Pain Management in Acute Appendicitis
Administer analgesics immediately upon diagnosis of acute appendicitis—pain control with opioids, NSAIDs, or acetaminophen is a priority and does not delay diagnosis or lead to unnecessary intervention. 1
Immediate Analgesic Administration
- Provide pain relief without hesitation once appendicitis is suspected or confirmed, as multiple studies demonstrate that analgesia does not mask clinical findings, delay surgical intervention, or increase rates of perforation 1
- Opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen are all appropriate first-line options for pain control in acute appendicitis 1
Recommended Analgesic Regimens
For mild to moderate pain:
- Acetaminophen and NSAIDs are first-line treatment options for most patients with acute mild to moderate pain 2
- NSAIDs should be used with caution in patients with history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 2
- Acetaminophen requires dose reduction in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 2
For severe pain:
- Escalate to opioid medications (morphine, hydromorphone, fentanyl) or tramadol/tapentadol for severe or refractory acute pain 2
- Acetaminophen/opioid or NSAID/opioid combinations can be used for enhanced analgesia 2
- Short-term opioid use is appropriate for severe acute pain with attention to minimizing risk 2
Critical Timing Considerations
- Pain management should begin immediately in the emergency department upon diagnosis, regardless of whether surgical or non-operative management is planned 3
- All patients diagnosed with appendicitis should receive antibiotics immediately in the ED (amoxicillin/clavulanate, ceftriaxone + metronidazole, or cefotaxime + metronidazole), which also contributes to overall symptom relief 3
Common Pitfalls to Avoid
- Do not withhold analgesia due to concerns about masking peritoneal signs—this outdated practice has been definitively disproven and causes unnecessary patient suffering 1
- Avoid routine use of selective COX-2 inhibitors as first-line agents, as they are more expensive alternatives reserved for patients requiring gastrointestinal protection from nonselective NSAIDs 2
- In elderly patients (>65 years) with perforation rates of 18-70%, aggressive pain management is essential as they often present with atypical symptoms and may underreport pain severity 3