A Case of Narcotic Bowel Syndrome

Abstract

Narcotic bowel syndrome (NBS) is becoming increasingly recognized although it is a challenging and under-diagnosed condition. It is characterized chronic or recurrent and unresolving abdominal pain associated with escalating doses of narcotic pain medications. A 64-year-old male patient with a history of unremitting chronic abdominal pain despite extensive negative organic gastrointestinal workup, on high extremely dose opioids presented to the hospital with continued abdominal pain and new onset explosive diarrhea for seven days. On admission, he was normotensive and afebrile. Abdominal examination revealed a soft, diffusely tender to palpation, distended abdomen with normal bowel sounds. Laboratory workup showed normocytic normochromic anemia, no leukocytosis, and liver and kidney function within normal limits. KUB showed dilated loops of bowel. CT abdomen revealed distention of the entire colon, measuring up to 9.3cm at the level of the distal transverse colon without small bowel or colonic obstruction and no evidence of bowel ischemia (Figure A). Patient had positive Clostridium difficile polymerase chain reaction (PCR) for which he was treated. Repeat Clostridium difficile PCR was negative. Flexible sigmoidoscopy revealed dilated colon without pseudomembranes (Figure B). Despite treatment of CDI, patient continued to endorse abdominal pain and distention during hospitalization and on follow up. The diagnostic criteria for NBS is chronic or intermittent abdominal pain, sometimes severe, as the predominant symptoms with at least three of the following; pain worsens or dose not resolved with continued or escalating doses of narcotics; the episodes of pain have a progression of frequency, duration and intensity; when the narcotic dose wanes, a markedly intense pain is felt which improves with reinstitution of narcotic; other causes of gastrointestinal etiology for the pain have been ruled out or cannot be explained otherwise. The patient population that develops NBS is often originally prescribed opioids for intra-abdominal or extra-abdominal etiology. Over time, abdominal pain develops or worsens. The best treatment for NBS is to de-escalate opioid doses and frequency. The persistence of chronic, intermittent, crampy abdominal pain especially when symptoms worsen with effects of narcotics wear off should prompt physicians to keep narcotic bowel syndrome very high on the differential even when faced with concomitant infections.Figure 1Figure 2