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Early signs of appendicitis include pain in the right lower quadrant and anatomical changes of the appendix that are seen in other abdominal diseases on radiologic imaging studies. The appendix lies posteromedial to the cecum; it is a blind pouch with no branchings and no mesentery. Lateral to its posterior mediocolic sidewall, the appendix loops caudally and a variable amount of terminal ileum may wrap around the mesojejunal lymph node. Superiorly, the appendix continues by looping around the mesenteric vessels off the medial aspect of the inferior vena cava (IVC). The area lateral to the mesojejunal lymph nodes in approximately 5% of the population may be infiltrated with adipose tissue, and in rare cases, lymphoid hyperplasia results in a palpable mass that moves with bowel movements. Resection of the appendiceal mesentery without splenectomy may not reveal an appendix that is invaded. The appendix is common in 60% of the population and is 1.5-4.5 cm long, although appendices are rarely shorter than 1.2 cm. The appendix varies in width from 0.5 to 1.5 cm.1,6

The clinical presentation and physical examination of appendicitis is variable and may be misleading. The pain is typically referred to the right lower quadrant area in 80%-90% of patients, and is described as postprandial or colicky. The severity of the pain oscillates from vague, non-specific discomfort to frank, sharp, and intensely localized pain. The pain is often aggravated by movement or bending at the waist. Occasionally, intense pain may spread to the right shoulder or downward into the groin.7,8,17,18

Presentation includes guarding, rigidity, fever and leukocytosis in 75% of patients, and a mass felt on rectal examination in 20%. Other findings include rebound tenderness (67%); localized tenderness (of which a localized non-oval, firm mass is the most common finding) (44%), and a non-tender fecal mass in 50%. Abdominal radiologists interpret radiographic findings with the symptoms of appendicitis in mind. d2c66b5586