Analgesia and assessment of abdominal pain
Date First Published:
March 1, 2000
Last Updated:
April 26, 2001
Report by:
Kevin Mackway-Jones, Consultant (Manchester Royal Infirmary)
Search checked by:
Magnus Harrison, Manchester Royal Infirmary
Three-Part Question:
In a [patients with abdominal pain] does [analgesia prior to surgical consultation] affect [the accuracy of surgical diagnosis]?
Clinical Scenario:
A 12 year old girl presents to the emergency department with "tummy ache". The history and examination are suggestive of appendicitis. You call the surgical team but they are unable to attend for one hour as they are tied up in theatre. You wonder if giving analgesia will affect the accuracy of the surgical diagnosis.
Search Strategy:
Medline 1966-12/99 using the OVID interface.
Search Details:
([ exp abdominal pain OR abdominal pain$.mp OR exp peritonitis OR peritonitis.mp] OR {[exp pain OR pain$.mp] AND [abdom$.mp OR exp stomach OR stomach.mp OR tummy.mp]}) AND [exp analgesia OR exp morphine OR exp analgesia, opioid OR analgesi$.mp maximally sensitive RCT filter) LIMIT to human and english.
Outcome:
78 papers of which 73 irrelevant or of insufficient quality for inclusion. The remaining 5 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Analgesia in the acute abdomen. Zoltie N and Cust MP. 1986, UK | 288 patients with acute abdominal pain. Buprenorphine 200µg vs buprenorphine 400µg vs placebo |
PRCT | Pain relief | Proportional to dosage | |
| Clinical diagnosis | Not affected | ||||
| Safety of early pain relief for acute abdominal pain. Attard AR, Corlett MJ, Kidner NJ et al. 1992, UK | 100 consecutive patients admitted to a surgical firm. Papaveretum 20mg vs N saline |
PRCT | Pain score | Significantly better with papaveretum (P < 0.0001) | Papaveretum no longer used |
| Tenderness score | Significantly better with papaveretum (P < 0.0001) | ||||
| Incorrect diagnosis | 2 after papaveretum vs 9 after saline | ||||
| Intravenous morphine for early pain relief in patients with acute abdominal pain. Pace S and Burke TF. 1996, USA | 71 adult patients with acute, atraumatic abdominal pain in an emergency department Morphine IV (35) vs N Saline (36) |
PRCT | Pain score | Significantly better with morphine (P < 0.001) | |
| Accuracy of provisional diagnosis | No difference | ||||
| Accuracy of final diagnosis | No difference | ||||
| The use of analgesics in patients with acute abdominal pain. LoVecchio F, Oster N, Sturmann K et al. 1997, USA | 48 patients with acute abdominal pain Morphine 10mg vs morphine 5mg vs placebo |
PRCT | Change in physical examination | Significant changes in both morphine groups | Very small numbers |
| Delay in diagnosis | No diagnostic delay in any group | ||||
| Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate - a randomized trial. Vermeulen B, Morabia A, Unger PF et al. 1999, Switzerland | 340 patients aged 16 years or more with suspected appendicitis Morphine IV (175) vs placebo (165) |
PRCT | Pain relief | Greater in morphine group | |
| Sensitivity and specificity of ultrasound diagnoses | No significant difference | ||||
| Appropriateness of the decision to operate | No significant difference |
Author Commentary:
All the studies show considerable benefit to the patient from pain relief with either no change in diagnostic accuracy or an improvement.
Bottom Line:
Patients with acute, atraumatic abdominal pain should have analgesia administered without delay.
References:
- Zoltie N and Cust MP.. Analgesia in the acute abdomen.
- Attard AR, Corlett MJ, Kidner NJ et al.. Safety of early pain relief for acute abdominal pain.
- Pace S and Burke TF.. Intravenous morphine for early pain relief in patients with acute abdominal pain.
- LoVecchio F, Oster N, Sturmann K et al.. The use of analgesics in patients with acute abdominal pain.
- Vermeulen B, Morabia A, Unger PF et al.. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate - a randomized trial.