Opioids and the Gastrointestinal Tract - A Case of Narcotic Bowel Syndrome and Literature Review
A 26-year old woman had presented our institution on multiple occasions with a 5-year history of intractable chronic abdominal pain. Three years prior to admission she had been diagnosed with slow transit constipation, on the basis of a colonic marker study, and had been tried on multiple laxatives. In the absence of any discernable therapeutic benefit she was referred for a tertiary opinion where she underwent anorectal physiology and biofeedback without any changes in her symptoms. Subsequently, she underwent a subtotal colectomy, which increased the frequency of her bowel movement but had no effect on her pain.\nShe described the pain as being omnipresent, burning in nature throughout her abdomen. There were no specific findings on the haematological, biochemical, metabolic, immunological, endoscopic and radiological investigations. Of specific note, her computed tomographical scan of abdomen and pelvis and ileocolonoscopy with histology revealed normal findings in the last 12 months. She was then started on a number of opioid agonists in increasing doses.\nThe first author decided to electively admit her for further management. At this point her daily analgesic requirements were 150 µg/hr fentanyl, 100 mg oramorph and 400 mg tramadol (equivalent to approximately 740 mg oral morphine/24 hr). A clinical diagnosis of narcotic bowel syndrome (NBS) was made. A detoxification regimen was prescribed which included rapid opiate withdrawal and commencement of methadone, lorazepam, clonidine and duloxetine. She was discharged opiate free, with no abdominal pain, 14 days post admission. At outpatient review for 3 months after discharge, her abdominal pain has not returned and she remains well with no further hospital admissions. She is under active follow-up. Informed written consent was obtained from the patient.