Abdominal Pain

Garcia EM, Camacho MA, Karolyi DR, et al. ACR appropriateness criteria right lower quadrant pain — suspected appendicitis. J Am Coll Radiol. 2018;15(11S):S373-S387. PMID: 30392606

Appendicitis

Appendicitis is a condition in which your appendix gets inflamed. The appendix is a small pouch attached to the end of the large intestine.

There are three body views (front, back, and side) that can help you to identify a specific body area. The labels show areas of the body which are identified either by anatomical or by common names. For example, the back of the knee is called the “popliteal fossa,” while the “flank” is an area on the side of the body.

The esophagus, stomach, large and small intestine, aided by the liver, gallbladder and pancreas convert the nutritive components of food into energy and break down the non-nutritive components into waste to be excreted.

The appendix is a small, finger-shaped pouch of intestinal tissue located between the small intestine (cecum) and large intestine (colon).

The appendix is a small finger-shaped tube that branches off the first part of the large intestine. The appendix can become inflamed or infected causing pain in the lower right part of the abdomen.

Causes

Appendicitis is a very common reason for emergency surgery. The problem most often occurs when the appendix becomes blocked by feces, a foreign object, a tumor or a parasite in rare cases.

Symptoms

• Chills and shaking
• Hard stools
• Diarrhea
• Fever
• Nausea and vomiting

You may never have given much thought to your appendix, the little pouch that’s attached to the top of your large intestine. And you wouldn’t have much reason to think about it, because it doesn’t seem to do anything. But if your appendix were to become swollen and inflamed, it would probably move to the front of your mind. The pain of appendicitis can make you quickly, and unpleasantly, familiar with this organ. You can get appendicitis if your appendix becomes blocked. That blockage could be from feces, a foreign object, or, in rare cases, a tumor. When your appendix is blocked up, bacteria that normally live inside it start multiplying like crazy, and cause an infection. If you’ve got appendicitis you’ll usually have pain that’s centered around the area of your belly button. At first the pain may be minor, but it can get very severe and will usually drift downward to the bottom right part of your abdomen. You may also have nausea, vomiting, diarrhea or constipation, and a low fever. Your pain may let up for a time. This relief can be misleading, though. Just when you think you’re getting better, your appendix may have actually burst. If that’s the case, the pain will get start to get more and more intense. To diagnose appendicitis, your doctor will ask about your symptoms and press on your abdomen, which will feel very tender. You may need imaging tests, such as a CT scan or ultrasound of your abdomen, so the doctor can see if the problem is with your appendix. If you have appendicitis, the number one way to treat it is with surgery to remove your appendix. In fact, appendicitis is the number one cause of emergency abdominal surgery in the U.S. You may be treated for an infection first, before your surgery. It’s important to treat the appendicitis quickly because you can develop a collection of pus called an abscess in your abdomen once your appendix bursts. Don’t worry about going through life without an appendix. People live healthy lives without it. Once you’ve had your appendix taken out, you should feel a lot better. If your appendix has ruptured, it may take you longer to recover. You may also develop an abscess or other complications. That’s why you don’t want to wait until your appendix has already burst to get treated. Call your doctor for any severe pain in your abdomen, especially if you also have a fever, vomiting, constipation, dizziness, or other severe symptoms.

Exams and Tests

Your health care provider may suspect appendicitis based on the symptoms you describe.

Your provider will do a physical exam.

• If you have appendicitis, your pain will increase when your lower right belly area is pressed.
• If your appendix has ruptured, touching the belly area may cause a lot of pain and lead you to tighten your muscles.
• A rectal exam may find tenderness on the right side of your rectum.

A blood test will often show a high white blood cell count. Imaging tests that may help diagnose appendicitis include:

• CT scan of the abdomen
• Ultrasound of the abdomen

Treatment

Most of the time, a surgeon will remove your appendix as soon as you are diagnosed.

If a CT scan shows that you have an abscess, you may be treated with antibiotics first. You will have your appendix removed after the infection and swelling have gone away.

The tests used to diagnose appendicitis are not perfect. As a result, the operation may show that your appendix is normal. In that case, the surgeon will remove your appendix and explore the rest of your abdomen for other causes of your pain.

Appendectomy, the removal of the small pouch attached to the beginning of your large intestine when you have an acute bout of appendicitis is one of the most common emergency abdominal surgeries. The appendix is a small, finger-shaped organ that comes out of the first part of the large intestine. It needs to be removed when it becomes swollen or infected. If the appendix is not removed, it can leak bacteria and infect your entire belly, which can be very life threatening. So, what are the signs that you have appendicitis? Well, this condition can be fairly hard to diagnose, especially in children, older people, and women of childbearing age. Usually, the first symptom is pain around your belly button. The pain might be mild at first, but then it gets sharp and severe before not too long. The pain may then move into your right lower abdomen. You may also have diarrhea, fever, nausea, and a reduced appetite. Sometimes, people think that they might be having food poisoning. Your doctor will make a diagnosis based on your symptoms. You may also have blood tests and a CT scan or ultrasound. Once it’s clear that you have appendicitis, your doctor will probably schedule you for emergency surgery. In surgery, you will receive anesthesia and be asleep and pain free. The doctor will make a small cut in the lower right side of your belly and remove your appendix. If the surgeon uses the laparoscopic technique, you will have several small cuts in your abdomen for the surgical instruments. If your appendix broke open, or a pocket of infection has formed, your doctor will wash out your belly during the surgery. A small tube may remain to help drain out fluids or pus. Once you’ve had an appendectomy, you will probably recover pretty quickly. It feels good to get a bad appendix out. Most patients leave the hospital 1 to 2 days after surgery. The good news is that you’ll be able to go back to all those normal activities within 2 to 4 weeks.

Outlook (Prognosis)

Most people recover quickly after surgery if the appendix is removed before it ruptures.

If your appendix ruptures before surgery, recovery may take longer. You are also more likely to develop problems, such as:

• An abscess
• Blockage of the intestine
• Infection inside the abdomen (peritonitis)
• Infection of the wound after surgery

When to Contact a Medical Professional

Contact your provider if you have pain in the lower-right portion of your belly, or other symptoms of appendicitis.

References

Carlberg DJ, Himelfarb NT. Acute appendicitis. In: Walls RM, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 79.

Garcia EM, Camacho MA, Karolyi DR, et al. ACR appropriateness criteria right lower quadrant pain — suspected appendicitis. J Am Coll Radiol. 2018;15(11S):S373-S387. PMID: 30392606

Rosenthal MD, Sarosi GA. Appendicitis. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 120.

Sifri CD, Madoff LC. Appendicitis. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 9th ed. Philadelphia, PA: Elsevier; 2020:chap 78.

Version Info

Last reviewed on: 5/2/2023

Reviewed by: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Pain Locator: Where Does it Hurt?

Abdominal pain could be indicative of many ailments, ranging from gas and constipation to gallstones or pancreatitis. Understanding the type of pain you’re experiencing, where it’s originating from, and the severity of your ailment, could help you get the correct treatment before symptoms worsen.

It’s important to become acquainted with the nine regions of the abdomen, so you can better understand how your digestive organs function and are susceptible to a variety of medical issues.

NAVIGATION – Jump to: The 9 Regions of the Abdomen Quadrants of the Abdomen

9 Regions of the Abdomen

Envision the sections of your abdomen as a Tic-Tac-Toe board. To simplify this even further, let’s number each region of your abdomen: Regions 1 to 3 are the top row (right, middle, left), regions 4 through 6 encompass the middle boxes, and regions 7 to 9 comprise the bottom row.

• Region 1: Right Hypochondriac Region (upper, right)
  Liver, Gallbladder, Right Kidney, Small Intestine

Exact origins of abdominal pain can be tricky to pinpoint. You may have noticed, for instance, that the liver is listed under several regions: the right hypochondriac, epigastric, and right lumbar. For our purposes, these nine regions will be reduced to four quadrants when discussing pain points.

Right Upper Quadrant

Organs found in this quadrant include: the liver, the gallbladder, duodenum, the upper portion of the pancreas, and the hepatic flexure of the colon.

Pain in the right upper quadrant may be indicative of hepatitis, cholecystitis, or the formation of a peptic ulcer.

• Nausea
• Vomiting
• Belly pain (may worsen when taking deep breaths)
• Possible aches in back or right shoulder blade

Note: Bacteria also can cause Cholecystitis.

Hepatitis
Regardless of cause, inflammation of the liver is referred to as hepatitis. Most instances of hepatitis are viral, but the disease may also be caused by drugs or alcohol. The most common types of viral hepatitis include:

• Hepatitis A – This virus causes an acute inflammation and will usually heal on its own. It’s easily spread in food and water, and often infects many people at once.
• Hepatitis B – This virus can be both acute (short-term illness) and chronic (ongoing illness), and is spread through blood or other body fluids in various ways.
• Hepatitis C – The Hepatitis C Virus (HCV) is almost always chronic and spreads usually by blood. Hepatitis A and B can be prevented by vaccination, but not hepatitis C. However, certain strains of Hepatitis C may be cured by a regimen of direct-acting antiviral medication.

Peptic Ulcer
A hole in the lining of the digestive tract is called a peptic ulcer. Peptic ulcers are created by erosive digestive action of pepsin and stomach acid, which may be linked to any of the following root causes:

• Helicobacter pylori (H. pylori), a type of stomach infection and inflammation causing bacteria
• Excessive use of NSAIDs (non-steroidal anti-inflammatory drugs) like aspirin (Bayer), ibuprofen (Advil), and other anti-inflammatory drugs
• Smoking and drinking
• Radiation therapy
• Stomach cancer

Right Lower Quadrant

Organs found in the right lower quadrant include the appendix, the upper portion of the colon, and the right ovary and the Fallopian tube in women.

The right lower quadrant may be assessed when diagnosing appendicitis, in which case, this quadrant would be tender and painful.

Appendicitis
Appendicitis is a condition in which the appendix becomes inflamed and filled with pus, causing pain. If left untreated, appendicitis may cause your appendix to rupture and cause infection, which can be serious and even fatal.

Left Upper Quadrant

Organs in the left upper quadrant include the stomach, spleen, left portion of the liver, main body of the pancreas, the left portion of the kidney, adrenal glands, splenix flexure of the colon, and bottom part of the colon.

This quadrant may feel tender in cases of appendicitis and abnormalities of the intestines, such as malrotation.

Left Lower Quadrant

Organs found in this quadrant include the sigmoid colon, and the left ovary and Fallopian tube in women.

Pain in this quadrant may be symptomatic of colitis, diverticulitis, or kidney stones. Ovarian cysts (in women) or pelvic inflammation may also be at the root of pain in this quadrant.

Diverticulitis
Diverticula are small, bulging pouches that can form in the lining of your digestive system. Sometimes, however, one or more of the pouches become inflamed or infected. That condition is known as diverticulitis.

Ureteral Colic
This is most commonly caused by the obstruction of the urinary tract by kidney stones.

Colitis
Colitis, simply put, is inflammation of the colon. The three most common forms of colitis are: ulcerative colitis, Crohn’s disease, and infection.

Ulcerative Colitis
This is a chronic IBD that causes sores (ulcers) in the lining of your colon, as well as inflammation.

Crohn’s Disease
This is a chronic inflammatory bowel disease that affects the lining of the digestive tract. Inflammation can appear anywhere in the digestive tract, from the mouth to the anus, and it generally affects all the layers of the bowel walls, not just the inner lining.

C. Diff. Colitis
This is inflammation of the colon caused by the bacteria Clostridium difficile which can occur after treatment with antibiotics.