Analgesia in patients with acute abdominal pain: Cochrane systematic review

Abstract

Assessed as up to date: 2010/02/10

Background

For decades, the indication of analgesia in patients with Acute Abdominal Pain (AAP) has been deferred until the definitive diagnosis has been made, for fear of masking symptoms, generating a change in the physical exploration or obstructing the diagnosis of a disease requiring surgical treatment. This strategy has been questioned by some studies that have shown that the use of analgesia in the initial evaluation of patients with AAP leads to a significant reduction in pain without affecting diagnostic accuracy.

Objectives

To determine whether the evidence available supports the use of opioid analgesics in the diagnostic process of patients with AAP.

Search methods

Trials were identified through searches in Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library, issue 2, 2009), MEDLINE (1966 to 2009) and EMBASE (1980 to 2009). A randomised controlled trial (RCT) filter for a MEDLINE search was applied (with appropriate modification for an EMBASE search). Trials also were identified through "related articles". The search was not limited by language or publication status.

Selection criteria

All published RCTs which included adult patients with AAP, without gender restriction, comparing any opioids analgesia regimen with the non-use of analgesic before any intervention and independent of the results.

Data collection and analysis

Two independent reviewers assessed the studies identified via the electronic search. Articles that were relevant and pertinent to the aims of the study were selected and their respective full-text versions were collected for subsequent blinded evaluation. The allocation concealment was considered in particular as an option to diminish the biases.

The data collected from the studies were reviewed qualitatively and quantitatively using the Cochrane Collaboration statistical software RevMan 5.0. After performing the meta-analysis, the chi-squared test for heterogeneity was applied. In situations of significant clinical heterogeneity, statistical analyses were not applied to the pool of results. In situations of heterogeneity, the random effect model was used to perform the meta-analysis of the results. A sensitivity analysis was also applied based on the evaluation to the methodological quality of the primary studies.

Main results

Eight studies fulfilled the inclusion criteria. Differences with use of opioid analgesia were verified in variables: Change in the intensity of the pain, change in the patients comfort level.

Authors' conclusions

The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.

Author(s)

Manterola Carlos, Vial Manuel, Moraga Javier, Astudillo Paula

Summary

The use of analgesia for acute abdominal pain (AAP) does not mask clinical findings, nor does it delay diagnosis.

The use of analgesia for AAP does not mask clinical findings nor does it delay diagnosis.

Surgeons are reluctant to use analgesics during the diagnostic process and clinical evaluation of patients with AAP where there may be the possible requirement of surgical intervention. Generally, the fear is that analgesia can mask clinical findings and cause a delay in the diagnosis. Some reports suggest that the use of opioid analgesics in patients with AAP is not associated with masking the clinical picture or delaying the diagnosis.

Hence the research question of this review is: Does available evidence support the use of opioid analgesics in patients with AAP during the diagnostic process?

The aim of this review is to determine whether the evidence available to date supports the use of opioid analgesics in patients with AAP during the diagnostic process.

Clinical trials were performed, in which the use of any analgesic regime with opioids was compared to a placebo administered in the diagnosis process prior to decision-making in adult subjects with AAP, with no limitation on gender. The valued outcomes were: change in the intensity of the pain, change in the patient’s comfort level, time necessary to formulate diagnosis, time necessary to operate (in the applicable cases), rate of correct decision-making, error rate in the treatment undertaken, hospital stay and morbidity.

Reviewer's Conclusions

Implications for practice

Some evidence indicates that the use of opioid analgesics in patients with AAP, in addition to improving their comfort while the diagnostic process is concluded, does not increase the risk of diagnosis error or the risk of error in decisions for treatment. However, this review is not attempting to recommend any analgesic regime in particular.

Implications for research

More high-quality clinical trials are needed to establish the most effective treatment protocols. The included studies are in generally adequate to answer the questions; however, some methodological issues make it imperfect (different research objectives, small sample size and inadequate randomisation). Thus, primary studies require a common objective, an adequate sample size estimation and proper use of random assignment of study subjects. These are the methodological details that can determine that the final conclusion is inappropriate, truthful and non-reliable. In this case, the results suggest that “the use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment”, but if the primary studies were less heterogeneous and had a larger number of in study subjects, it is possible that the end result was different; for example that “the non use of opioid analgesics in the therapeutic diagnosis of patients with AAP does increase the risk of diagnosis error or the risk of error in making decisions regarding treatment” (this, based on the trend observed in the graphs of meta-analysis).

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