1) The document discusses the effects of different analgesic medications like morphine and meperidine on the sphincter of Oddi in patients with acute pancreatitis. 2) While morphine is known to cause sphincter of Oddi spasms, studies have found conflicting evidence on whether meperidine increases bile pressure and sphincter activity less than morphine. 3) Both direct and indirect studies produced mixed results, with some finding no significant differences between morphine and meperidine in sphincter pressure and activity, while others detected higher pressures and frequencies with morphine.

1. Evidence Based MedicineEvidence Based Medicine
R1R1 黃俊清黃俊清
96.09.1396.09.13

2. BackgroundBackground
 Patient: a young female with a history ofPatient: a young female with a history of
gallstone admitted due to pancreatitisgallstone admitted due to pancreatitis
 Problem: analgesics selectionProblem: analgesics selection

3. PICOPICO
 P: A patient of acute pancreatitisP: A patient of acute pancreatitis
 I: Analgesics with morphineI: Analgesics with morphine
 C: or other narcotics such as demerolC: or other narcotics such as demerol
 O: Analgesic effectO: Analgesic effect

10. Narcotic Analgesic Effects on theNarcotic Analgesic Effects on the
Sphincter of Oddi:Sphincter of Oddi:
A Review of the Data and TherapeuticA Review of the Data and Therapeutic
Implications in Treating PancreatitisImplications in Treating Pancreatitis
Donald R. Thompson, M.D.Donald R. Thompson, M.D.
Gastroenterology Division, Department of InternalGastroenterology Division, Department of Internal
Medicine, Baylor University Medical Center, Dallas, TexasMedicine, Baylor University Medical Center, Dallas, Texas
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

11. IntroductionIntroduction
 Morphine causes sphincter of Oddi (SO)Morphine causes sphincter of Oddi (SO)
spasmsspasms
 Meperidine does not elevate SO pressureMeperidine does not elevate SO pressure
 Dependence, side effect, and drug-drugDependence, side effect, and drug-drug
interactionsinteractions
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

12. Materials and MethodsMaterials and Methods
 Medline search with keywordsMedline search with keywords
 Published in English from 1966 to 2001Published in English from 1966 to 2001
 Contact the manufacturers of meperidineContact the manufacturers of meperidine
for reports on studiesfor reports on studies
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

13. Result (1)Result (1)
 Study on opossums (Study on opossums ( 負鼠負鼠 ))
 Migrating motor complexes of theMigrating motor complexes of the
duodenum increases, but not SOduodenum increases, but not SO
 No significant change of biliary pressureNo significant change of biliary pressure
in animals with a gallbladderin animals with a gallbladder
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

14. Result (2)Result (2)
 Increase of SO toneIncrease of SO tone  stone dislodgedstone dislodged 
relief of biliary colic? Greenstein(1972)relief of biliary colic? Greenstein(1972)
 No significance between pentazocineNo significance between pentazocine
(114%) and meperidine (93%)(114%) and meperidine (93%)
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

15. Result (3): Indirect measureResult (3): Indirect measure
Investigator Method Medication Biliary pressure
(baseline)
Biliary pressure
(postmedication)
Coelho(1985)
N=7
Postcholecystectomy
in opossum
Pentazocine
Morphine
Meperidine
Tramadol
13.1±2.9
13.2±2.3
12.9±2.3
12.4±2.6
(mmHg)
17.0±2.1
17.2±1.5
16.2±1.9
13.3±2.5
Greenstein(1972)
N=12
Postop T tube Pentazocine
Meperidine
80
78
(mmH2
O)
168
151
Economou(1971)
N=31
Postop T tube Morphine
Meperidine
Pentazocine
Phenazocine
0
0
0
0
(cm of bile)
8.5±1.7
3.9±0.8
2.8±0.9
3.8±1.8
Mc
Cammon(1983)
N=56
Intraop post-
cholecystectomy
Fentanyl
Butorphanol
Nalbuphine
14.3±0.8
13.6±0.7
14.4±0.9
(cm of saline)
17.6
15.2
15.3

16. Result (4)Result (4)
 Hepatobiliary scans: HIDAHepatobiliary scans: HIDA
 Narcotics: all delay more than 60 minsNarcotics: all delay more than 60 mins
 Morphine : meperidine = 200 : 100 minsMorphine : meperidine = 200 : 100 mins
 Morphine delayed > 3.5h in 75%Morphine delayed > 3.5h in 75%
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

17. Result (5)Result (5)
 Indirect measure: unphysiologicalIndirect measure: unphysiological
 Intraopreative: anesthesiaIntraopreative: anesthesia
 Postoperative: artificiallyPostoperative: artificially
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

18. Result (6)Result (6)
 Direct measurement byDirect measurement by SO manometrySO manometry
using ERCPusing ERCP
 SO is sensitive to morphineSO is sensitive to morphine
 Naloxone have little effect on SONaloxone have little effect on SO
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

19. Result (7)Result (7)
 Direct comparing morphine to meperidineDirect comparing morphine to meperidine
with SO manometry in 1990 by Thunewith SO manometry in 1990 by Thune
 Phasic wave frequency↑in morphinePhasic wave frequency↑in morphine
 No significanceNo significance in SO pressurein SO pressure
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

20. Result (8)Result (8)
 Duration of contractionDuration of contraction↓↓
 Frequency of contractionFrequency of contraction↑↑
 No increaseNo increase in basal SO pressurein basal SO pressure
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

21. DiscussionDiscussion
 Indirect: all narcotics invoked bile stasisIndirect: all narcotics invoked bile stasis
 Direct: frequency↑ and amplitude ↑Direct: frequency↑ and amplitude ↑
 Morphine increases SO pressureMorphine increases SO pressure only inonly in
one study.one study. Helm(1988)Helm(1988)
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

22. ConclusionConclusion
 No definite benefit of meperidineNo definite benefit of meperidine
 No absolute contraindication of morphineNo absolute contraindication of morphine
 No evidenceNo evidence of meperidine better thanof meperidine better than
morphinemorphine
The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

23. Thanks for your attention!Thanks for your attention!