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Pethidine, Pentazocine, and Phenazocine on Biliary Pressure G

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Pethidine, Pentazocine, and Phenazocine on Biliary Pressure G Gut: first published as 10.1136/gut.12.3.218 on 1 March 1971. Downloaded from Gut, 1971, 12, 218-221 A cross-over comparison of the effect of morphine, pethidine, pentazocine, and phenazocine on biliary pressure G. ECONOMOU AND J. N. WARD-McQUAID From the Mansfield Group of Hospitals suMMARY The effects on biliary pressure of pentazocine, morphine, pethidine, and phenazocine were compared by direct measurement through a 'T' tube after choledochotomy. In two within- patient comparisons, the mean increases in biliary pressure following intramuscular morphine were significantly greater than those following pentazocine. When pethidine and phenazocine were compared with pentazocine, the mean increases were lower following pentazocine but not to a statistically significant extent. Pentazocine appears to be the most appropriate strong analgesic in biliary and pancreatic disease. Morphine and pethidine are perhaps the two drugs through the sphincter at operation, but a formal most commonly used for pain of biliary and pan- sphincterotomy had not been performed on any creatic origin, but both produce a marked rise in patient. Bile pressure was measured directly in biliary pressure. The effect of morphine is about centimetres of bile through a transparent plastic twice that of pethidine (Jacobsson, 1957; Efron, tube attached to the shortened 12F 'T' tube. 1958; Kjellgren and Lof, 1959; Kjellgren, 1960; The trial was of cross-over design and the patients Hopton and Torrance, 1967). Hopton and Torrance willingly cooperated. In each patient the resting http://gut.bmj.com/ (1967) advocated the use of phenazocine (Narphen), pressure was measured, the patient lying flat with the first benzomorphan derivative used extensively one pillow. There was a variation of up to 1.5 cm for pain, as it produced only a minimal rise in on respiration; the mean was taken. The bile pres- biliary pressure. sure, sometimes raised after operation, had settled We have used the newer benzomorphan deriva- in all patients, at least to less than 18 cm of bile tive pentazocine (Fortral) extensively for pain above the duct. The distance from the duct to relief (Conaghan, Jacobsen, Rae, and Ward- the skin at the anterior abdominal wall had been on September 27, 2021 by guest. Protected copyright. McQuaid, 1966; Ward-McQuaid, 1969; Economou, measured at operation, and this was used as a base Monson, and Ward-McQuaid, 1971) and have line for postoperative measurements. Each patient found it to be efficient and with few side effects. received the two drugs given intramuscularly on The object of the present cross-over trial was to consecutive days, the order of administration being compare the effects on biliary pressure of penta- randomized. The effect on bile pressure was mea- zocine with that of morphine, pethidine, and sured 30, 60, and 120 minutes after the injection. phenazocine. A simple direct manometric method Two groups of patients were studied two to four was used. No previous such controlled study on the days after operation. One group of 11 patients effect of pentazocine on the biliary pressure could received 30-45 mg pentazocine and 10-15 mg be found in the literature. morphine (group 1) and the other group of 11 patients received 30-45 mg pentazocine and 75- Method 100 mg pethidine (group 2). A further two groups of patients were studied Measurements of bile pressure were made after eight to ten days after operation. One group of 10 operation through the 'T' tube draining the com- patients received 30-45 mg pentazocine and 10-15 mon bile duct after cholecystectomy and choledo- mg morphine (group 3) and a second group of 10 chotomy. In the 31 patients studied, cholangiography patients received 30-45 mg pentazocine and 2-3 mg had been normal after exploration of the duct. phenazocine (group 4). Several of the patients were A small sound had been passed into the duodenum studied both at two to four days and eight to ten Received for publication 9 December 1970. days after operation. 218 Gut: first published as 10.1136/gut.12.3.218 on 1 March 1971. Downloaded from Comparison of the effect ofmorphine, pethidine, pentazocine, andphenazocine on biliary pressure 219 Results The mean changes in biliary pressure are shown in Figure 1. In the pentazocine group, only the mean GROUP 1 increase of 1-5 cm of bile 60 minutes after injection In this group of 11 patients, the mean dose was is statistically significant (p < 0.02). In the mor- 31.4 mg of pentazocine and 10.5 mg of morphine. phine group, the mean increase of 7 cm 30 minutes The mean number of days after operation when the after injection, and the maximum mean increase injections were given was 3.1 for pentazocine and of 8.4 cm at 60 minutes, are both statistically highly 3.2 for morphine. significant (p < 0.001), and the mean increase at 120 minutes is also statistically significant 10 (p < The differences between the effects of ,9 0.01). .9 _ 8.5 + ~~~~~1.7 and at 30 8. pentazocine morphine minutes and 120 are 7 minutes both statistically significant at the 1% level while the difference at 60 minutes is significant 589 1.5 Morphine (n 11) at the 0.2 % level. 3- GROUP 2 0 + 0 15 -+ 0.5 In this group also of 11 patients the mean dose of ~~~~~~~~Oj; * iP~~~~~entazociile (n =11 pentazocine was 36.6 mg and that of pethidine 89.5 mg. The mean number of days after operation when the injections were given was 2.8 for penta- Mlintites after injection zocine and 2-7 for pethidine. The mean increases in this group were both maxi- Fig. 1 Changes in biliary pressure after pentazocine mal at 60 minutes, 2.0 cm for pentazocine and 3.9 cm and morphine (means + or - standard error). for pethidine (Fig. 2). None of the mean increases for pentazocine is statistically significant. In the pethidine group all the mean increases are statistically significant; at 30 min P < 001, at 60 min P < 0-001, and at 120 min P 0-02. The differ- ence between the effects of pentazocine and pethidine http://gut.bmj.com/ 61 is not statistically significant at any time after the 0.8. 4- 3s9 injections. 3.7 3.2+ 1.0 1.2 Pethidine PQ3 a G)-- 1.7 + 0.8 Pentazocine GROUP 3 1 In this group of 10 patients the mean dose of 0- pentazocine was 35 4 mg and 12.3 mg of morphine. 1- 1 The mean interval between on September 27, 2021 by guest. Protected copyright. 0 30 60 120 operation and injection Minutes was 9.1 days for pentazocine and 9.7 days for morphine. The mean changes in biliary pressure Fig. 2 Changes in biliary pressure after pentazocine are shown in Figure 3. In the pentazocine group, and + or - standard pethidine (means error). only the mean increase of 2-1 cm bile at 30 min is statistically significant (p < 0.02). In the morphine 10 group all the mean increases are statistically 9 significant; 6-2 cm at 30 min and 4.9 cm at 120 min 8 (p < 0002) and 5.7 cm at 60 min (p < 0.001). 7- +I.4 The differences between the 66.2 0. effects of pentazocine and morphine at and 120 min are ; / < 5 4.9 + 1.1 Morp 30, 60, statistically significant, at 5%, 1 %, and 2% levels respectively. 15 3 / ,! . GROUP 4 There were 10 patients in this group and the mean doses were 34.5 mg of pentazocine and 2.3 mg of phenazocine. The mean number of days after operation was 8.5 for pentazocine and 9.2 for Mlinutes phenazocine. Fig. 3 Changes in biliary pressure after pentazocine The mean increase of 2.8 cm of bile with penta- and morphine (means + or - standard error.) zocine 30 min after injection (Fig. 4) is the Gut: first published as 10.1136/gut.12.3.218 on 1 March 1971. Downloaded from 220 G. Economou and J. N. Ward-McQuaid highest of all the four pentazocine groups, and is slower with a lower peak than that obtained by statistically significant (p < 0.01). The mean phena- intramuscular injection (Kjellgren, 1960; Hopton zocine rise at 30 min was 3'8 cm of bile. Two and Torrance, 1967) and as could be expected by patients had relatively large increases following intravenous injection (Efron, 1958; Boulter, 1961). injection of the two drugs. None of the differences Our maximum rise occurred at 30 minutes nine days between the effects of pentazocine and phenazocine after operation, compared with 10-30 minutes, is statistically significant. while three days after operation the rise was maximal at 60 minutes. We confirmed the proportionate increase in pressure after morphine and pethidine (Jacobsson, 1957; Efron, 1958; Hopton and 10- Torrance, 1967) but the maximum rise with pethi- 9 in 8- dine, as with morphine, occurred earlier than our 7 - patients. All our patients, however, were examined 6 - three days after operation. Kjellgren and Lof (1959) had lower and slower rises with both morphine and 4 3. 1.8 pethidine in similar dosage when given by sub- 3 - .2.8+ . *. cutaneous injection (Kjellgren and Lof, 1959). The usual specific gravity of bile duct bile is approximately 11, so our results could be 10% Pentazocine - higher in cm water. O :0.2 + Phenazocine The mean rise at one hour after injection of pethi- 0 30 60 12,0 dine three days after operation was almost twice that Minutes of pentazocine (3.9:2.0 cm). This is not statistically Fig. 4 Changes in biliary pressure after pentazocine significant, but further data from a short unpublished andphenazocine (means + or - standard error).
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