Appendix Pain: Location, Characteristics & Mimics

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Appendix pain typically starts around the umbilicus and then becomes localized in the right lower abdomen. It is severe and associated with tenderness, gardening, anorexia, nausea, and vomiting.

In this article, You will learn the basics about appendix pain, such as typical locations, characteristics, associated symptoms, mimics, and treatments.


Table of Contents

Appendix pain location.

A. Typical appendix pain locations.

  1. Starts around the umbilicus and then shifts to the right lower abdomen.

Typically, the pain starts in the center of the abdomen (around the umbilicus or belly button). The pain gradually shifts to the right iliac fossa after one or two days.

This classical shift of the appendix pain from around the umbilicus to the right lower abdomen occurs in about 60% of the cases (reference).

  1. Right lower abdominal pain from the start.

The appendix pain is located in the Lower right abdominal quadrant (the Right iliac fossa). It presents with severe pain and tenderness over the right lower abdomen. It also may start around the umbilicus, then shifts to the right iliac area.

The pain is typically associated with severe anorexia, nausea, vomiting, and severe tenderness over the appendix area.

B. Atypical appendix pain locations.

In A minority of cases, the inflamed appendix pain may vary in location, character, and severity. The location of appendix pain depends on the site of the tip of the appendix.

Common examples of atypical appendix pain locations:

  • Bladder pain and increased urine frequency: in case of pelvic appendix adjacent to the urinary bladder.
  • Diarrhea, tenesmus, and bowel habit changes in the case of the pelvic appendix adjacent to the rectum.
  • Right Upper abdominal pain (subhepatic appendix).
  • Left lower quadrant.
  • Dull aching diffuse abdominal pain (retrocausal appendix).
  • Lower back pain.

Appendix pain symptom characteristics.

The following is the typical scenario in appendicitis:

  • It starts with mild abdominal pain around the umbilicus (belly button).
  • Within hours, the inflammation of the umbilicus irritates the peritoneum over it (the peritoneum is a thin layer that envelopes most of the abdominal organs). The appendix pain localizes in the lower right abdomen when the peritoneum becomes irritated.
  • The appendix pain starts mild. Soon, it becomes more severe, constant, and localized.
  • Nausea and anorexia follow the onset of pain (pain is the first sign).
  • The pain doesn’t improve with defecation (unlike the pain from IBS and gastroenteritis).
  • Severe tenderness and gardening over the area of pain.
  • Fever (in 40% of the cases).
  • Diarrhea or constipation (abnormal poop smell or color are NOT specific for appendicitis.
  • Generalized fatigue (malaise).
  • Sometimes, urinary frequency or urgency.


  • Abscess formation.
  • Gangrene: Severe inflammation and edema prevent blood from reaching the appendix tissues. Cutting the blood supply leads to the death of the appendix tissues (gangrene). Gangrene often leads to a burst (rupture) in the appendix.
  • Perforation (rupture of the appendix): the risk increases as time passes without diagnosis and treatment.
  • Peritonitis: the peritoneum is a thin double-layered membrane that envelops most of your abdominal organs. Peritonitis results from a ruptured appendix or appendicular abscess. Peritonitis results in more extreme symptoms such as high-grade fever, intense abdominal pain, and tenderness.

Appendix pain diagnosis.

The diagnosis of appendicitis depends on the following:

1. Typical appendix pain.

Starts around the belly button and then becomes localized in the lower right abdomen. The pain rapidly progresses and becomes intolerable, associated with severe tenderness (especially in the right lower abdomen). Fever, nausea, vomiting, and diarrhea may occur in some cases.

2. Characteristic signs.

Your doctor may do specific clinical tests that help the diagnosis of appendicitis. These tests include:

  • Severe tenderness on pressing the right lower abdomen.
  • Rebound tenderness (sudden increase in pain when the doctor removes his hand abruptly).
  • Cough tenderness (increase in pain by coughing).
  • Abdominal rigidity.
  • Psoas and obturator signs.
  • Rovsing’s sign: pain on the Right lower abdomen when the left lower abdomen (crossed tenderness).

3. Laboratory Investigations.

The most important laboratory test is the White Blood Cell count. An elevated white cell count of more than 10000 is suggestive of appendicitis.

Other tests include CRP (C-reactive Protein) and pregnancy tests to exclude ectopic pregnancy in females.

4. Imaging Studies.

  • Abdominal Ultrasound.
  • Abdominal CT.
  • MRI.

Appendix pain treatment

1. Non-operative treatment.

Non-operative treatment treats appendix pain and inflammation in non-complicated cases using antibiotics. It is often preserved for mild cases without diffuse peritonitis or complications.

2. Appendix removal (appendectomy).

Surgical or laparoscopic of the appendix is the definitive treatment.

It is suitable for patients with severe or complicated appendicitis. Appendicectomy is done in an emergency setting in case of complications such as a perforated appendix.

The table below compares the two main treatments of appendicitis (reference).

Appendix pain Mimics.

Several conditions can mimic appendicitis pain. For example, the below condition can cause lower right abdominal pain that comes and goes:

  • Acute gastroenteritis (stomach flu and food poisoning): in such cases, nausea and diarrhea often proceed the pain. After that, diarrhea and vomiting are more prominent. And the pain can occur where it is partially relieved by defecation.
  • Irritable bowel syndrome.
  • Mesenteric adenitis.
  • Right renal colics.
  • Inflammatory bowel diseases (Crohn’s commonly affects the right lower abdomen).
  • Familial Mediterranean fever.
  • Cecal diverticulitis.
  • Right ovary pain or right pelvic inflammatory disease.
  • Right ectopic pregnancy, and others.

An organism called yersinia can cause a form of gastroenteritis that leads to right lower abdominal pain (especially in children). In addition, the organism causes inflammation of the lymph nodes in the right lower abdomen that produces a picture that mimics appendicitis.

The following are the main differences (reference):

 Appendicitis (early stage)Enteritis
1. Abdominal pain LocationAround the umbilicus, then shifts to the right.Anywhere, mainly in the lower central abdomen
2. Improvement of pain after defecationNoYes (partial or complete)
3. Nausea onsetAfter the onset of pain.Before the onset of pain
FeverNone or slightNone or slight
Pain on touching the abdomen (tenderness)It may not present around the umbilicus in the early stages.Mild or none.
Vomitingin <50% of cases (children)in >50% of patients (children)
The course of pain-Increases over time-becomes more localized (lower right)starts severe and often decreases over time.
White blood cell countoften > 10000Often < 10000