Thompson D R
Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA.
Am J Gastroenterol. 2001 Apr;96(4):1266-72. doi: 10.1111/j.1572-0241.2001.03536.x.
Traditional teaching dictates that morphine induces "spasm" in the sphincter of Oddi (SO) and should not be used in acute pancreatitis and that meperidine is the analgesic of choice because it does not elevate SO pressures. A literature search and review was performed to evaluate this teaching examining the effect of narcotic analgesic's effects on SO.
A Medline search was performed using keywords and phrases. The manufacturers of meperidine were contacted and their reports and studies were obtained and reviewed.
Initial studies measured biliary pressure after narcotic administration in animals, and postoperative and intraoperative cholecystectomy patients. All narcotics increased biliary pressure, but morphine was associated with the largest elevation. Later studies using endoscopic retrograde cholangiopancreatography with direct SO manometry demonstrated that the SO is exquisitely sensitive to all narcotics including meperidine and that a small increase in biliary sphincter pressure is seen with higher doses of morphine. All narcotics increase SO phasic wave frequency and interfere with SO peristalsis.
Narcotic-induced increases in phasic wave frequency interfere with SO filling and are responsible for the increase in bile duct pressure seen on the initial studies. No studies directly compare the effects of meperidine or morphine on SO manometry and no comparative studies exist in patients with acute pancreatitis. No outcome-based studies comparing these drugs have been performed in patients with acute pancreatitis. Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.
传统教学认为吗啡会诱发Oddi括约肌（SO）“痉挛”，不应在急性胰腺炎中使用，而哌替啶是首选镇痛药，因为它不会升高SO压力。进行了文献检索和综述，以评估这一教学观点，研究麻醉性镇痛药对SO的影响。
使用关键词和短语进行Medline检索。联系了哌替啶的制造商，获取并审查了他们的报告和研究。
最初的研究测量了动物、术后和术中胆囊切除患者使用麻醉药后的胆管压力。所有麻醉药都会升高胆管压力，但吗啡导致的压力升高幅度最大。后来使用内镜逆行胰胆管造影术直接测量SO压力的研究表明，SO对包括哌替啶在内的所有麻醉药都非常敏感，高剂量吗啡会使胆管括约肌压力略有升高。所有麻醉药都会增加SO的相波频率并干扰SO蠕动。
麻醉药引起的相波频率增加会干扰SO充盈，这是最初研究中观察到的胆管压力升高的原因。没有研究直接比较哌替啶或吗啡对SO测压的影响，急性胰腺炎患者中也没有比较性研究。没有针对急性胰腺炎患者进行基于结果的比较这些药物的研究。吗啡可能比哌替啶更有益，因为它能提供更长时间的疼痛缓解，且癫痫发作风险更低。没有研究或证据表明吗啡在急性胰腺炎中使用是禁忌的。
