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5 Appendicitis Signs you Don’t Want to Miss!

Emergency (ER) Gastro (GI) Nursing Assessment
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Knowing Appendicitis signs is super important for nurses and medical professionals.

Appendicitis is the number one cause for abdominal pain needing emergent surgery. Missing appendicitis can lead to worsened outcomes including sepsis, perforation, longer hospital stays, and an increased chance of death.

The Appendix and Appendicitis Signs

The appendix is a small appendage at the beginning of the large intestine which stems off of the cecum.

The actual function of the appendix is unknown, although there are some theories that it assists with maintaining healthy gut bacteria as well as with the immune system.

The appendix can become blocked and inflamed which leads to appendicitis, which is inflammation of the appendix.This is usually blocked by a small piece of feces that occludes the appendix, termed a fecalith.Fecolith appendicitis

The appendix can also be blocked by stones, lymphoid tissue, infections, and even cancer.

This blocked appendix eventually develops bacterial overgrowth, ischemia, and possibly can even perforate the bowel. It can cause sepsis and severe infection.

Many cases of appendicitis happen between the ages of 10-30. While common in children, it also occurs in young adults and sometimes even older individuals.

Abdominal pain is very common, and sometimes it can be difficult to tell what is causing it because there are so many potential causes of abdominal pain.

Pain in the abdominal doesn’t always present where you would expect as well. There are specific physical exam appendicitis signs which can be used to raise the suspicion of appendicitis.


A patient who presents with appendicitis will often complain of the following appendicitis symptoms:

  • General malaise, indigestion, or change in bowel habits
  • Vague abdominal pain, usually near the umbilicus, which eventually migrates toward right lower quadrant (RLQ)
  • Nausea and/or vomiting
  • Fever

There are other symptoms as well, but these are the most common. As you can see – these are not super specific aside from the location of the pain which can be a late sign.

Up to 33% of patients can have retrocecal or pelvic appendix which can cause right flank pain or pelvic pain instead of the typical RLQ pain. This is why it is so important to know not only appendicitis symptoms but also appendicitis signs.

The physical exam is super important when evaluating abdominal pain. There are multiple physical exam maneuvers that you can do as the nurse or APP to detect appendicitis signs and further guide the need for imaging.

Related Article: 5 Advanced Physical Exam Maneuvers

Appendicitis signs - FB

1. Mcburney’s Sign

The first appendicitis sign to know is Mcburney’s sign. This is the bread and butter of recognizing appendicitis.

Mcburney’s sign, also known as Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Ok… so where exactly is that?Appendicitis signs - Mcburneys sign

Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closer to the iliac spine is Mcburney’s point.

If you press generally in the RLQ and they are tender, appendicitis should be high up in your differential.

If a patient has abdominal pain with this being their most tender area, they should undergo further testing to rule out acute appendicitis.

Mcburney’s sign is 50-94% sensitive, and 75-86% specific for appendicitis. This means if the pain is specific to this location, it very well could be appendicits.

Other causes of RLQ tenderness include kidney stones, ovarian cysts or torsion, ectopic pregnancy, testicular torsion, abdominal wall strain, or some other type of abdominal condition.

2. Guarding and Rebound Tenderness

Appendicitis signs - GuardingGuarding is when a patient involuntarily tenses their abdominal muscles when you palpate.

Rebound tenderness is when the pain temporarily worsens when you suddenly release pressure.

While these aren’t specific appendicitis signs, they indicate potential peritonitis which is inflammation of the inside of the abdominal wall cavity.

Causes of peritonitis include ruptured appendicitis, perforated bowel in another area like with perforated diverticulitis, or direct infection through trauma or with peritoneal dialysis.Appendicitis signs - Rebound

Any guarding or rebound with abdominal pain should raise suspicion for serious pathology, and CT imaging should be highly considered.

Bottom line – if the patient is tender in the RLQ and they are guarding and have rebound tenderness – this is highly suspicious for acute ruptured appendicitis.

Related Article: 6 Steps for Sepsis Management

Appendicitis signs - Rovsings

3. Rovsing’s Sign

Rovsing’s sign is when you palpate the left lower quadrant and the patient is tender in the right lower quadrant (RLQ) area.

This indicates local peritoneal irritation. This is also called indirect tenderness.

This appendicitis sign is only 22-68% sensitive, and 58-96% specific. This means it’s not always going to be present with appendicitis, but if it is there – you should be ruling appendicitis out.

4. Psoas Sign

Psoas sign is when the patient lies supine and attempts to flex their hip against resistance. Place your hand on their thigh and ask them to lift their leg. If they have pain in the RLQ – this is a positive Psoas sign.

Alternatively, you can lie them on their left side and passively extend their right hip behind them. If this causes pain in the RLQ – this is also a positive Psoas sign.

This appendicitis sign checks for irritation of the iliopsoas muscle. This because the iliopsoas muscle lies in close proximity to the appendix.

The Psoas sign tends to correlate more with retrocecal appendicitis. This is when the appendage is in the direction of the colon behind the cecum, which can present in up to 33% of cases.

5. Obturator Sign

The Obturator Sign is when the patient is lying supine, and you passively flex their hip and knee, and then internally rotate. If this causes pain in the RLQ – this is a positive obturator sign.

Sometimes the appendix lies in close proximity to the right obturator internus muscle. This specific sign is associated with a pelvic appendix when the appendix tip migrates in the direction of the pelvis.

Appendicitis Management

After using these appendicitis signs into your physical exam, you should have a pretty good idea of how suspicious you are of appendicitis.

The next steps usually involve abdominal imaging.

In children and sometimes pregnant women, this can be a RLQ ultrasound. However, in most adults, this involves a CT abdomen/pelvis with contrast.

The CT abdomen/pelvis is the preferred test for appendicitis and has the highest sensitivity. This is recommended to be done with IV contrast, with or without PO contrast. If the patient has a BMI <25, it is a good idea to use PO contrast to enhance visualization of the appendix. The use of PO contrast is often facility dependent.

CT abdomen/pelvis is also great because it can give you possible alternative causes of abdominal pain. The downside is the obvious radiation exposure.

Once appendicitis is diagnosed, antibiotics should be started and surgery should be consulted emergently.

Antibiotics for acute appendicitis include:

  • Zosyn
  • Flagyl + Ceftriaxone or Cefepime
  • Ertapenem

For a full list, please look out the EMRA app. or read about the management here on UpToDate

Ultimately, the patient will likely need emergent surgery to remove the appendix, although rarely it can be just managed medically with antibiotics.

Don’t forget about these essential appendicitis signs to incorporate into your physical exam of your patient!

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