Evaluating Residual Pain after Abdominal Surgery
Talia Firestein and Alyson McGregor, MD
Case Overview: Although research has shown that men and women experience pain differently, this concept has not been fully realized in post-operative pain and will be considered in assessing this patient.
History: JC is a 25 year old woman presenting to an emergency department (ED) complaining of acute, 8/10 right upper quadrant pain that started one day ago and radiates laterally to both sides and to her right shoulder. The pain increases on inspiration. The patient experienced 5 episodes of this pain, each lasting one hour, accompanied by diaphoresis, nausea, 2 episodes of vomiting, shortness of breath, and lightheadedness. She had a cholecystectomy seven days ago due to a sevenyear history of gall stones. The patient reports that the pain feels similar to her preoperative symptoms, only less severe. She has no other medical conditions. Her family history is significant for cholelithiasis.
Medications: Depo provera
Relevant Vital Signs:
BP: 129/64 Pulse: 81, regular
Temp: 96.7 RR: 20
Laboratory Evaluation:
WBC: 7.3 ALB: 3.4 ALT:70 AST: 66
Chem 7: within normal limits
Alkaline phosphatase: 160
UA (-) UCG (-)
Physical Exam: A young woman who is 5’5”and 145 lbs, JC has a BMI of 24, is alert and appears her stated age. Her exam is positive for abdominal tenderness, without rigidity or distention. Lungs are clear, and heart shows regular sinus rhythm without murmurs.
Testing: Pre-op ultra sound shows a contracted gallbladder packed with stones and no radiographic evidence of cholecystitis. No post-op imaging was performed.
Emergency Department Course: JC required multiple doses of morphine and IV fluids before her pain was under control. The patient’s surgeon examined her in the emergency department. Based on her presentation and unremarkable laboratory values, the surgeon declared her pain as post-op residual pain rather than lingering stones or inflammation. No further imaging was performed. The patient’s pain improved over several hours and eventually was discharged home with surgical follow up the following day.
Discussion:
There is a growing body of literature exploring the differences in pain experience between genders. Numerous studies indicate that women display increased sensitivity, have lower pain thresholds and report higher pain ratings compared with men.2,4 In a review by Hoffman and Tarzian (2001), the authors write that women show a higher prevalence of chronic pain syndromes, are biologically more sensitive to pain and respond differently to analgesics. Women tend to respond better to analgesics of the kappa-opioid class, including pentazocine, nalbuphine and butorphanol, due to the difference in Ҡ-opioid-activated endogenous pain modulating circuits.5 Perhaps this could have been considered as part of JC’s pain regimen.
Relating to the patient discussed above, there is clinical evidence that women show increased pain intensity after a laparoscopic cholecystectomy.7 In fact, women require 30% more morphine to achieve an equal degree of analgesia compared with men in addition to having a more intense pain experience.3 Finally, women are also more likely to report persisting abdominal pain that mimics pre-operative pain, an event which occurs in up to 30% of patients.1,8 The presenting patient demonstrated this pre-cholecystectomy pain experience.
Patient Follow-up: One week after JC’s presentation to the ED, a follow-up phone call revealed she continued with daily abdominal pain. She remained frustrated but optimistic that this residual postoperative pain will eventually subside.
References:
1. Berger MY, Olde Hartmann TC, Bohnen AM. “Abdominal symptoms: do they disappear after cholecystectomy? A systematic literature review,” Surg Endosc, 2003; 17:1723–1728.
2. Berkley KJ, “Sex Differences in Pain,” Behavioral & Brain Sciences, 1997; 20(3): 371-80.
3. Cepeda MAS, Carr DB ,“Women experience more pain and require more morphine than men to achieve a similar degree of analgesia,” Anesth Analg, 2003;97(5):1464-8.
4. Fillingim RB, Maixner W, “Gender Differences in the Responses to Noxious Stimuli,” Pain Forum, 1995; 4(4): 209-21.
5. Gear RW, Miaskowski C, Gordon NC, Paul SM, Heller PH, Levine JD, “Kappa-opioids produce significantly greater analgesia in women than in men,” Nat Med, 1996; 2(11):1248-50.
6. Hoffman DE, Tarzian AJ, “The girl who cried pain: a bias against women in the treatment of pain,” J Law Med Ethics, 2001; 29(1):13-27.
7. Uchiyama K, Kawai M, Tani M, Ueno M, Hama T, Yamaue H, “Gender differences in postoperative pain after laparoscopic cholecystectomy,” Surg Endosc, 2006; 20(3):448-51.
8. Vetrhus M, Berhane T, Soreide O, Sondenaa K, “Pain persists in many patients five years after removal of the gallbladder: Observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis,” J Gastrointest Surg, 2005; 9: 826-831.
About the Authors: Talia Firestein is a second year medical student at Warren Alpert Medical School of Brown University. She received a BA in Community Health from Brown in 2009. Alyson J. McGregor, MD is an assistant Professor of Emergency Medicine at Brown. Correspondence: Talia_Firestein@Brown.edu with any questions or comments.
Key Words: Emergency Medicine, Gastroenterology, pain, surgery
