Colic Pain

Colic Pain

Biliary Colic

56. B.C., a 42-year-old man, is admitted for severe, intermittent right upper quadrant pain accompanied by nausea, vomiting, and clay-colored stools. The differential diagnosis is biliary colic versus acute pancreatitis. Two doses of meperidine 100 mg IM 3 hours apart fail to ease the pain. What other potent analgesics are preferred in this situation?

Opioid analgesics can induce smooth-muscle spasms in the sphincter of Oddi and thereby increase intrabiliary pressure.^184,185 The resulting intraductal back pressure can aggravate pain symptoms and increase the serum concentrations of amylase 5 to 10 times above the control value.¹⁸⁶ Although it often is claimed that meperidine is less likely than morphine to cause spasm of the sphincter of Oddi, no clear evidence indicates the superiority of one agent over the other.¹⁸⁷ Significant increases in intrabiliary pressures of patients receiving fentanyl (Sublimaze), morphine, meperidine, pentazocine (Talwin), butorphanol (Stadol), and oxycodone are documented.^188,189

In one study,¹⁹⁰ buprenorphine (Buprenex) did not increase biliary pressure, but further controlled investigations are needed to substantiate this finding. Generally, biliary pressure increases and spasm begins within 5 minutes of parenteral opioid administration. These effects peak within 20 to 60 minutes, and values gradually return to normal over 1 to 2 hours.^191,192 Because the reported severity, intensity, and duration of biliary hypertension vary greatly, it is unlikely that any agent presently available has a clear advantage over another.¹⁸⁷

Opioid-induced biliary hypertension and sphincter of Oddi spasm can be reversed by parenteral glucagon or naloxone.^191,193 It is still unclear whether orally administered naloxone will have similar effects, although orally administered naloxone prevented opioid-induced constipation in one study.¹⁹⁴ It is unclear whether B.C. is having more pain because of an adverse drug effect or primary failure of meperidine. Because no consistent way exists to measure intraductal pressure clinically, it is recommended that he be given a longer-acting opioid, such as methadone 5 mg IV every 8 hours for pain.

 

Renal Colic

57. M.J., a 36-year-old woman with a history of urolithiasis, comes to the ED because of severe flank pain along with microscopic hematuria. She is diagnosed with renal colic by the ED physician who wishes to treat her pain with meperidine 100 mg IM, but M.J. does not want to take opioids. What can M.J. be given for her severe pain from her renal colic?

Renal colic is extremely painful, and patients often require parenteral opioid analgesics. No significant clinical difference is seen between any of the opioids for this type of acute analgesic indication. Because M.J. does not want to receive opioids, the choice of analgesics is limited. The parenteral nonsteroidal analgesic ketorolac is likely to be the best alternative.¹⁹⁵ It would be appropriate to start M.J. on ketorolac 15 mg IV every 6 hours as an alternative to the opioids for acute analgesia.

Posted in: General Care,Pain and Its Management