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 Table of Contents  
LETTER TO THE EDITOR
Year : 2017  |  Volume : 31  |  Issue : 3  |  Page : 204-205

Nalbuphine relieves esophageal spasmodic pain: A report of three cases


1 Department of Anaesthesiology, Combined Military Hospital, Dhaka, Bangladesh
2 Department of Gastroenterology, Combined Military Hospital, Dhaka, Bangladesh

Date of Web Publication18-Jan-2018

Correspondence Address:
Md Rabiul Alam
Department of Anaesthesiology, Combined Military Hospital, Dhaka Cantonment, Dhaka 1206
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_62_17

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How to cite this article:
Alam MR, Rahman S M, Karim KI, Haque M. Nalbuphine relieves esophageal spasmodic pain: A report of three cases. Indian J Pain 2017;31:204-5

How to cite this URL:
Alam MR, Rahman S M, Karim KI, Haque M. Nalbuphine relieves esophageal spasmodic pain: A report of three cases. Indian J Pain [serial online] 2017 [cited 2018 Nov 21];31:204-5. Available from: http://www.indianjpain.org/text.asp?2017/31/3/204/223676



Sir,

Esophageal spasm causes severe retrosternal pain and discomfort at times. Patients with achalasia cardia, esophageal reflux, and esophageal ulcers suffer a lot for this intractable pain. The antispasmodics, calcium-channel blockers, proton-pump inhibitors, tricyclic antidepressants, and opioids are recommended as the remedies to relief this pain.[1] Phosphodiesterase inhibitor-5 is also reported to relief this symptoms.[2] We used almost all the optional agents on three of our patients with esophageal spasm in the postanesthesia care unit but did not get desired effects. Then, we switched over to administer intravenous nalbuphine, and we got excellent results out of it.


  Case Reports Top


Case 1

A 53-year-old female was reported with severe retrosternal pain with repeated melena for 20 h. She was found to be very anxious, restless, and severely anemic. Hence, blood transfusion was started, and an emergency upper gastrointestinal (GI) tract endoscopy was done. There was an anomalous dilated longitudinal vein along the luminal wall of the lower one-third of the esophagus with multiple ulcerations, from which there was oozing of blood [Figure 1]. The patient was excluded of having cirrhosis, chronic viral hepatitis, or portal hypertension. She was then treated conservatively with infusions of vasopressin, proton-pump inhibitors, calcium-channel blockers, and antispasmodic agents. Varieties of opioids including morphine, pethidine, and fentanyl were also tried to relieve her retrosternal pain along with imipramine. Yet, the symptoms were not relieved satisfactorily. However, we found excellent result instantaneously while used intravenous nalbuphine.
Figure 1: An anomalous dilated longitudinal vein along the luminal wall of the lower one-third of the esophagus with multiple ulcerations and oozing of blood

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Case 2

A 58-year-old male with severe retrosternal pain and melena was received. He was a known case of achalasia cardia. There was bleeding from a large organized blood clot observed endoscopically in the luminal wall of the lower third of the esophagus. This patient was also attempted with all conventional analgesics and antispasmodics but relieved significantly when we used intravenous nalbuphine.

Case 3

A 31-year-old female developed severe peritonitis following hysterosalpingography with dye for investigation of her primary sterility. Within hours, she suffered from severe dyspepsia and intractable retrosternal pain due to esophageal spasm. Her upper GI endoscopy revealed normal, but she was a known case of gastroesophageal reflux disease. This patient was also tried with varieties of antispasmodics and analgesics, but there was a remarkable relief of symptoms following intravenous administration of nalbuphine.

Initially, we used 5 mg of nalbuphine intravenously, and then, we added 5 mg as increment at an interval of 15 min up to a total of 20 mg within 1 h. The possible mechanism of relaxation and analgesia may be explained by the direct actions of opioids on the opioid receptors (i.e., mu, kappa, and delta) in enteric neurons of esophagus [Figure 2].[3] When the esophageal receptors are activated, the propulsive activity, secretions, and peristalsis decrease, resulting relaxations and analgesia as well.[4] Moreover, the agonist-antagonists causes fewer adverse effects of pure agonist opioids such as nausea, constipation, and biliary spasm.[5]
Figure 2: Locations of the opioid receptors

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The patients experienced a little drowsiness and sweating for a while just after administration of the drug and following that, there were no other complications which conforms to other reports.[6] The respiration and hemodynamics were stable. These reports show that intravenous nalbuphine has a significant role on relieving retrosternal pain due to esophageal spasm when other remedies failed. Our limitations were – we did not perform and monitor the esophageal manometry and the pain scoring system. Large-scale studies are recommended to advocate the routine use of nalbuphine for the relief of esophageal spasmodic pain.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Achem SR. Management of esophageal chest pain. Gastroenterol Hepatol (N Y) 2007;3:765-7.  Back to cited text no. 1
    
2.
Fox M, Sweis R, Wong T, Anggiansah A. Sildenafil relieves symptoms and normalizes motility in patients with oesophageal spasm: A report of two cases. Neurogastroenterol Motil 2007;19:798-803.  Back to cited text no. 2
    
3.
Pergolizzi JV Jr. Opioid-Induced Constipation: Treating the Patient Holistically. Pain Medicine News: 27 August, 2015. Available from: http://www.painmedicinenews.com/Review-Articles/Article/08-15/Opioid-Induced-Constipation-Treating-the-Patient-nbsp-Holistically/33226/ses=ogst. [Last accessed on 2017 Dec 06].  Back to cited text no. 3
    
4.
Lacy BE. Effects of opioids on esophageal dysfunction. Gastroenterol Hepatol (N Y) 2016;12:323-5.  Back to cited text no. 4
    
5.
Rosow CE. The clinical usefulness of agonist-antagonist analgesics in acute pain. Drug Alcohol Depend 1987;20:329-37.  Back to cited text no. 5
    
6.
Greif R, Laciny S, Rajek AM, Larson MD, Bjorksten AR, Doufas AG, et al. Neither nalbuphine nor atropine possess special antishivering activity. Anesth Analg 2001;93:620-7.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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