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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.
([ 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.

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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
Attard AR 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
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
LoVecchio F 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
Vermeulen B 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

Comment(s)

All the studies show considerable benefit to the patient from pain relief with either no change in diagnostic accuracy or an improvement.

Clinical Bottom Line

Patients with acute, atraumatic abdominal pain should have analgesia administered without delay.

References

1. Zoltie N and Cust MP. Analgesia in the acute abdomen. J Roy Coll Surg Engl 1986;68:209-210.
2. Attard AR, Corlett MJ, Kidner NJ et al. Safety of early pain relief for acute abdominal pain. Br Med J 1992;305:554-556.
3. Pace S and Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996;3:1086-1092.
4. LoVecchio F, Oster N, Sturmann K et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997;15:775-9.
5. 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. Radiology 1999;210:639-43.