title: Sudden severe abdominal pain after a single low dose of paracetamol/codein in a cholecystectomized patient: learning from a case report.
abstract: We report the case of an elderly patient with diastolic heart failure and renal insufficiency admitted to hospital as he complained of having a history of hypogastric pain and dysuria without fever due to renal lithiasis and urinary infection. Because the pain was persistence, and considering the presence of renal dysfunction, it was administered a single low dose of paracetamol/codein (500/30 mg). After about 1 hour of the administration, he suddenly complained of the onset of a lancinating epigastric pain radiating to the whole abdomen and retrosternum accompanied by nausea. The electrocardiogram (EKG) was negative for myocardial infarction and computed tomography excluded aortic dissection and other causes of acute abdomen. Laboratory tests showed instead liver and pancreatic damage. The symptomatology was relieved 3 hours later of the onset after antispastic treatment with anticholinergics (floroglucine). The likely underlying pathophysiological mechanism is the codein-induced spasm of the sphincter of Oddi combined with dysfunction of the same sphincter and reduced bile storage capacity related to a previous cholecystectomy. When a similar event does not regress, it may lead to more severe conditions such as acute pancreatitis. Since codein is a widely used drug, this report may suggest cholecystectomy as a contraindication during administration for the risk of occurrence of these complications.
authors.affiliation: Biomedical Department of Internal and Specialist Medicine, Policlinico Paolo Giaccone, University Hospital of Palermo, Palermo, Italy. daniele_torres@libero.it
authors.forename: Daniele
authors.initials: D
authors.lastname: Torres
authors.forename: Gaspare
authors.initials: G
authors.lastname: Parrinello
authors.forename: Caterina
authors.initials: C
authors.lastname: Trapanese
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Licata
mesh_terms: D015746:Abdominal Pain / Q000139:chemically induced; D000082:Acetaminophen / Q000008:administration & dosage / Q000009:adverse effects*; D000368:Aged; D018712:Analgesics, Non-Narcotic / Q000008:administration & dosage / Q000009:adverse effects; D000701:Analgesics, Opioid / Q000009:adverse effects; D002763:Cholecystectomy; D003061:Codeine / Q000008:administration & dosage / Q000009:adverse effects*; D004338:Drug Combinations; D006801:Humans; D008297:Male; D012720:Severity of Illness Index; D013035:Spasm / Q000139:chemically induced; D009803:Sphincter of Oddi / Q000187:drug effects* / Q000378:metabolism
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D004338:Drug Combinations; D000082:Acetaminophen; D003061:Codeine