Must-read article: everything you didn’t realize you wanted to know about narcotic bowel syndrome

October 19, 2012, 11:58 am

★★★★★

 

The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology and Management. Grunkemeier DMS et al. Clin Gastrointerol Hepatol 2007 Oct;5:1126-1139.

Full text

TPR has discussed in the past how the important diagnosis of narcotic bowel syndrome (NBS) is often missed, causing patients to undergo unnecessary procedures (CT scans, laparotomies, etc) and endure escalating gastrointestinal pain and distress. These patients also experience considerable psychological suffering, both from unrelieved symptoms and the fact that they are often labelled as drug seekers. Finally, they can have morbidity and even mortality from the adverse effects of surgery and diagnostic testing, as well as treatment with ever-increasing doses of narcotic medication.

This must-read 2007 article — from the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders — contains the most comprehensive discussion I’ve seen to date of all aspects of NBS.  The entire text is available on-line free under the NIH Public Access program. Any physician who sees patients with gastrointestinal complaints should get a copy.

As the authors point out:

It has long been recognized that opiates affect gastrointestinal motility. These effects, known as opioid bowel (or gastrointestinal) dysfunction are manifest as constipation, nausea, bloating, ileum and sometimes pain. When pain is the predominant symptom, the condition has been termed narcotic bowel syndrome. NBS is characterized by the progressive and somewhat paradoxical increase in abdominal pain despite continued or escalating dosages of narcotics prescribed in an effort to relieve the pain.

Many physicians are still not aware that chronic narcotic use — in addition to decreasing GI motility and secretion — can increase pain sensation. In addition to pain, NBS can present with nausea, bloating, vomiting, and constipation. Lab tests are usually unremarkable. Abdominal x-rays often suggest partial bowel obstruction. Increasing doses of narcotics exacerbate symptoms, creating a vicious cycle. NBS can also occur in patients with functional GI disorders such as Crohn’s Disease or Irritable Bowel Syndrome treated with narcotics.

This is a diagnosis you don’t want to miss. I am aware of a case of a young woman who underwent endoscopy, colonoscopy, laparotomy, ERCP, and multiple CT scans in a fruitless effort to diagnose her chronic abdominal pain. On her umpteenth return visit to the emergency department, she was admitted to the hospital and given IV hydromorphone. She had a respiratory arrest which was not fatal but left her with persistent severe neurological deficits.

As I said, you don’t want to miss this diagnosis.

Related post:

Narcotic bowel syndrome: an important diagnosis you may not have heard of (I hadn’t)

To read my Emergency Medicine News column on NBS, click here.

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