Acute Abdominal Pain and Analgesia: A Critical Review

Acute abdominal pain: An insight

Acute abdominal pain is a nociceptive pain response and is one of the commonest presentations seen in the primary outpatient care and emergency settings. It is the presenting complaint in ~1.5% of office-based visits and in about 5% of emergency department visits.¹Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008;77(7):971-8.   In both these settings, the condition can be reflective of a wide array of underlying disorders, ranging from benign, selflimited disease forms to life-threatening emergencies relevant to specialist care.²Cartwright SL, Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015;91(7):452-9.   ³Ditkofsky NG, Singh A, Avery L, et al. The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol.2014;21(6):615-24.   ⁴Falch C, Vicente D, Haberle H, et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain. 2014;18(7):902-13.  2-4 Nevertheless, the healthcare burden could be typically significant for the general practitioners (GPs). This is because most abdominal pain is benign and GPs care for a major proportion (up to 3/4th) of such cases. Accordingly, they face the challenge of meeting a wide and inhomogeneous spectre of complaints when dealing with population with acute abdominal pain.⁵Brekke M, Eilertsen RK. Acute abdominal pain in general practice:tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care. 2009;27(3):137-40.  

Causes of acute abdominal pain:Dependent on pain location

Acute abdominal pain has a very broad and of ten confusing differential diagnoses.⁶del Arco Galan C, Parra Gordo ML, Garcia-Casasola Sanchez G. Imaging tests in acute abdominal pain. Rev Clin Esp.2008;208(10):520-4.   ⁷Flasar MH, Cross R, Goldberg E. Acute abdominal pain. Prim Care.2006 Sep;33(3):659-84, vi.   ⁸Cole E, Lynch A, Cugnoni H. Assessment of the patient with acute abdominal pain. Nurs Stand. 2006;20(39):67-75.  The causative clinical conditions encompass multiple organ systems, including gastrointestinal, gynecologic, urologic, vascular, and musculoskeletal system, and can be broadly categorized into urgent (conditions requiring treatment within 24 hour) and non-urgent (conditions not requiring treatment within 24 hour to prevent complications).Often, the most common non-urgent causes are nonspecific abdominal pain, labeled in up to one-fifth of patients,⁵Brekke M, Eilertsen RK. Acute abdominal pain in general practice:tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care. 2009;27(3):137-40.   and gastrointestinal diseases; whereas most common urgent causes include acute appendicitis, acute diverticulitis, and bowel obstruction. Figure 1 depicts some most frequent diagnosis for acute abdominal pain in primary care, but the list of diseases could be very extensive (Table 1).¹Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008;77(7):971-8.  

Diagnosis of acute abdominal pain

Diagnostic practices for acute abdominal pain often show wide variations, and are mostly based on physicians’ preferences in real time. In addition, as complaints of acute abdominal pain can be very non-specific at the start, this increases the difficulty of an accurate identification of the underlying cause. Nevertheless, an approach to narrowing the differential diagnosis of acute abdominal pain would typically be based on history, physical examination, and laboratory testing [such as, c-reactive protein (CRP)], and,if required, imaging.⁹Mahler CW, Boermeester MA, Stoker J, et al. Diagnostic modalities in diagnosis of adult patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2004;148(50):2474-80.   It is though suggested that work-up be preceded by consideration of a uniform terminology to avoid difficulty in interpretation of patients with acute abdominal pain. In this context, while acute abdominal pain is often considered as sudden onset of abdominal pain that lasts for < 24 hours; some experts propose the use of the following definition for acute abdominal pain:pain of non-traumatic origin with a maximum duration of five days.¹⁰Gans SL, Pols MA, Stoker J, et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23-31.  

For a thorough pain related history, patients’ may be asked where they feel the pain (location), what kind of pain it is (character), when and how it began (onset), how bad it is (intensity), and where else they feel it,what makes it worse or better, how it has changed over time, and whether they have ever had it before (Table 2).¹¹Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012; 5:789-797.    ¹²Abdullah M, Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Medica Indonesiana 2012;44(4): 344-350.   Subsequently, clinical evaluation in all cases should focus on common conditions that cause abdominal pain as well as on more serious conditions with aim to differentiate between non-urgent and urgent causes,because further management would differ accordingly.¹³Flasar MH, Goldberg E. Acute abdominal pain. Med Clin North Am.2006;90(3):481-503.   Such clinical assessment – driven mostly by pain location-is of high value in primary care practice, because even if the diagnostic accuracy of physical examination and clinical assessment is insufficient to correctly identify the diagnosis, it can often discriminate between urgent and non-urgent causes.¹⁰Gans SL, Pols MA, Stoker J, et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23-31.   For instance; positive palpatory findings like rigidity and guarding are helpful diagnostic indicators if acute appendicitis or peritonitis is suspected, even if negative palpatory findings are of little value in excluding these conditions.¹⁴Moll van Charante E, de Jongh TO. Physical examination of patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2011;155:A2658.  

Diagnostic imaging

Diagnostic imaging may be infrequently required in several common causes of acute abdominal pain seen in primary care practice; but is indicated if patient history, physical examination, and laboratory testing do not identify an underlying cause of pain, and if serious pathology remains a clinical concern (Table 3).²Cartwright SL, Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015;91(7):452-9.   To facilitate clinical decision making in such situations;the American College of Radiology (ACR) has developed clinical guidelines, the Appropriateness Criteria, based on the location of abdominal pain. This Appropriateness Criteria, facilitated by topographic classification, will help the physicians choose the most appropriate imaging study, when required in patients presenting with acute abdominal pain. Generally, conventional radiography has limited diagnostic value in assessment of most patients with abdominal pain, and is therefore often unnecessary.¹⁵Gans SL, Pols MA, Stoker J, et al. Guideline ‘Diagnostics in acute abdominal pain in adults’. Ned Tijdschr Geneeskd. 2014;158:A7494.   Though it may comprises the initial diagnostic test when perforation of a hollow viscus,intestinal obstruction, or ingestion of a foreign body is suspected. Ultrasonography is the initial imaging test of choice for patients presenting with right upper quadrant pain and in suspected biliary tract pathology,complicated renal colic and gynecological disease;whereas computed tomography (CT) is recommended for evaluating right or left lower quadrant pain.²Cartwright SL, Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015;91(7):452-9.  

It is however important to consider that although CT leads to the highest sensitivity and specificity in patients with acute abdominal pain and facilitates triage through an accurate and reproducible diagnosis in urgent conditions,¹⁰Gans SL, Pols MA, Stoker J, et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23-31.   ¹⁶Stoker J, van Randen A, Lameris W, et al. Imaging patients with acute abdominal pain. Radiology. 2009;253(1):31-46.   unwarranted and widespread use of CT also raises concerns about patients’ exposure to ionizing radiation. To circumvent such concerns, several strategies to reduce exposure are being studied, for instance, using ultrasonography as an initial study before obtaining CT (negative or inconclusive ultrasound is followed by CT), and using low-dose CT rather than standard-dose CT.Magnetic resonance imaging (MRI) is another emerging technique for evaluation of abdominal pain, which avoids ionizing radiation.³Ditkofsky NG, Singh A, Avery L, et al. The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol.2014;21(6):615-24.  

Management: Pain as the primary determinant

As discussed earlier, the underlying cause of acute abdominal pain can lie in many different specialties, such as gynecology, surgery, internal medicine, and urology.¹⁰Gans SL, Pols MA, Stoker J, et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23-31.   Accordingly, handling and definite treatment of these patients would vary depending on the urgency and need of the specific problem raised. Regardless, since pain is a major determinant for clinical decisions in almost all cases in initial period, most of the strategy is directed at successful alleviation of the pain, without challenging the underlying diagnosis.

Appropriate pain therapy prior to diagnosis in patients with acute abdominal pain has, however, remained controversial.⁴Falch C, Vicente D, Haberle H, et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain. 2014;18(7):902-13.   Often, it is seen that administration of (opiate) analgesics at the emergency department is delayed in order to prevent masking of the symptoms and avoid any undue influence of analgesics on the reliability of the physical examination.¹⁰Gans SL, Pols MA, Stoker J, et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23-31.   ¹⁷Ranji SR, Goldman LE, Simel DL, et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14):1764-74.   ¹⁸D’Ambrogio A, Peloponissios N, Blanc C, Schreyer N. Does early analgesia interfere with diagnostic process in acute abdominal pain syndrome? Rev Med Suisse. 2006;2(70):1593-6.   The approach is debated to have sound concerns that analgesia in patients with acute abdominal pain may obscure the physical examination and lead to missing an urgent diagnosis, such as appendicitis,¹⁹Poonai N, Paskar D, Konrad SL, et al. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014;21(11):1183-92.   which could require acute admission and an urgent intervention to avoid complications. Thus, it may have a negative effect on treatment decisions. Besides these fears, other possible confounders that may contribute to inadequate or delayed pain therapy in patients with acute abdominal pain are concerns over side effects from analgesics, lower physicians’ rating of pain than patients, and crowding of patients at the place.⁴Falch C, Vicente D, Haberle H, et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain. 2014;18(7):902-13.  ²⁰Stork B, Hofmann-Kiefer K. Analgesia as an important component of emergency care. Anaesthesist. 2009;58(6):639-48;quiz 649-50.   ²¹Mills AM, Shofer FS, Chen EH, et al. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med. 2009;16(7):603-8.   ²²Marinsek M, Kovacic D, Versnik D, et al. Analgesic treatment and predictors of satisfaction with analgesia in patients with acute undifferentiated abdominal pain. Eur J Pain. 2007;11(7):773-8.   These factors could affect patients’ satisfaction with analgesia.

Despite these prevailing views, however, it remains true that a timely and adequate pain control would assist in decreasing pain-related complications and achieving faster recuperation, with an associated increase in patient satisfaction, quality-of-life and overall reduced healthcare cost and burden. Accordingly, pre-diagnostic administration of analgesia seems appropriate regardless of the etiology of the abdominal pain.²³Schreyer N, D’Ambrogio A, Demartines N. Acute abdominal pain:what about analgesia. Rev Med Suisse. 2007;3(117):1647-50.   Further tailoring of analgesics could be based on physicians’ and patients’perception; and objective assessment of pain intensity with tools such as the numerical rating scale (NRS; figure 2): administering non-opioid analgesic agents at a pain intensity of NRS ≤ 3, and a combination of non-opioids and opioids at an intensity of NRS > 3.4 Repeated pain assessment will help to improve and titrate the pain therapy to the effect.

Rationale of using antispasmodics in acute abdominal pain: Focus on Drotaverine

While pre-diagnostic analgesia is debatable and applicable to both urgent and non-urgent diagnoses of abdominal pain, it might have different relative positioning. In urgent conditions, the aim would mainly be directed at determining the need and timing of surgical intervention; whereas this need of pre-diagnostic analgesia could possibly be more relevant in primary care in those who suffer from a less serious condition and thus can be treated conservatively and without any pressure of time.²⁴Trentzsch H, Werner J, Jauch KW. Acute abdominal pain in the emergency department – a clinical algorithm for adult patients. Zentralbl Chir. 2011;136(2):118-28.   In all, it would be preferred to initiate pain control simultaneously with efforts to make the diagnosis. Here, targets for modulation might include smooth muscle cells of the gastrointestinal tract, or other target mechanisms. Especially, since pain caused by smooth muscle spasm is severe enough, anti-spasmodic treatment is considered, with following objectives:

• Symptomatic treatment of spasm without being involved in disease pathogenesis; and
• Spasmolytic drug may be a part of causal therapy,if spasm is a leading symptom or cause of the underlying disease.

Anti-cholinergics as anti-spasmodics

As depicted above, spasmolysis is typically required in cases of acute abdominal pain. Anti-cholinergic medications might be considered in these painful spasmodic conditions, owing to their effects in decreasing the smooth muscle spasms. However, their use may not suitably fulfill the above mentioned treatment objectives of “not interfering with an accurate evaluation”. These drugs often mask the physical symptoms of “acute abdomen”, making it difficult to achieve a rapid definite diagnosis and accurate management in emergency situations. In addition, anti-cholinergic agents have also been associated with several bothersome side-effects,such as sedation, constipation, dryness of mouth (Table 4), which may interfere with the work-up and diagnostic evaluation. Considering all these limitations, use of anti-cholinergics as anti-spasmodics is generally discouraged in subjects with abdominal pain.

Drotaverine – a drug of choice for alleviating pain caused by smooth muscle spasm

The above-mentioned objectives of pre-diagnostic analgesia and limitations of anticholinergics clearly depict the need of having effective and well-tolerated analgesics, which do not mask the symptoms of underlying etiology, and do not interfere with the diagnosis. Drotaverine – an isoquinoline derivative – is one such analgesic agent that may be a drug of choice in treatment of acute abdominal pain. The drug has a powerful spasmolytic action on smooth muscle cells,and it thus capable of relieving or preventing smooth muscle spasm of various organs. Its efficacy in different painful indications is based on evidence of pain relief in most patients; while it is well-tolerated as well without any major side effects.²⁵Rai RR, Dwivedi M, Kumar N. Efficacy and safety of drotaverine hydrochloride in irritable bowel syndrome: a randomized double-blind placebo-controlled study. Saudi J Gastroenterol.2014;20(6):378-82.   Drotaverine’s effects have in fact been confirmed for over 35 years by clinical studies on more than 10,000 patients.²⁶Romics I, Molnár DL, Timberg G, et al. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones. BJU Int. 2003;92(1):92-6.  

Drotaverine has several favorable features to support its usage in acute abdominal pain (Table 5). The drug is absorbed quickly from all parts of the small intestine through linear absorption. In addition, at therapeutic concentrations, it was noted to exhibit no inhibitory effect on gastrointestinal motility, which is in contrast to the general concept that spasmolytics inhibit intestinal passage. An evaluation of the mechanism of action of drotaverine shows that it has significant inhibitory effect on the phosphodiesterase (PDE) enzyme, that is accompanied by a mild Ca-channel blocking effect;²⁷Aggarwal V. Drotaverine for recurrent abdominal pain in children.Indian Pediatr 2015;52:843-844.   invitro,it inhibited PDE IV enzyme without inhibiting PDE III and PDE V. Such selectivity of drotaverine for PDE IV seems to favor its clinical usage, because PDE IV appears,functionally, to be very important in influencing the contractile activity of the smooth muscles. This suggests that selective inhibitors of PDE IV may be useful in the treatment of hypermotility disorders and various diseases associated with painful spasm. Accordingly, this makes drotaverine a spamolytic suitable for use in a large number of indications with smooth muscle spasm. In fact,drotaverine has been extensively employed in suspected biliary, intestinal and renal colic, dysmenorrhea, and prior to instrumental investigative procedures. Furthermore,the drug is free of the side-effects associated with anticholinergic anti-spasmodics, such as dicyclomine etc,and may be considered for use over long-term.

As mentioned above, the most significant and favorable fact to support use of drotaverine in cases of acute abdominal pain is that its anti-spasmodic and pain-relieving effect does not mask the symptoms of “acute abdomen”. This indeed is in keeping with the desired objectives of pre-diagnostic analgesia, having relevant application to achieve pain-alleviation and a rapid diagnosis. As follows, drotaverine may be given in most cases of acute abdominal pain without finalized diagnosis since such pre-treatment in emergency would not interfere with the association of correct diagnosis while decreasing the pain and spasm.²⁷Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent-drotaverine.JAMA India-The physician update;vol 4(12).   Such prompt alleviation of pain of unknown cause is always desired since it is per se the cause of most of the distress and discomfort. Also, this could have important real-life implication since the patient would effectively cooperate for physical evaluations, and other treatment measures,only once the pain has subsided. Drotaverine could be given in these cases without finalized diagnosis.

Paracetamol: Another important alternative for undifferentiated acute abdomen

Paracetamol, a cyclooxygenase inhibitor, is another important analgesic that shares this unique attribute of drotaverine in not interfering the correct diagnosis,and thus could safely be used as a reliable pain relieving agent.²⁹Mousavi SM, Paydar S, Tahmasebi S, et al. The effects of intravenous acetaminophen on pain and clinical findings of patients with acute appendicitis; a randomized clinical trial. Bulletin Of Emergency And Trauma, 2016;2:22-26.   Intravenous paracetamol was documented to have comparable effectiveness with opioids in the last decades in an emergency setting and in various acute pain patterns, but with fewer side effects.³⁰Gulen B, Dur A, Serinken M, et al. Pain treatment in patients with acute pancreatitis: A randomized controlled trial. Turk J Gastroenterol 2016;27:192-6.   ³¹Golzari SEJ, Soleimanpour H, Rahmani F, et al. Therapeutic approaches for renal colic in the emergency department: A review article. Anesth Pain Med. 2014; 4(1): e16222.   A Turkish study examining the effects of early administration of analgesics in patients with acute abdominal pain on pain severity, abdominal findings and diagnostic accuracy,demonstrated that early administration of paracetamol provided effective pain relief in patients with nontraumatic acute abdominal pain and those administrations did not interfere with diagnosis. Diagnostic accuracy of paracetamol (94%) was in fact equivalent to that of placebo (94%).³²Oguzturk H, Ozgur D, Turtay MG, et al. Tramadol or paracetamol do not effect the diagnostic accuracy of acute abdominal pain with significant pain relief – a prospective, randomized, placebo controlled double blind study. Eur Rev Med Pharmacol Sci.2012;16(14):1983-8.   Based on such comparable efficacy to other drugs used in acute abdominal pain, some authors even recommend paracetamol as agent of choice for the management of acute mild to moderate undifferentiated abdominal pain.³³Remington-Hobbs J, Petts G, Harris T. Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial. Emerg Med J 2012;29:989-994.  

Drotaverine in combination therapies

In daily practice, drotaverine can be given orally,intramuscularly or intravenously, and is generally used in combination with an analgesic to potentiate the spasmolytic effect.²⁶Romics I, Molnár DL, Timberg G, et al. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones. BJU Int. 2003;92(1):92-6.   ³⁴Ortiz MI, Molina MAR, Arai YCP, et al. Analgesic drugs combinations in the treatment of different types of pain. Pain Research and Treatment 2012;Article ID 612519:2 pages.   ³⁵Vinod KM, Ashish D. Oral drotaverine and aceclofenac combination versus aceclofenac alone for postoperative pain relief: a prospective randomized clinical trial. Indian Journal of Pharmacy Practice 2013;6(4):18-21.   ³⁶Mahaparale S, Telekone RS, Raut RP, et al. Simultaneous spectrophotometric determination of drotaverine hydrochloride and paracetamol in tablet. Indian J Pharm Sci. 2010;72(1):133-136.   For instance; drotaverine is available in combination with paracetamol in tablet dosage form in the ratio of 2:12.5.³⁶Mahaparale S, Telekone RS, Raut RP, et al. Simultaneous spectrophotometric determination of drotaverine hydrochloride and paracetamol in tablet. Indian J Pharm Sci. 2010;72(1):133-136.   Based on the rationale that such combinations would counter the pain components both related or unrelated to spasm or secondary spasm where several inflammatory mediators are involved; the combination therapy is expected to provide a synergistic effect and better effectiveness in pain-relieving owing to the complimentary mechanisms of action of different active ingredients.

The combination of drotaverine with agents such as aceclofenac or mefenamic acid has also been demonstrated to be highly effective in relief of acute spasmodic pain.³⁴Ortiz MI, Molina MAR, Arai YCP, et al. Analgesic drugs combinations in the treatment of different types of pain. Pain Research and Treatment 2012;Article ID 612519:2 pages.   Aceclofenac is a long-acting, welltolerated non-steroidal anti-inflammatory drug (NSAID)with lower incidence of side-effects and established safety profile, which provides sustained pain relief by preferentially blocking Cyclo-oxygenase (COX) II enzyme.This profile in fact makes aceclofenac an ideal NSAID for combining with the fast acting drotaverine, for effective pain relief as the drugs are complimentary for effective pain relief.³⁵Vinod KM, Ashish D. Oral drotaverine and aceclofenac combination versus aceclofenac alone for postoperative pain relief: a prospective randomized clinical trial. Indian Journal of Pharmacy Practice 2013;6(4):18-21.   The combination helps to break the vicious circle of pain, spasm and inflammation, leading to better efficacy and fast onset of pain relief.

Furthermore, the fixed dose combination of drotaverine with mefenamic acid has also been found to be highly effective in relief of acute spasmodic pain.³⁷Porwal A, Mahajan AD, Oswal DS, et al. Efficacy and tolerability of fixed-dose combination of dexketoprofen and Dicyclomine injection in acute renal colic. Pain Research and Treatment 2012 (2012);Article ID 295926:5 pages.   It has been demonstrated that drotaverine allays earlyonset pain and potentiates the sustained analgesic effect of another drug in the combination (mefenamic acid). A post hoc analysis of a study aimed to evaluate the effect of premedication with oral drotaverine-mefenamic acid on pain perception during an outpatient procedure revealed adequate power, suggesting oral drotaverinemefenamic acid an effective option for analgesia for outpatient procedures causing spasmodic pain.38 Peak plasma concentration of drotaverine is achieved in 45 minutes to 1 hour, and that of mefenamic acid is attained in 2 to 4 hours.²⁷Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent-drotaverine.JAMA India-The physician update;vol 4(12).   ³⁹Sharma JB, Aruna J, Kumar P, Roy KK, Malhotra N, Kumar S.Comparison of efficacy of oral drotaverine plus mefenamic acid with paracervical block and with intravenous sedation for pain relief during hysteroscopy and endometrial biopsy. Indian J Med Sci. 2009;63(6):244-52.   In all, the fixed-dose combination of drotaverine with other analgesics may therefore be a suitable, effective and well-tolerated treatment option for subpopulations of patients with abdominal pain associated with spasm.³⁹Sharma JB, Aruna J, Kumar P, Roy KK, Malhotra N, Kumar S.Comparison of efficacy of oral drotaverine plus mefenamic acid with paracervical block and with intravenous sedation for pain relief during hysteroscopy and endometrial biopsy. Indian J Med Sci. 2009;63(6):244-52.   ⁴⁰Pareek A, Chandurkar NB, Patil RT, et al. Efficacy and safety of aceclofenac and drotaverine fixed-dose combination in the treatment of primary dysmenorrhoea: a double-blind, doubledummy,randomized comparative study with aceclofenac. Eur J Obstet Gynecol Reprod Biol. 2010;152(1):86-90.  

Conclusion

Acute abdominal pain is one of the most common presentations in both primary care and specialist,and outpatient and emergency settings. In many such cases, the pain is non-specific. A detailed history,physical examination, and basic investigations, are sufficient to narrow down the diagnosis in cases of acute abdominal pain. Nevertheless, in order to have prompt managed care in cases of acute abdominal pain characterized and/or accompanied by smooth muscle spasms, it is important that the analgesic used does not mask the underlying pathology. This objective well matches the clinical usage of drotaverine, seeing that it provides effective analgesia without interfering with the association of correct diagnosis; which per se is important for definite management of individual disorders. This highly potent and well-tolerated spasmolytic agent is thus well-suited for administration for relieving or preventing smooth muscle spasm of various organs causing acute abdominal pain. Because it does not mask the symptoms of “acute abdomen”, it would be valuable both as initial medication used for relieving spasmodic pain, and for the maintenance of spasmolysis. Overall, drotaverine can thus be given effectively in all cases of acute abdominal pain to decrease pain and spasm without waiting for a final diagnosis.

References

1. Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008;77(7):971-8.
2. Cartwright SL, Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015;91(7):452-9.
3. Ditkofsky NG, Singh A, Avery L, et al. The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol.2014;21(6):615-24.
4. Falch C, Vicente D, Haberle H, et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain. 2014;18(7):902-13.
5. Brekke M, Eilertsen RK. Acute abdominal pain in general practice:tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care. 2009;27(3):137-40.
6. del Arco Galan C, Parra Gordo ML, Garcia-Casasola Sanchez G. Imaging tests in acute abdominal pain. Rev Clin Esp.2008;208(10):520-4.
7. Flasar MH, Cross R, Goldberg E. Acute abdominal pain. Prim Care.2006 Sep;33(3):659-84, vi.
8. Cole E, Lynch A, Cugnoni H. Assessment of the patient with acute abdominal pain. Nurs Stand. 2006;20(39):67-75.
9. Mahler CW, Boermeester MA, Stoker J, et al. Diagnostic modalities in diagnosis of adult patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2004;148(50):2474-80.
10. Gans SL, Pols MA, Stoker J, et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23-31.
11. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012; 5:789-797.
12. Abdullah M, Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Medica Indonesiana 2012;44(4): 344-350.
13. Flasar MH, Goldberg E. Acute abdominal pain. Med Clin North Am.2006;90(3):481-503.
14. Moll van Charante E, de Jongh TO. Physical examination of patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2011;155:A2658.
15. Gans SL, Pols MA, Stoker J, et al. Guideline ‘Diagnostics in acute abdominal pain in adults’. Ned Tijdschr Geneeskd. 2014;158:A7494.
16. Stoker J, van Randen A, Lameris W, et al. Imaging patients with acute abdominal pain. Radiology. 2009;253(1):31-46.
17. Ranji SR, Goldman LE, Simel DL, et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14):1764-74.
18. D’Ambrogio A, Peloponissios N, Blanc C, Schreyer N. Does early analgesia interfere with diagnostic process in acute abdominal pain syndrome? Rev Med Suisse. 2006;2(70):1593-6.
19. Poonai N, Paskar D, Konrad SL, et al. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014;21(11):1183-92.
20. Stork B, Hofmann-Kiefer K. Analgesia as an important component of emergency care. Anaesthesist. 2009;58(6):639-48;quiz 649-50.
21. Mills AM, Shofer FS, Chen EH, et al. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med. 2009;16(7):603-8.
22. Marinsek M, Kovacic D, Versnik D, et al. Analgesic treatment and predictors of satisfaction with analgesia in patients with acute undifferentiated abdominal pain. Eur J Pain. 2007;11(7):773-8.
23. Schreyer N, D’Ambrogio A, Demartines N. Acute abdominal pain:what about analgesia. Rev Med Suisse. 2007;3(117):1647-50.
24. Trentzsch H, Werner J, Jauch KW. Acute abdominal pain in the emergency department – a clinical algorithm for adult patients. Zentralbl Chir. 2011;136(2):118-28.
25. Rai RR, Dwivedi M, Kumar N. Efficacy and safety of drotaverine hydrochloride in irritable bowel syndrome: a randomized double-blind placebo-controlled study. Saudi J Gastroenterol.2014;20(6):378-82.
26. Romics I, Molnár DL, Timberg G, et al. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones. BJU Int. 2003;92(1):92-6.
27. Aggarwal V. Drotaverine for recurrent abdominal pain in children.Indian Pediatr 2015;52:843-844.
28. Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent-drotaverine.JAMA India-The physician update;vol 4(12).
29. Mousavi SM, Paydar S, Tahmasebi S, et al. The effects of intravenous acetaminophen on pain and clinical findings of patients with acute appendicitis; a randomized clinical trial. Bulletin Of Emergency And Trauma, 2016;2:22-26.
30. Gulen B, Dur A, Serinken M, et al. Pain treatment in patients with acute pancreatitis: A randomized controlled trial. Turk J Gastroenterol 2016;27:192-6.
31. Golzari SEJ, Soleimanpour H, Rahmani F, et al. Therapeutic approaches for renal colic in the emergency department: A review article. Anesth Pain Med. 2014; 4(1): e16222.
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