Appendicitis & Peritonitis

The moment appendicitis pain suddenly "gets better" before a diagnosis is confirmed, the situation just got dramatically worse — a rupture may have occurred, and peritonitis is next.

Appendicitis begins as periumbilical pain that migrates to McBurney's point (right lower quadrant, one-third the distance from the anterior superior iliac spine to the umbilicus) over 12–24 hours. This migration pattern is the clinical hallmark. Low-grade fever (up to 38.3°C/101°F), anorexia, nausea, and rebound tenderness follow. WBC rises to 10,000–18,000/mm³. The danger pivot: if the appendix ruptures, pain may briefly decrease as pressure is relieved — then diffuse, rigid-board abdomen and high fever signal peritonitis, a life-threatening infection of the peritoneal cavity. Peritonitis triggers a systemic inflammatory response: fever spikes above 38.9°C/102°F, tachycardia, absent bowel sounds, and sepsis risk. Pre-operatively, position the patient in right side-lying or low Fowler's with knees flexed for comfort. NPO status is critical — no laxatives, enemas, or heat application to the abdomen, as these can increase peristalsis or pressure and promote rupture. Surgical intervention (appendectomy) is the definitive treatment. Post-rupture, expect wound drains, IV antibiotics, and monitoring for abscess formation.

Key Distinctions

Don't confuse the brief pain relief after rupture with clinical improvement — it signals perforation and imminent peritonitis. Students mix up rebound tenderness (pain on release of pressure) with referred pain (pain felt away from the source). Never apply heat to an RLQ with suspected appendicitis; the inflamed appendix is friable, and any external manipulation — heat, enemas, vigorous palpation — should be avoided to reduce perforation risk and prevent masking of symptoms.

Clinical Pearl

No heat, no laxatives, no enemas on a hot appendix. If RLQ pain suddenly disappears without surgery, think rupture — not resolution.