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Jesus Salas Noain, MD
Drexel Hill, Pennsylvania
Jesus M. Salas Noain, MD1, Sindusha Gudipally, MD2, Shengnan Zheng, MD2, Arun Minupuri, MD3, Rafael Amaral, MD2, Oleg Kinachtchouk, MD2
1Mercy Catholic Medical Center, Drexel Hill, PA; 2Mercy Catholic Medical Center, Darby, PA; 3Mercy Health System, Yeadon, PA
Introduction: Several studies have shown an increase in biliary pressure after administration of narcotics. Direct sphincter of Oddi (SO) manometry has demonstrated that the sphincter of Oddi is particularly sensitive to all narcotics including morphine, meperidine, pentazocine, fentanyl, and codeine. Opiates are known to increase the phasic wave (via mu receptors) as well as basal pressure (via non-mu receptors) of the SO. This case report illustrates a possible difference in affinity among narcotics to these receptors leading to SO dysfunction.
Case Description/Methods: 54 years old male with a history of knee meniscal repair presented to the emergency department with epigastric pain associated with nausea and vomiting for one day. The patient described the pain as severe, sharp, and worsening with food intake. He denied alcohol use, illicit drug abuse, or taking any medication. He had a lipase of 200 U/L, with normal transaminases and bilirubin. Physical exam revealed severe tenderness on the epigastric area. CT showed acute edematous interstitial pancreatitis. Ultrasound of the liver and HIDA scan demonstrated a patent cystic and common bile duct. The patient was started on IV fluids and IV morphine. The patient reported slight relief of abdominal pain with low doses of IV morphine. Therefore, the frequency and dose of morphine were increased. Interestingly, the patient reported acute worsening of the epigastric pain a few minutes after administration of higher morphine doses lasting for approximately 2 hours. Laboratory studies drawn during pain exacerbation showed no elevation of transaminases or lipase. IV morphine was discontinued resulting in immediate abdominal pain relief. Upon further questioning, the patient reported recent use of oxycodone and tramadol for knee pain without any side effects from these medications.
Discussion: Opiates have been reported to incite biliary colic pain and their effect on the SO represents the most likely etiology. Our patient showed a particular susceptibility to morphine, but not to other narcotics previously prescribed suggesting a possible variable effect on the OD from different narcotics. It is worth noting that our patient denied cholecystectomy, a known risk factor that predisposes to SO dysfunction. In conclusion, SO dysfunction should be considered in patients with pancreatitis reporting worsening of abdominal pain while on opioids. SO manometry is contraindicated during acute pancreatitis, therefore discontinuation of the narcotic helps guide diagnosis.
Citation: Jesus M. Salas Noain, MD; Sindusha Gudipally, MD; Shengnan Zheng, MD; Arun Minupuri, MD; Rafael Amaral, MD; Oleg Kinachtchouk, MD. P0964 - VARIABLE EFFECT ON THE SPHINCTER OF ODDI FROM NARCOTICS. Program No. P0964. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.