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114 Biliary tract pain
n Summary and recommendations
First line: ketorolac (15–30 mg IV q6 h) buprenorphine (initial dose 0.3 mg
IV, then titrate)
Reasonable: morphine (initial dose 4–6 mg IV, then titrate)
Pregnancy: buprenorphine (initial dose 0.3 mg IV, then titrate)
Pediatric:
n NSAIDs (e.g. liquid naproxen 10 mg/kg PO BID)
n buprenorphine (initial dose 2–6 μg/kg IV, then titrate)
Special cases:
n opioid exposure prior to development of biliary colic: naloxone (initial dose
0.4 mg IV)
n operative intervention likely: buprenorphine (initial dose 0.3 mg IV, then
titrate); NSAIDs only after consultation with surgeon
n failure of, or ineligibility for, NSAIDs and opioids: propinoxate (20 mg IV)
References
1. Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of
the data and therapeutic implications in treating pancreatitis. Am J
Gastroenterol. 2001;96(4):1266–1272.
2. Staritz M, Poralla T, Manns M, et al. Effect of modern analgesic drugs (tramadol,
pentazocine, and buprenorphine) on the bile duct sphincter in man. Gut.
1986;27(5):567–569.
3. Staritz M. Pharmacology of the sphincter of Oddi. Endoscopy. 1988;20(Suppl
1):171–174.
4. Rosow CE. The clinical usefulness of agonist–antagonist analgesics in acute
pain. Drug Alcohol Depend. 1987;20(4):329–337.
5. Hubbard GP, Wolfe KR. Meperidine misuse in a patient with sphincter of Oddi
dysfunction. Ann Pharmacother. 2003;37(4):534–537.
6. Druart-Blazy A, Pariente A, Berthelemy P, et al. The underestimated role of
opiates in patients with suspected sphincter of Oddi dysfunction after cholecystectomy.
Gastroenterol Clin Biol. 2005;29(12):1220–1223.