Why it matters
Abdominal pain is one of the most common ED complaints. At 2 AM, when your mental bandwidth is low, it’s tempting to dismiss vague pain as “gastritis” or “indigestion.” But missing an early appendicitis is one of the most common rookie errors. The key: pattern recognition, systematic assessment, and not getting fooled by atypical presentations.
1) The 30-second story
- Appendicitis: classically periumbilical pain migrating to RLQ, anorexia, low-grade fever, nausea.
- Gastritis/GERD: epigastric burning, relation to meals, often with history of NSAID use, alcohol, or stress.
- Reality: appendicitis is a shape-shifter — from vague epigastric discomfort to diffuse abdominal pain.
2) Quick differential (beyond “gastritis vs appy”)
- Surgical: appendicitis, cholecystitis, SBO, perforated ulcer, AAA, ectopic pregnancy.
- Medical: gastritis, PUD, gastroenteritis, pancreatitis, renal colic, UTI/pyelo.
- Always in women: pregnancy test first — ectopic until proven otherwise.
3) Physical exam pearls
- Appendicitis
- RLQ tenderness (McBurney point)
- Guarding/rebound → peritoneal irritation
- Special signs: Rovsing, Psoas, Obturator (supportive, not diagnostic)
- Gastritis
- Epigastric tenderness only, no peritoneal signs
- Rookie trap: elderly, diabetics, immunosuppressed, and pregnant patients often lack fever or leukocytosis.
4) Red flags 🚨
- Peritonitis (rigid abdomen, rebound pain, guarding)
- Hemodynamic instability (tachycardia, hypotension)
- Persistent vomiting, bilious or bloody
- GI bleed (melena/hematemesis)
- Positive pregnancy test + abdominal pain → ectopic until proven otherwise
- Elderly with “gastritis” but abdominal tenderness = consider AAA
5) Labs & imaging
- CBC: leukocytosis supports but not required for appendicitis
- BMP: check electrolytes in vomiting patients
- LFTs, lipase: if epigastric pain; rule out pancreatitis, biliary disease
- UA: rule out UTI/stone (may mimic appy)
- Pregnancy test: mandatory in females of childbearing age
- Imaging
- US: first-line in pediatrics and pregnancy
- CT Abd/Pelvis with IV contrast: gold standard in adults with unclear diagnosis
- Plain X-ray: limited value except in SBO/perforation suspicion
6) Management in the ED
- Appendicitis
- NPO, IV fluids, analgesia, antiemetics
- Broad-spectrum antibiotics (e.g., ceftriaxone + metronidazole)
- Early surgical consult
- Gastritis/dyspepsia
- Symptomatic: antacids, PPIs, antiemetics, fluids if dehydrated
- Discharge if no red flags, reliable follow-up
- Uncertain cases
- Observation, serial exams, repeat vitals, consult if worsening
- Never be afraid to CT at 3 AM — better than a missed appendicitis!
7) Disposition
- Appendicitis confirmed or highly suspected → admit for surgery.
- Uncomplicated gastritis/dyspepsia → safe discharge with return precautions.
- If in doubt → observe or image; do not dismiss.
Rookie pearls
- The worst belly pain at night deserves your attention.
- Appendicitis can start as vague epigastric pain — don’t get tricked.
- Pregnancy test always — saves you from missing ectopic pregnancy.
- Serial abdominal exams are your friend; the belly tells the story over time.
- Don’t be shy about pain control — analgesia does not mask surgical signs.
Common pitfalls
- Labeling early appendicitis as “gastritis” or “viral” and sending home.
- Forgetting ectopic pregnancy in abdominal pain.
- Over-relying on labs — normal WBC does not rule out appendicitis.
- Sending home elderly with abdominal pain without considering AAA.
- Neglecting serial reassessment in equivocal cases.
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