MBBS Year
1st Year
Subject
What Is Usually Asked
Positions of the appendix, blood supply, McBurney's point
ReferenceAll Years (1st-Final)All UniversitiesAppendicitis
Appendicitis: Notes, PPT and PYQs for MBBS
Acute appendicitis is inflammation of the vermiform appendix and is one of the most common causes of the acute abdomen requiring surgery. It is a classic Final Year General Surgery topic, with links to Anatomy in 1st Year and Pathology in 2nd Year.
SME-reviewed. Updated 2026.
Open in GeckoMed for PPT slides and notes.Quick Summary: What You Need to Know for University Exams
- Appendicitis usually begins with obstruction of the appendiceal lumen, often by a faecolith (appendicolith) or lymphoid hyperplasia.
- Pain typically starts around the umbilicus and shifts to the right iliac fossa.
- Retrocaecal is the most common position of the appendix, followed by pelvic.
- Tenderness is maximal at McBurney's point; useful signs include Rovsing's, psoas and obturator signs.
- The Alvarado score supports the clinical diagnosis.
- Ultrasound is useful in children and pregnancy; CT is the most accurate test in adults.
- Treatment is usually appendicectomy, open or laparoscopic.
Appendicitis Across MBBS Subjects
| MBBS Year | Subject | What Is Usually Asked |
|---|---|---|
| 1st Year | Anatomy | Positions of the appendix, blood supply, McBurney's point |
| 2nd Year | Pathology | Pathogenesis and morphology of acute appendicitis, carcinoid tumour |
| Final Year | General Surgery | Clinical features, differential diagnosis, investigations, management, complications |
| Final Year | Obstetrics and Gynaecology | Appendicitis in pregnancy |
| Final Year | Paediatrics | Appendicitis in children |
MBBS Year
2nd Year
Subject
What Is Usually Asked
Pathogenesis and morphology of acute appendicitis, carcinoid tumour
MBBS Year
Final Year
Subject
What Is Usually Asked
Clinical features, differential diagnosis, investigations, management, complications
MBBS Year
Final Year
Subject
What Is Usually Asked
Appendicitis in pregnancy
MBBS Year
Final Year
Subject
What Is Usually Asked
Appendicitis in children
Definition and Classification
Definition: Acute appendicitis is acute inflammation of the vermiform appendix, usually caused by obstruction of its lumen followed by infection.
Types
| Type | Key Features |
|---|---|
| Acute non-obstructive (catarrhal) | Mucosal inflammation without luminal obstruction |
| Acute obstructive | Luminal obstruction with rapid progression |
| Gangrenous | Ischaemic necrosis of the wall |
| Perforated | Rupture with local or generalised peritonitis |
| Appendicular mass | Inflamed appendix walled off by omentum and bowel |
| Appendicular abscess | Pus collection around the appendix |
Type
Acute non-obstructive (catarrhal)
Key Features
Mucosal inflammation without luminal obstruction
Type
Acute obstructive
Key Features
Luminal obstruction with rapid progression
Type
Gangrenous
Key Features
Ischaemic necrosis of the wall
Type
Perforated
Key Features
Rupture with local or generalised peritonitis
Type
Appendicular mass
Key Features
Inflamed appendix walled off by omentum and bowel
Type
Appendicular abscess
Key Features
Pus collection around the appendix
Positions of the Appendix
| Position | Clinical Relevance |
|---|---|
| Retrocaecal (most common) | Less anterior tenderness; positive psoas sign |
| Pelvic (second most common) | Suprapubic pain, urinary or rectal symptoms; positive obturator sign; tenderness on rectal examination |
| Subcaecal | Pain in the right iliac fossa |
| Pre-ileal and post-ileal | May mimic gastroenteritis |
Position
Retrocaecal (most common)
Clinical Relevance
Less anterior tenderness; positive psoas sign
Position
Pelvic (second most common)
Clinical Relevance
Suprapubic pain, urinary or rectal symptoms; positive obturator sign; tenderness on rectal examination
Position
Subcaecal
Clinical Relevance
Pain in the right iliac fossa
Position
Pre-ileal and post-ileal
Clinical Relevance
May mimic gastroenteritis
Aetiology (Causes)
- Faecolith (appendicolith): most common cause of obstruction in adults
- Lymphoid hyperplasia: common in children and young adults, often after viral infections
- Foreign bodies and worms such as Enterobius vermicularis
- Tumours such as carcinoid tumour (neuroendocrine tumour)
- Strictures from previous inflammation
Pathophysiology
Flowchart
- The appendiceal lumen is obstructed
- Mucus continues to be secreted, increasing pressure inside the lumen
- Bacteria multiply in the closed loop
- Rising pressure obstructs lymphatic and venous drainage, causing oedema
- Arterial supply becomes compromised, leading to ischaemia and gangrene
- The wall perforates, causing localised abscess or generalised peritonitis
Why the Pain Shifts
| Stage | Type of Pain | Reason |
|---|---|---|
| Early | Vague periumbilical pain | Visceral pain from distension, carried by nerve fibres entering the spinal cord at T10 |
| Later | Sharp, localised pain in the right iliac fossa | Inflammation reaches the parietal peritoneum, which has somatic innervation |
Stage
Early
Type of Pain
Vague periumbilical pain
Reason
Visceral pain from distension, carried by nerve fibres entering the spinal cord at T10
Stage
Later
Type of Pain
Sharp, localised pain in the right iliac fossa
Reason
Inflammation reaches the parietal peritoneum, which has somatic innervation
(Examiner may ask you to draw the positions of the appendix.)
Clinical Features
Symptoms:
- Periumbilical pain shifting to the right iliac fossa
- Anorexia (very common)
- Nausea and vomiting, usually after the onset of pain
- Low-grade fever
- Murphy's triad: pain, vomiting and fever, typically in that order
Signs:
| Sign | Description |
|---|---|
| McBurney's point tenderness | Maximum tenderness at the junction of the lateral one-third and medial two-thirds of a line from the anterior superior iliac spine to the umbilicus |
| Rebound tenderness | Pain on sudden release of pressure, showing peritoneal irritation |
| Guarding and rigidity | Muscle spasm over the inflamed area |
| Rovsing's sign | Pressure in the left iliac fossa causes pain in the right iliac fossa |
| Psoas sign | Pain on extending the right hip; suggests a retrocaecal appendix |
| Obturator sign | Pain on internal rotation of the flexed right hip; suggests a pelvic appendix |
| Cough sign | Pain in the right iliac fossa on coughing |
Sign
McBurney's point tenderness
Description
Maximum tenderness at the junction of the lateral one-third and medial two-thirds of a line from the anterior superior iliac spine to the umbilicus
Sign
Rebound tenderness
Description
Pain on sudden release of pressure, showing peritoneal irritation
Sign
Guarding and rigidity
Description
Muscle spasm over the inflamed area
Sign
Rovsing's sign
Description
Pressure in the left iliac fossa causes pain in the right iliac fossa
Sign
Psoas sign
Description
Pain on extending the right hip; suggests a retrocaecal appendix
Sign
Obturator sign
Description
Pain on internal rotation of the flexed right hip; suggests a pelvic appendix
Sign
Cough sign
Description
Pain in the right iliac fossa on coughing
Alvarado Score (MANTRELS)
| Feature | Points |
|---|---|
| Migration of pain to the right iliac fossa | 1 |
| Anorexia | 1 |
| Nausea or vomiting | 1 |
| Tenderness in the right iliac fossa | 2 |
| Rebound tenderness | 1 |
| Elevated temperature (37.3°C or above) | 1 |
| Leucocytosis | 2 |
| Shift of white cells to the left | 1 |
| Total | 10 |
Feature
Migration of pain to the right iliac fossa
Points
1
Feature
Anorexia
Points
1
Feature
Nausea or vomiting
Points
1
Feature
Tenderness in the right iliac fossa
Points
2
Feature
Rebound tenderness
Points
1
Feature
Elevated temperature (37.3°C or above)
Points
1
Feature
Leucocytosis
Points
2
Feature
Shift of white cells to the left
Points
1
Feature
Total
Points
10
A score of 7 or more suggests appendicitis is likely, 5 to 6 is equivocal, and 4 or less makes it unlikely. See the full guide on the Alvarado score for appendicitis.
Special Groups
| Group | Key Points |
|---|---|
| Children | Harder to diagnose; perforation is more common because the omentum is less developed |
| Elderly | Atypical, milder symptoms; higher risk of perforation |
| Pregnancy | The appendix is displaced upwards as the uterus enlarges, so pain may be higher; ultrasound or MRI is preferred |
Group
Children
Key Points
Harder to diagnose; perforation is more common because the omentum is less developed
Group
Elderly
Key Points
Atypical, milder symptoms; higher risk of perforation
Group
Pregnancy
Key Points
The appendix is displaced upwards as the uterus enlarges, so pain may be higher; ultrasound or MRI is preferred
Differential Diagnosis
| Category | Conditions |
|---|---|
| Gastrointestinal | Mesenteric lymphadenitis, gastroenteritis, Meckel's diverticulitis, Crohn's disease, typhoid perforation, perforated peptic ulcer |
| Urological | Right ureteric colic, urinary tract infection |
| Gynaecological | Ectopic pregnancy, ruptured ovarian cyst, ovarian torsion, pelvic inflammatory disease |
| Others | Right lower lobe pneumonia (especially in children), diabetic ketoacidosis |
Category
Gastrointestinal
Conditions
Mesenteric lymphadenitis, gastroenteritis, Meckel's diverticulitis, Crohn's disease, typhoid perforation, perforated peptic ulcer
Category
Urological
Conditions
Right ureteric colic, urinary tract infection
Category
Gynaecological
Category
Others
Conditions
Right lower lobe pneumonia (especially in children), diabetic ketoacidosis
Diagnosis
| Investigation | Findings or Purpose |
|---|---|
| Complete blood count | Leucocytosis with neutrophilia |
| C-reactive protein | Often raised |
| Urine examination | Excludes urinary infection; a few cells may be seen with a pelvic appendix |
| Urine pregnancy test | In all women of reproductive age |
| Ultrasound | Non-compressible, thickened appendix (commonly more than 6 mm in diameter); first choice in children and pregnancy |
| CT abdomen | Most accurate test in adults; shows complications such as abscess |
| MRI | Useful in pregnancy when ultrasound is inconclusive |
Investigation
Complete blood count
Findings or Purpose
Leucocytosis with neutrophilia
Investigation
C-reactive protein
Findings or Purpose
Often raised
Investigation
Urine examination
Findings or Purpose
Excludes urinary infection; a few cells may be seen with a pelvic appendix
Investigation
Urine pregnancy test
Findings or Purpose
In all women of reproductive age
Investigation
Ultrasound
Findings or Purpose
Non-compressible, thickened appendix (commonly more than 6 mm in diameter); first choice in children and pregnancy
Investigation
CT abdomen
Findings or Purpose
Most accurate test in adults; shows complications such as abscess
Investigation
MRI
Findings or Purpose
Useful in pregnancy when ultrasound is inconclusive
Management
Initial Management
- Nil by mouth
- Intravenous fluids
- Analgesia
- Intravenous antibiotics covering gut organisms, including anaerobes
Appendicectomy
| Approach | Key Points |
|---|---|
| Laparoscopic appendicectomy | Smaller wounds, less pain, quicker recovery; useful when the diagnosis is uncertain, especially in women |
| Open appendicectomy | Through a gridiron (McBurney's) or Lanz incision in the right iliac fossa |
Approach
Laparoscopic appendicectomy
Key Points
Smaller wounds, less pain, quicker recovery; useful when the diagnosis is uncertain, especially in women
Approach
Open appendicectomy
Key Points
Through a gridiron (McBurney's) or Lanz incision in the right iliac fossa
Non-Operative Management
Antibiotic treatment alone may be used in selected patients with uncomplicated appendicitis confirmed on imaging, with close follow-up because appendicitis can recur.
Appendicular Mass and Abscess
| Condition | Management |
|---|---|
| Appendicular mass | Conservative (Ochsner-Sherren) regimen: rest, nil or limited oral intake, fluids, antibiotics and close monitoring; interval appendicectomy may be considered later |
| Appendicular abscess | Drainage (often image-guided) with antibiotics |
Condition
Appendicular mass
Management
Conservative (Ochsner-Sherren) regimen: rest, nil or limited oral intake, fluids, antibiotics and close monitoring; interval appendicectomy may be considered later
Condition
Appendicular abscess
Management
Drainage (often image-guided) with antibiotics
Signs that conservative treatment is failing: increasing pain, rising pulse and fever, spreading tenderness or an enlarging mass. These need surgery.
Complications
Of the disease:
- Perforation and generalised peritonitis
- Appendicular mass and abscess
- Pelvic abscess
- Portal pyaemia (pylephlebitis) and liver abscess
- Adhesions and later intestinal obstruction
After surgery:
- Wound infection (the most common)
- Intra-abdominal or pelvic abscess
- Faecal fistula
- Paralytic ileus
- Adhesive intestinal obstruction
Prognosis
Uncomplicated appendicitis treated promptly has an excellent outcome. Morbidity and mortality rise with perforation, and are higher in children, elderly patients and pregnant women because diagnosis is often delayed.
Quick Viva Questions
Q: What is the most common position of the appendix? A: Retrocaecal.
Q: What is the most common cause of luminal obstruction in adults? A: A faecolith (appendicolith).
Q: What is Rovsing's sign? A: Pain in the right iliac fossa when pressure is applied in the left iliac fossa.
Q: Why does the early pain of appendicitis start around the umbilicus? A: Visceral pain from the appendix is carried by nerve fibres entering the spinal cord at T10, the same segment that supplies the umbilical skin.
Q: What is the most common complication after appendicectomy? A: Wound infection.
Q: What is the Ochsner-Sherren regimen? A: A conservative treatment plan for an appendicular mass, with rest, fluids, antibiotics and close monitoring.
How Appendicitis Appears in MBBS University Exams
Typical question styles (not attributed to specific papers or years):
- "Discuss the aetiology, clinical features, differential diagnosis and management of acute appendicitis." (Long essay, Surgery)
- "Write a short note on appendicular mass." (Short note)
- "Write a short note on the Alvarado score." (Short note)
- "Write a short note on the positions of the appendix and their clinical significance." (Short note, Anatomy or Surgery)
- "Write a short note on appendicitis in pregnancy." (Short note)
Frequently Asked Questions
What is the most common cause of acute appendicitis?
Obstruction of the appendiceal lumen, most often by a faecolith in adults and by lymphoid hyperplasia in children and young adults.
Which investigation is best for diagnosing appendicitis?
CT is the most accurate test in adults. Ultrasound is preferred first in children and pregnant women.
Can I download the appendicitis PPT for my presentation?
Yes. Use the Download PPT button at the top of this page. The GeckoMed app also gives offline access to the slides and notes.
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