DOI: https://doi.org/10.

53350/pjmhs22168131
ORIGINAL ARTICLE

Effect of Narcotic Analgesia on Decision to Operate in Acute Appendicitis

MUHAMMAD FAHEEM ANWER1, FIZZA ANWAR2, WASIF MAJEED CHAUDHRY3, MUHAMMAD ADIL KHURSHID4, MUHAMMAD
WASEEM ANWAR5, SHAHID MAJEED6
1
CMH Lahore Medical College and Institute of Dentistry
2
Pak Red Crescent Medical and Dental College
3
Lahore Medical and Dental College, Lahore
4,5,6
CMH Lahore Medical College and Institute of Dentistry
Correspondence to Dr. Faheem Anwer, Email: [email protected], Cell: 0333-6970895

ABSTRACT
Aim: To study that narcotic analgesia administration in patients of acute appendicitis does not delay the diagnosis and does not
interfere with the decision to operate in these patients.
Study design: A randomized cross-over study.
Setting and duration of study: Study was done at surgery department of Combined military hospital Lahore over a period of
two years from March 2019-2021.
Methodology: It was a double-blind randomized crossover study. A total of 100 patients, who were confirmed as acute
appendicitis by clinical examination, were included. All the male and female patients of age 16 years and above were included in
the study. The patients were divided in two groups each having 50 patients. The drugs were labelled as drug A and drug B. Drug
A was morphine and drug B was placebo. Each drug was given to both the groups by crossover with an interval of 30 minutes
and the components of physical examination were analyzed for both groups. The pain score was calculated by the visual
analogue scale (VAS) for both the groups at both intervals. The p-value was calculated by using student’s t-test. The frequency
and percentages of the decision to operate were calculated. The data was tabulated and then analyzed on SPSS version 23.
Results: The pain score was calculated for both groups of male and females. The pain score difference was calculated in both
groups and then p-value was calculated which came out to be significant. The frequencies of the decision to be operated were
also calculated in both the groups and the results showed that there was no effect of narcotic analgesia on the decision to
operate in patients with clinically diagnosed acute appendicitis
Conclusion: The use of morphine analgesia in the patients of acute appendicitis does not alter the diagnostic efficacy of the
patients of acute appendicitis.
Keywords: Acute abdominal pain, acute appendicitis, Narcotic analgesia, Visual analog scale (VAS)

INTRODUCTION 100 patients on groups of 50 patients each. The effect of analgesia

were studied in both groups and the results were that there is no
Acute appendicitis is the most common cause of abdominal pain difference of narcotic analgesia on the diagnostic accuracy of the
all over the world.1 Its incidence is 7% and approximately 260000 acute abdomen and acute appendicitis7. A study was done in
appendectomies are being performed in United States every 2019, on a Covid positive patient to see the effect of conservative
year1. The common symptoms are nausea, vomiting, fever and management and analgesia and it was recorded that the patient
abdominal pain. These symptoms are more pronounced in adults was satisfactorily recovered to delay the surgery with analgesia
than in children. Acute appendicitis is equally common in children use8.
and adults2. 20-30 % of all the patients admitted with acute Similarly a study in 2019 also showed that the surgical
abdomen in the emergency departments are diagnosed with acute treatment of acute appendicitis is the gold standard and the use of
appendicitis. The diagnosis of acute appendicitis is essentially narcotic analgesia prior to the operation did not alter the decisive
clinical and sometimes may be difficult and this can lead to severe accuracy of the acute appendicitis9.
complications3. Also a study done in children in 2020 showed that
As far as the practice of the doctors in the emergency ward appendectomy proved to be the better option for acute appendicitis
and hospital is concerned it is a general practice to provide in children also. On the other hand interval appendectomy with
analgesia to the patients received with abdominal pain. In narcotics use had also been applied as another alternate treatment
emergency department, it is very common that the doctors on duty option10.
give analgesia to the patients even prior to the consultation with Many surgeons believed that use of narcotic analgesia may
the surgical team4. mask and delay the symptom appearance and hence can delay
Many studies have shown that the analgesia practice has the treatment of acute appendicitis. The above-mentioned
been safely used prior to the surgical planning in a patient3. Many researches suggest that there is no correlation of the use of
previous researches have shown that surgeons are reluctant to narcotic analgesia and delay in the decision to operate in patients
use any kind of analgesia prior to surgery as this would mask the of acute appendicitis. But still there is a lot room in the field to fill
diagnostic accuracy of the acute appendicitis and can delaying the with the supporting information on the topic. Narcotic analgesia
surgery and hence can increase the chances of complications5. In helps in localizing the pain to the specific region hence making the
2019, an article in American journal of surgery proposed the use of diagnosis more accurate and specific.
analgesia for acute abdomen, providing a data base to safely use The objective of this study was to evaluate that whether
the narcotic analgesia, for acute abdomen in patients in narcotic analgesia administration in the patients of acute
emergency departments6. A review in 2021 showed that appendicitis delays the diagnosis and the decision to operate in the
appendectomy had been the first line treatment for acute patients or not.
appendicitis and also that the analgesia did not mask the
symptoms of acute appendicitis and hence had no effect on the
MATERIALS AND METHODS
diagnostic accuracy and plan for the surgery1.
Another research was conducted to see the effect of narcotic It was a double-blind randomized crossover study. A total of 100
analgesia on the outcome of acute abdomen was carried out on patients presenting in the emergency department with acute
----------------------------------------------------------------------------------------- abdominal pain, which was confirmed as acute appendicitis by
Received on 11-03-2022 clinical examination, were included11. All the male and female
Accepted on 27-07-2022 patients of age 16 years and above were included in the study.

P J M H S Vol. 16, No. 08, August 2022 131

Effect of Narcotic Analgesia on Decision to Operate in Acute Appendicitis

Those having a previous appendectomy were excluded. After Another systematic review of the randomized controlled trials
taking ethical approval from Ethical Review Board and a proper were done from 1980-2013 to identify the effect of narcotic
informed consent, all the patients were assessed on a visual analgesia on the appendectomy decision. And it was concluded
analog scale for pain from 0-10cm. The patients were divided in that opioid analgesia had no effect on the decision to operate in
two groups each having 50 patients. The drugs were labelled as acute appendicitis in children also, hence proving our point of
drug A and drug B. Drug A was morphine 0.1 mg/kg of the body discussion as well. However it was recommended that further more
weight and drug B was placebo. Each drug was given to the both trials are needed in this regard13.
groups by crossover with an interval of 30 minutes and the Another systematic review from years 1929-2011 was
components of physical examination were analyzed for both carried out to see the same effect of narcotic analgesia on the
groups. A doctor on duty was assigned to perform the duty to diagnostic accuracy. It included 84 papers from very renowned
examine the groups before the administration and after 30 minutes databases like PubMed, Cochrane etc. and the conclusion was
of administration of drugs also. The pain score was calculated by that narcotic analgesia did not affect the diagnostic accuracy of
the VAS scale for both the groups at both intervals. The p-value appendicitis14.
was calculated by using student’s-test. Also, the frequency and Another systematic review published in Cochrane database
percentages of the decision to operate were calculated. The data suggested that several trials were included from 1996-2009 to see
was tabulated and then analyzed on SPSS 23 for statistical the effects of narcotic analgesia on the decision to operate. Total
analysis. eight trials were included in the review and the conclusion was that
opioid or narcotic analgesia did not affect the surgical decision of
RESULTS acute appendicitis in any age and gender15.
As per the results of our study as well it was observed that
The results were based on the two factors. First, the pain scoring narcotic analgesia of any type did not alter the diagnostic accuracy
was done and then p- value was calculated by applying t-test. 60 and the decision to operate in the patients of acute appendicitis.
female patients and 40 male patients were divided in two equal Hence the use of narcotic analgesia will not be affected due to the
groups receiving morphine as a drug and placebo. Pain scoring on fear of the change in the decision of appendectomy.
visual analog scale was performed before the administration of
these two drugs and then 30 minutes after administration of the
CONCLUSION
both drugs. The pain score difference was calculated in both
groups and then p-value was calculated which came out to be It is concluded that use of morphine analgesia in the patients of
significant (Table 1). acute appendicitis, does not alter the diagnostic efficacy of the
patients of acute appendicitis. Further, more researches and data
Table 1: Pain scoring by VAS scale: collaboration can be made to make a universally acceptable
Characteristics Pain score Pain score Difference p- standard for the use of narcotic analgesia in the patients of acute
before adm. after adm of scores value appendicitis.
Females (n=60) Conflict of interest: Nil
Morphine(n=30) 6.00 3.50 2.5 0.001
Placebo(n=30) 5.50 4.00 1.5 0.001
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