testes
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for appendicitis?
- Urine — Always in women of childbearing age.
- Bloods — FBC, CRP, U&E, G&S.
- Imaging — Children, young women, pregnancy.
Admit or discharge: how is the plan decided for appendicitis?
- Home — Low-probability score, well, tolerating oral, pain controlled: safety-net strongly (worsening pain, fever, vomiting → return) or arrange review within 24 h.
- Admit / theatre — Intermediate/high probability, peritonism, raised markers, or confirmed on imaging.
Is there a clerking template for appendicitis?
Yes — there is a free clerking template for appendicitis on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
Keep going
one more?More from General Surgery