Appendicitis: Symptoms, Causes, and Why It's an Emergency

Appendicitis is one of the most common reasons people end up needing emergency surgery. It can start as a mild stomachache and turn into a serious problem within a day or two. Knowing the signs of appendicitis, and acting on them early, can make a real difference in how well and how quickly a person recovers.

Robert Gullinese, M.D., physician on the medical staff and emergency medicine associate medical director at Texas Health Fort Worth, sees this condition often in the emergency department. Here is what he wants people to understand about appendicitis, from the first warning signs to why it should never be ignored.

What is Appendicitis?

The appendix is a small pouch attached to the large intestine. It sits in the lower right part of the belly and is only about the size of a finger.

“It's kind of a vestige, or leftover,” Dr. Gullinese said. “It's a little small finger-like shaped pouch next to the large intestine, and it is not an important structure at all.”

Appendicitis happens when the appendix becomes blocked, then swollen and infected.

“That little structure gets plugged up with bacteria, stool or food, or sometimes a stone-like collection of food that hardens and calcifies over time,” Dr. Gullinese said. “It can get inflamed, and bacteria get in there, causing an infection and inflammation of that structure.”

If the infection is not treated, the appendix can burst. That is what people mean when they say an appendix “ruptured.”

Symptoms of Appendicitis

The symptoms of appendicitis often build slowly, which is one reason people mistake them for a stomach bug. The pain usually does not go away, though, and that is an important clue.

Early Signs of Appendicitis

The first signs of appendicitis are usually mild. Many people feel a vague discomfort near the upper belly or belly button, along with a loss of appetite.

“It's kind of vague, kind of a discomfort, really, is what most people say,” Dr. Gullinese said.

Abdominal Pain: The Key Indicator

Abdominal pain is the main sign of appendicitis, and the way it moves is what sets it apart. It often starts near the belly button and then shifts to the lower right side of the belly.

“The classic sign of appendicitis, kind of its trademark, is that it's a pain that moves. It's migratory,” Dr. Gullinese said. “It tends to move down to the right lower abdomen, and that is its signature.”

This pain tends to be steady and does not let up. People often think they can wait it out, but the discomfort keeps going.

“They think they had a stomach bug, but they usually find their way in because it just doesn't let up,” Dr. Gullinese said. “It doesn't get better.”

By the time many people reach the emergency department, their pain is very strong, often around an 8 or 9 on a scale of 10.

Other Symptoms of Appendicitis

Along with pain, other symptoms of appendicitis can include nausea and a complete loss of appetite. A fever is less common and usually shows up only when the infection has become serious.

People with appendicitis also tend to protect the sore area. They may hold the right side of the belly and pull away if someone tries to touch it. “They certainly wouldn't let a family member push on their belly or push on the right lower abdomen,” Dr. Gullinese said. “They would 100 percent push away a family member's hand in that situation.”

What Causes Appendicitis?

Common Causes: Appendicitis starts with a blockage. Stool, food, or a small hardened mass can plug the opening of the appendix. Once it is blocked, bacteria build up inside, and the appendix becomes inflamed and infected. Over time, the wall of the appendix weakens and can tear open.

Risk Factors: Appendicitis can happen to anyone, at any age. Still, some patterns stand out. It is most common in people in their 20s, and slightly more common in men, who face about 1.4 to 1.5 times the risk. Over a lifetime, about 8.5 percent of men and 6.5 percent of women will have appendicitis.

Diet may play a role too. According to Dr. Gullinese, a low-fiber diet is the one risk factor people can do something about.

“There's a higher association with people who eat a low-fiber diet,” he said. “That fast-food diet is the main preventable risk factor.”

The 4 Stages of Appendicitis

Appendicitis tends to get worse in stages. It can move from mild irritation to a medical emergency in about 48 hours, so understanding how it progresses helps explain why time matters.

Stage 1: Initial Inflammation

The appendix becomes blocked and begins to swell. At this point, the pain is often mild and hard to place, usually felt near the belly button.

Stage 2: Advanced Inflammation

As the swelling increases, the pain grows stronger and moves to the lower right side of the belly. Nausea and loss of appetite often set in.

Stage 3: Infection

Bacteria multiply inside the appendix, and pus can form, almost like an abscess, which is a pocket of pus that collects in one spot.

Stage 4: Ruptured Appendix

If the pressure and infection continue, the appendix can burst. Its contents spill into the belly, where the other organs sit. This can lead to a body-wide infection called sepsis, which is a life-threatening emergency.

“It develops an opening into your body cavity where the rest of your organs are,” Dr. Gullinese said. “That can make you very sick and septic, and that's truly a surgical emergency at that point.”

Why Appendicitis is an Emergency

Appendicitis is the most common condition that requires emergency surgery. Left alone, it can turn dangerous quickly.

Complications of Delayed Treatment

When appendicitis is not treated, the risk of serious problems climbs. About 20 to 30 percent of people will develop a wider infection, a rupture, or sepsis. A ruptured appendix can lead to a longer hospital stay and, in some cases, more surgery. Some patients even end up needing an ostomy, a surgical opening that reroutes waste while the body heals.

Importance of Early Diagnosis

Getting care early gives patients more options. In the emergency department, doctors usually start an IV, run blood work, and order a CT scan to look at the appendix. Pain medicine and antibiotics may be given depending on what they find.

When surgery is needed, it is often minor. Nine times out of 10, surgeons can remove the appendix using a few small incisions, and many patients go home the same day or the next. Catching appendicitis early can even open the door to treatment without surgery.

“If you go early enough and it's uncomplicated, there is some literature that says a lot of patients can be treated with antibiotics alone, without surgery, without removing the appendix,” Dr. Gullinese said.

Conclusion

Appendicitis can move from a mild stomachache to a true emergency in a matter of hours. The warning signs to watch for are pain that shifts to the lower right belly, pain that does not let up, and a complete loss of appetite. Anyone with these symptoms should seek medical care right away rather than trying to wait it out.

“The main thing is coming in early, so that they give themselves more options,” Dr. Gullinese said.

One more note for expecting mothers: appendicitis is the most common surgical emergency during pregnancy, and it is not related to the baby. Because a growing uterus can shift the appendix, the pain may not appear on the lower right side. It can show up closer to the bladder or higher in the belly, so any steady, unexplained abdominal pain during pregnancy is worth a call to a doctor.

When symptoms point to a possible emergency, help is close by. Texas Health emergency rooms are open 24 hours a day, seven days a week, with emergency-trained physicians and staff ready for serious injuries and illnesses across North Texas.

Appendicitis: What to Know

• What it is: Appendicitis is an infection of the appendix, a small pouch attached to the large intestine. It is the most common condition that requires emergency surgery.
• The telltale sign: Pain that starts near the belly button and moves to the lower right side of the belly. This shift is the hallmark of appendicitis.
• It does not let up: Unlike a stomach bug, the pain stays steady and keeps getting worse instead of passing.
• Other symptoms: Nausea and a complete loss of appetite. Fever usually shows up only once the infection is serious.
• Move fast: Appendicitis can go from mild to dangerous in about 48 hours. Left untreated, 20 to 30 percent of people develop a rupture, a wider infection, or sepsis.
• Early care means more options: Caught early, some cases can be treated with antibiotics alone. When surgery is needed, it is usually minor, and many patients go home the same day or the next.
• During pregnancy: Appendicitis is the most common surgical emergency in pregnancy. The pain may not appear on the lower right side, so any steady, unexplained abdominal pain is worth a call to a doctor.