Biliary spasm

Increase in sphincter tone Biliary spasm, urinary retention (varies among agents)... 

As for all opioids common adverse effects are constipation, slowed gastric emptying and biliary spasm. Urinary retention may occur. There is an increased risk of respiratory depression in young children and in the elderly. Allergic reactions are rare, but wheals and pain at the injection site due to histamine release may occur. CNS depressants will potentiate the depressant effects of morphine and that of other opioids. 

Butorphanol is generally believed to have a much smaller effect on biliary pressure than morphine, fentanyl, or pethidine, but 2 mg has caused biliary spasm (3). 

BILIARY TRACT After the subcutaneous injection of 10 mg morphine sulfate, the sphincter of Oddi constricts, and the pressure in the common bile duct may rise more than tenfold within 15 minutes this effect may persist for 2 hours or more. Fluid pressure also may increase in the gallbladder, producing symptoms that vary from epigastric distress to typical biliary cohc. All opioids can cause biliary spasm. Atropine only partially prevents morphine-induced biliary spasm, but opioid antagonists prevent or relieve it. Nitroglycerin (0.6-1.2 mg) administered sublingually also decreases the elevated intrabiliary pressure. 

Smooth muscle Opioids cause contraction of biliary tract smooth muscle (which may cause biliary spasm), increased ureteral and bladder sphincter tone, and a reduction in uterine tone that may contribute to prolongation of labor. 

Propantheline bromide is used in the treatment of acute and chomic panereatitis, pylorospasm, gastritis, and ureterie and biliary spasm. It also finds its application as an adjunct in the treatment of gastric and duodenal ulcer. 

The appeal of NSAIDs, COX-2 inhibitors, and acetaminophen is that the unfavorable opioid-related side effects may be mitigated. Although opioids are potent and effective drugs for pain control, they are well known for adverse side effects such as excessive sedation, dose-dependent respiratory depression, pruritus, nausea, vomiting, biliary spasm, hypotension, constipation, and urinary retention. Minimizing these effects has the advantage of earlier ambulation post-operatively and consequently a shorter hospitalization, as weU as higher patient satisfaction and quality of recovery. 

When used as monotherapy, IV acetaminophen does not cause excessive sedation, biliary spasm, respiratory depression, nausea, vomiting, ileus, or pruritus associated with opioids, nor the harmful cardiovascular, renal, gastrointestinal, and hematological effects associated with NSAIDs and COX-2 inhibitors. 

CNS agitation, dependency, CNS depression, lethargy, restlessness, sedation Cardiovascular bradycardia, orthostatic hypotension, palpitations, tachycardia Gastrointestinal nausea, vomiting, anorexia, constipation, paralytic ileus, biliary spasm, cholestatic jaundice Genitourinary urinary retention Respiratory respiratory depression, respiratory paralysis... 

Digestive system g agonists decrease secretion of stomach acid, reduce gastric motility, and prolong gastric emptying. Pancreatic, biliary, and intestinal secretions are reduced. Intestinal transit is also slowed. Peristaltic movements are reduced, but tone is increased, sometimes causing spasm. As a result, constipation is a frequent problem with opioid use. Bile duct pressure is also increased by opioids. 

Spasmolytics. N-Butylscopolamine (p. 104) is used for the relief of painful spasms of the biliary or ureteral ducts. Its poor absorption (N.B. quaternary N absorption rate <10%) necessitates parenteral administration. Because the therapeutic effect is usually weak, a potent analgesic is given concurrently, e.g., the opioid meperidine. Note that some spasms of intestinal musculature can be effectively relieved by organic nitrates (in biliary colic) or by nifedipine (esophageal hypertension and achalasia). 

Biliary tract surgery Use with caution in patients about to undergo biliary tract surgery because it may cause spasm of the sphincter of Oddi. 

Meperidine differs from morphine in that it has far less antitussive effect and little constipative effect. The drug is particularly useful in cancer patients and in pulmonary patients, in whom the cough reflex must remain intact. However, it does have more seizure-inducing activity than morphine. Although meperidine produces spasms of the biliary tract and colon, such spasms are of shorter duration than those produced by morphine. 

Gastrointestinal colic (as antispas-modic) Belladonna alkaloids relax the spasm of smooth muscles of intestinal, urinary and biliary tract. They are also effective in functional and drug induced diarrhoea, to relieve urinary urgency and frequency and enuresis in children. They are also used to reduce gastric secretion in peptic ulcer patients. Also, used to reduce the excessive sweating in tuberculosis and sweating and salivation in parkinsonian patients. 

The acute, severe pain of renal and biliary colic often requires a strong agonist opioid for adequate relief. However, the drug-induced increase in smooth muscle tone may cause a paradoxical increase in pain secondary to increased spasm. An increase in the dose of opioid is usually successful in providing adequate analgesia. 

Tertiary amines used for their antispasmodic properties are dicyclomine hydrochloride (Ben-tyl, others), oxyphencyclimine hydrochloride (daricon), flavoxate hydrochloride (Uripas), and oxyburynin chloride (Ditropan). The latter two are indicated specifically for urological disorders. These agents appear to exert some nonspecific direct relaxant effect on smooth muscle. In therapeutic doses they decrease spasm of the gastrointestinal tract, biliary tract, ureter, and uterus characteristic atropine-like effects on the salivary glands and the eye also are seen with oxybutynin. 

For the relief of pain arising from spasm of smooth muscle, as in renal or biliary colic, morphine is frequently employed. Other measures including antispasmodics such as atropine, atropine substitutes, theophylline, nitrites, and heat may be employed first however, if they are ineffective, meperidine, methadone, or opiates must be used. Morphine relieves pain only by a central action and may aggravate the condition producing the pain by exaggerating the smooth muscle spasm. Morphine may also be indispensable for the relief of pain due to acute vascular occlusion, whether this be peripheral, pulmonary, or coronary in origin. In painful acute pericarditis, pleurisy, and spontaneous pneumothorax, morphine is likewise indicated. Carefully chosen and properly spaced doses of codeine or morphine may occasionally be necessary in pneumonia to control pain, dyspnea, and restlessness. Traumatic pain arising from fractures, bums, etc., frequently requires morphine. In shock, whether due to trauma, poisons, or other causes, morphine may be required to relieve severe pain. 

Meperidine has replaced morphine to a large extent in medical practice because of the physician s reluctance to use an opiate and the belief that meperidine manifests less undesirable side effects than does morphine. However, both of these assumptions are ill founded. Addiction to meperidine is much less amenable to treatment than is addiction to morphine. Meperidine, similar to morphine and codeine, causes spasm of the upper gastrointestinal tract and typical attacks of biliary colic in biliary tract disease. Meperidine, in doses giving an equal analgesic effect, induces as much respiratory depression as does morphine. Similar to morphine, it also crosses the placental barrier and must therefore be used cautiously in the latter stages of labor. 

The opiates cause constipation by inducing spasm of the stomach and intestines, presumably by the stimulation of opioid receptors in the myenteric plexus and reducing the release of acetylcholine. This property can be used therapeutically for the symptomatic relief of diarrhoea. Biliary colic and severe epigastric pain can occur because of the contraction of the sphincter of Oddi and the resulting increase in pressure in the biliary ducts. 

Morphine has been reported to cause biliary pain by cansing contraction of the sphincter of Oddi and the lower common bile duct. Other opioids may be preferred over morphine in patients with biliary pain or where biliary tract spasm is undesirable [2]. 

Morphine can reduce biliary secretions, and patients with biliary colic may experience an exacerbation of pain after morphine. Similarly, opioids such as morphine can cause bile duct spasm [27]. Opioid-induced spasm of the sphincter of Oddi and increased intrabiliary pressure may result in a secondary increase in LFTs [55]. 

Morphine can reduce biliary secretions and can cause bile duct spasm, which could cause reduced biliary flow, potentially exacerbating this patient s problems. In practice this does not appear to be clinically significant. 

Pain due to spasm of visceral smooth muscle, e.g. biliary, renal colic, when severe, requires a substantial dose of morphine, pethidine or buprenorphine. These drugs themselves cause spasm of visceral smooth muscle and so have a simultaneous action tending to increase the pain. Phenazocine and buprenorphine are less liable to cause spasm. An antimuscarinic drug such as atropine or hyoscine may be given simultaneously to antagonise this effect. 

Intrabiliaiy pressure may rise substantially after morphine (as much as 10 times in 10 minutes), due to spasm of the sphincter of Oddi. Sometimes biliary colic is made worse by morphine, presumably in a patient in whom the dose happens to be adequate to increase intrabiliary pressvue, but insufficient to produce more than slight analgesia. In patients who have had a cholecystectomy this can produce a syndrome sufficiently like a myocardial infarction to cause diagnostic confusion. Naloxone may give dramatic symptomatic relief, as may glyceryl trinitrate. Another result of this action of morphine is to dam back the pancreatic juice and so cause a rise in the serum amylase concentration. Morphine is therefore best avoided in pancreatitis but buprenorphine has less of this effect. 

In general, when morphine is used and the smooth muscle effects are objectionable, atropine may be given simultaneously to antagonise spasm. Unfortunately this does not always effectively oppose the rise of pressure induced in the biliary system, nor does it restore bowel peristalsis. Glyceryl trinitrate will relax morphine-induced spasm. 

Smooth muscle is relaxed. In the gastrointestinal tract there is reduction of tone and peristalsis. Muscle spasm of the intestinal tract induced by morphine is reduced, but such spasm in the biliary tract is not significantly affected. Atropine relaxes bronchial muscle, an effect that is useful in some asthmatics. Micturition is slowed and urinary retention may be induced especially when there is pre-existing prostatic enlargement. 

The effect of nalbuphine 20 mg intravenously on biliary tract pressure was examined in 10 patients undergoing surgery for symptomatic cholelithiasis. There was a statistically significant rise in pressure 30 minutes after the administration of nalbuphine, but this did not have any apparent deleterious effects (11). Others have suggested that nalbuphine reverses opioid-induced spasm of the sphincter of Oddi (SEDA-17, 88). 

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