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Query: UMLS:C0030193 (pain)
 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Biliary pain resulting from motility disorders is common and may be overlooked due to the difficulty of diagnosing the presence of these disorders. A sound, logical approach to the evaluation and treatment of these specific groups of disorders is essential. In patients who have a gallbladder, we initially exclude the presence of gallstones by use of transcutaneous ultrasonography. If a patient's symptoms are atypical, we initiate therapy (eg, antispasmodics) for irritable bowel syndrome. Subsequently, we perform a quantitative cholescintigraphy with a low-dose infusion of cholecystokinin in patients with typical symptoms and in those with persistent atypical symptoms. Those patients who have abnormally low gallbladder ejection fractions are subsequently referred for laparoscopic cholecystectomy. In postcholecystectomy patients, a standard approach should include obtaining serum liver associated laboratory chemistries, amylase and lipase levels, and a transcutaneous ultrasound to measure bile duct size. Endoscopic retrograde cholangiopancreatography (ERCP) is done to measure bile duct size, assess biliary duct emptying, and exclude other etiologies for pain. In patients with more than two abnormal findings on these tests (type I sphincter of Oddi dyskinesia), we recommend performing an empiric endoscopic biliary sphincterotomy. In patients with no objective abnormalities (type III sphincter of Oddi dyskinesia), it is appropriate to begin medical therapy with antispasmodics and calcium-channel antagonists. In individuals who have one or two abnormalities (type II sphincter of Oddi dyskinesia) we prefer endoscopic biliary sphincterotomy; however, these individuals are offered the opportunity to have endoscopic biliary manometry performed in order to establish a clear diagnosis. If patients refuse this procedure, after careful explanation of risks, alternatives, and possible benefits of the procedure, empiric endoscopic biliary sphincterotomy is performed.
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PMID:Biliary Tract Dysmotility. 1109 61

We report on our experience with laparoscopic cholecystectomy in 15 patients, 12 females and 3 males (mean age: 44 years), with chronic acalculous cholecystitis. These patients presented with recurrent episodes of biliary colic together with a dysmorphic or dysfunctioning gallbladder as confirmed by ultrasound and/or cholescintiscan with 99m-Tc HIDA performed in fasting conditions and after meals. First of all, we considered the possible presence of concomitant digestive disease (peptic ulcer disease, recurrent pancreatitis, irritable bowel syndrome, chronic hepatitis) potentially responsible for the pain. Ultrasound investigations revealed a pathological gallbladder in 10 patients. Cholecystectomy was curative in 8/10. Cholescintiscan revealed a pathological gallbladder in 8 patients and cholecystectomy was curative in only 5 of these. No postoperative deaths or significant complications occurred. The mean duration of the operation (35 vs 48 min) and hospital stay (2.1 vs 2.8 days) were reduced in comparison to 346 cholecystectomies performed for gallstones. After 6-36 months' follow-up, resolution of symptoms was successful in 10/15 cases (66.6%); in 3 cases, only dyspepsia was reduced, whilst in the other 2 cases, who also presented concomitant irritable bowel syndrome and gastroduodenitis, there was no improvement in pain. In all but the latter two cases (86.6%), histological examination revealed chronic gallbladder inflammation. In conclusion, laparoscopic cholecystectomy was curative (66.6%) or led to an improvement in symptoms (20%) in patients with chronic acalculous cholcystitis. Cholescintiscans were not always diagnostic for the disease, whereas ultrasound findings were more useful as an indication for surgery.
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PMID:[Diagnostic problems and results of laparoscopic cholecystectomy in chronic acalculous cholecystitis]. 1119 May 28

Ketorolac is a nonsteroidal anti-inflammatory medication that is used widely for pain management. Its effects are mediated through the inhibition of prostaglandins, which makes it uniquely different from opioids in relieving pain. We conducted a randomized, prospective, double blind study of patients presenting to our Emergency Department (ED) with a diagnosis of acute biliary colic. Study patients were randomized into one of two treatment groups, meperidine 1.5 mg/kg with a maximum dose of 100 mg or ketorolac 60 mg given intramuscularly (i.m.). The patients rated their pain before and 30 min after medication on a scale of 1 to 10 using a Visual Analog Pain Scale. Overall pain relief was compared between the two groups using a two-sample t test. Thirty patients were enrolled in the study, 16 in the ketorolac group and 14 in the meperidine group. Patients ranged in age from 18 to 71 years and 6 (20%) were male. The average pain score at time 0 was 7.6 for the ketorolac group and 7.3 for the meperidine group. Pain relief at time 30 min was 3.8 in the ketorolac group and 3.9 in the meperidine group, which was not statistically different. The mean global pain score and need for an emergency cholecystectomy were similar in the two groups. Rescue medication for additional analgesia at 30 min was needed in 4 patients in the meperidine group and in 2 patients in the ketorolac group (28.6% versus 12.5%, respectively; NS). In this study of patients with acute biliary colic there was no significant difference in the pain relief achieved by using either ketorolac or meperidine.
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PMID:A prospective study comparing i.m. ketorolac with i.m. meperidine in the treatment of acute biliary colic. 1120 4

The most common infection of the hepatobiliary system and of the pancreas is the infestation with Ascaris lumbricoides. Pancreatobiliary ascariasis may present as recurrent biliary colic, acalculous cholecystitis, cholangitis, pancreatitis, or hepatic abscess. Although ultrasonography is a highly sensitive and specific method for the detection of the disease, endoscopy may have also therapeutical potential. The majority of these infections is registered in developing countries, but the number of reports from Europe and North America is increasing. So far there has not been any publication from Hungary. Both of the two reported patients were admitted the hospital with colic pain in the right hypochondrium. The laboratory parameters revealed cholestasis. The transabdominal ultrasonography was normal in one case, but suspected alien body in the choledochus in the other patient. Ascaris lumbricoides was identified with endoscopic procedure in the ductus choledochus in both cases. Endoscopic extraction of the worm resulted in cessation of the complaints in both patients, their cholestatic laboratory parameters became normal. Although the parasitic tests in the stool were negative in both patients and in their relatives, mebendazole therapy was administered.
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PMID:[Endoscopic treatment of cholestasis caused by Ascaris lumbricoides]. 1133 72

Spasm of the sphincter of Oddi is a well-recognized effect of the narcotic class of drugs. Although it is usually clinically silent, such spasm occasionally causes debilitating pain that may be mistaken for more serious disorders. We present the case of a patient who had undergone cholecystectomy previously, but in whom morphine given in the Emergency Department precipitated pain consistent with biliary colic; the pain resolved promptly after administration of naloxone. This entity may considered in the differential diagnosis of acute onset of colicky abdominal pain in the patient given narcotics.
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PMID:Relief by naloxone of morphine-induced spasm of the sphincter of Oddi in a post-cholecystectomy patient. 1235 95

To compare the analgesic efficacy and tolerability of intravenous (IV) ketorolac tromethamine with IV meperidine in the treatment of biliary colic, a prospective, randomized, double blind study was carried out upon a convenience sample of patients at a large inner city facility. Patients between the ages of 18 and 65 years of age with a history and physical examination consistent with biliary colic were enrolled over a 2-year period. Patients were randomly assigned to receive ketorolac 30 mg IV or meperidine 50 mg IV. Pain was quantified using a 4-point verbal rating system (VRS) as well as a visual analog scale (VAS). Patients were queried about their pain at times 0, 12 h, 1 h, and 2 h after administration of the study medication. Adverse effects were also recorded. A total of 324 patients completed the study protocol with 175 patients receiving ketorolac and 149 receiving meperidine. Patient demographics were similar for both groups with mean age for the ketorolac group of 36.1 years and for the meperidine group of 34.6 years. Both groups were predominantly Latino and over 80% of patients in both groups were female. No significant difference in pain control was found between ketorolac and meperidine in either the VAS or VRS for any time interval studied. The mean change in the VAS at time 2 h was 6.2 cm +/- 3.6 cm for the ketorolac group, compared with 6.7 cm +/- 3.6 cm for the meperidine group (p = 0.25). Although no significant difference was found in overall drug tolerability, patients receiving meperidine reported higher incidences of nausea and of dizziness than those receiving ketorolac (p = 0.009 and 0.003, respectively). Ketorolac tromethamine is a well-tolerated, effective medication in the treatment of acute biliary colic. It showed similar efficacy to meperidine with a decreased number of adverse effects.
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PMID:Comparison of intravenous ketorolac and meperidine in the treatment of biliary colic. 1242 13

Biliary pain is commonly reported in household surveys with the presumed cause being gallstones. When gallstones are absent or other abnormalities as a potential cause of similar pain do not exist, a different approach is necessary. Although trans-abdominal ultrasound can detect stones down to 3-5 mm, the advent of endoscopic ultrasound provides an even better definition for microlithiasis of < 3 mm. Duodenal aspiration of bile can further detect cholesterol microlithiasis or bilirubin granules, another potential source of biliary-type pain and perhaps even pancreatitis. Only in this way can acalculous gallbladder disease be clearly defined. The percentage of cholecystokinin-stimulated gallbladder emptying has been reputed to be the most sensitive diagnostic test for 'biliary dyskinesia', but abnormality of gallbladder emptying can be due to a smooth muscle defect of the gallbladder itself or heightened tone in the sphincter of Oddi. The value of surgical intervention has not been clearly established. The advent of laparoscopic cholecystectomy, however, has increased the number of patients with acalculous biliary disease who undergo surgery. Surgery is best done using impaired gallbladder emptying as the criterion for operation with improved outcome. Often, following cholecystectomy, biliary pain does not resolve the so-called 'post cholecystectomy syndrome'. Absence of the gallbladder as a pressure reservoir leaves the sphincter of Oddi as the prime determinant of bile duct pressure. Sphincter of Oddi dysfunction also exists in patients with an intact biliary tract and may become evident following cholecystectomy. Biliary manometry has clarified who might benefit from sphincterotomy. Choledochoscintigraphy is a non-invasive preliminary test. Advent of visceral hypersensitivity and better definition of this entity has shown, that in some of these patients with type III sphincter of Oddi, dysfunction appears to reside in duodenal hyperalgesia. It is clear that improved criteria are required to perform gallbladder emptying and better techniques to detect visceral hypersensitivity. Nonetheless, functional biliary pain in the absence of gallstone disease is a definite entity and a challenge for clinicians.
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PMID:Acalculous biliary pain: new concepts for an old entity. 1297 5

Meperidine is FDA-approved for relieving moderate to severe pain and has been widely used since its introduction in the 1930s. However, the drug is no longer considered a first-line analgesic. Many clinicians recommend that meperidine be removed from health-systems or that its use be restricted, due to concerns about adverse reactions, drug interactions, and normeperidine neurotoxicity. In addition, clinical evidence shows that meperidine has no advantage over other opioids for biliary colic or pancreatitis. The formulary status of meperidine has been extensively discussed at University of Utah Hospitals and Clinics. The Pharmacy and Therapeutics Committee has been working with hospital staff to assess the impact of either removing meperidine from the formulary, or limiting its use. The Drug Information Service developed this document to help pharmacists respond to prescribers' questions and to alleviate the prescribers' concerns about these changes. Information is provided comparing meperidine with other opioids, including dosage equivalency, pharmacodynamics, pharmacokinetics, cost, adverse effects, and drug interactions. Where available, alternatives to meperidine are suggested for various indications.
J Pain Palliat Care Pharmacother 2002
PMID:Removing meperidine from the health-system formulary--frequently asked questions. 1464 Mar 55

Tramadol, a centrally acting analgesic structurally related to codeine and morphine, consists of two enantiomers, both of which contribute to analgesic activity via different mechanisms. (+)-Tramadol and the metabolite (+)-O-desmethyl-tramadol (M1) are agonists of the mu opioid receptor. (+)-Tramadol inhibits serotonin reuptake and (-)-tramadol inhibits norepinephrine reuptake, enhancing inhibitory effects on pain transmission in the spinal cord. The complementary and synergistic actions of the two enantiomers improve the analgesic efficacy and tolerability profile of the racemate. Tramadol is available as drops, capsules and sustained-release formulations for oral use, suppositories for rectal use and solution for intramuscular, intravenous and subcutaneous injection. After oral administration, tramadol is rapidly and almost completely absorbed. Sustained-release tablets release the active ingredient over a period of 12 hours, reach peak concentrations after 4.9 hours and have a bioavailability of 87-95% compared with capsules. Tramadol is rapidly distributed in the body; plasma protein binding is about 20%. Tramadol is mainly metabolised by O- and N-demethylation and by conjugation reactions forming glucuronides and sulfates. Tramadol and its metabolites are mainly excreted via the kidneys. The mean elimination half-life is about 6 hours. The O-demethylation of tramadol to M1, the main analgesic effective metabolite, is catalysed by cytochrome P450 (CYP) 2D6, whereas N-demethylation to M2 is catalysed by CYP2B6 and CYP3A4. The wide variability in the pharmacokinetic properties of tramadol can partly be ascribed to CYP polymorphism. O- and N-demethylation of tramadol as well as renal elimination are stereoselective. Pharmacokinetic-pharmacodynamic characterisation of tramadol is difficult because of differences between tramadol concentrations in plasma and at the site of action, and because of pharmacodynamic interactions between the two enantiomers of tramadol and its active metabolites. The analgesic potency of tramadol is about 10% of that of morphine following parenteral administration. Tramadol provides postoperative pain relief comparable with that of pethidine, and the analgesic efficacy of tramadol can further be improved by combination with a non-opioid analgesic. Tramadol may prove particularly useful in patients with a risk of poor cardiopulmonary function, after surgery of the thorax or upper abdomen and when non-opioid analgesics are contraindicated. Tramadol is an effective and well tolerated agent to reduce pain resulting from trauma, renal or biliary colic and labour, and also for the management of chronic pain of malignant or nonmalignant origin, particularly neuropathic pain. Tramadol appears to produce less constipation and dependence than equianalgesic doses of strong opioids.
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PMID:Clinical pharmacology of tramadol. 1550 85

Many patients with gallstones can be managed expectantly. Generally, only persons with symptoms related to the presence of gallstones (e.g., steady, nonparoxysmal pain lasting four to six hours located in the upper abdomen) or complications (such as acute cholecystitis or gallstone pancreatitis) warrant surgical intervention. Biliary pain is alleviated by cholecystectomy in the majority of cases. Laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones. Medical management strategies are mostly palliative and are not widely supported. Patients with longer-lasting biliary pain, in combination with abdominal tenderness, fever, and/or leukocytosis, require an ultrasound evaluation to help establish a diagnosis of acute cholecystitis. Once a patient is diagnosed, having cholecystectomy early in the course of the disease can significantly reduce the hospital stay.
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PMID:Management of gallstones. 1612 53


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