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Biliary tract pain
STEPHEN H. THOMAS AND JONATHAN S. ILGEN
n Agents
n Opioids
n NSAIDs
n Cholecystokinin receptor agents
n Spasmolytics/anticholinergics
n Calcium channel blockers
n Evidence
OPIOIDS
Opioids are the benchmark against which other biliary tract analgesics are
assessed. Historically, the distinction between opioids used for biliary tract
pain (BTP) has been based upon differential effects on Oddi’s sphincter. We
believe that clinical tradition has tended to exaggerate the magnitude of, and
even mischaracterize, these differential effects. The evidence reveals that, in
terms of Oddi sphincter effects and induction of biliary tract spasm, there are
no significant differences between morphine and other pure mu receptor
agonists. 1 There is thus no evidence basis for the common practice of substituting
meperidine (pethidine) for morphine when treating BTP.
While the pure mu agonists are generally equivalent for BTP, there are other
opioid considerations that clinicians should keep in mind. Pentazocine is to be
avoided, since it increases frequency and duration of bile duct sphincter contraction;
there are no such untoward effects from tramadol or buprenorphine.
2,3,4 In fact, buprenorphine is arguably the opioid of choice for BTP,
since it even relieves pain from meperidine-induced spasm of Oddi’ssphincter. 5
The well-known association between pure mu agonism and biliary tract
spasm translates into an occasional role for naloxone for BTP in patients
(including those post-cholecystectomy) who have received opioids. 6,7
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