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Letter to the Editor
Nalbuphine Relieves Esophageal Spasmodic Pain: A Report of
Three Cases
Sir,
Esophageal spasm causes severe retrosternal pain and discomfort
at times. Patients with achalasia cardia, esophageal reflux,
and esophageal ulcers suffer a lot for this intractable pain.
The antispasmodics, calcium‑channel blockers, proton‑pump
inhibitors, tricyclic antidepressants, and opioids are recommended
as the remedies to relief this pain.[1] Phosphodiesterase inhibitor‑5
is also reported to relief this symptoms.[2] We used almost all the
optional agents on three of our patients with esophageal spasm
in the postanesthesia care unit but did not get desired effects.
Then, we switched over to administer intravenous nalbuphine,
and we got excellent results out of it.
Case Reports
Case 1
A 53‑year‑old female  was reported with severe retrosternal
pain with repeated melena for 20 h. She was found to
be very anxious, restless, and severely anemic. Hence,
blood transfusion was started, and an emergency upper
gastrointestinal (GI) tract endoscopy was done. There was an
anomalous dilated longitudinal vein along the luminal wall of
the lower one‑third of the esophagus with multiple ulcerations,
from which there was oozing of blood [Figure 1]. The patient
was excluded of having cirrhosis, chronic viral hepatitis,
or portal hypertension. She was then treated conservatively
with infusions of vasopressin, proton‑pump inhibitors,
calcium‑channel blockers, and antispasmodic agents. Varieties
of opioids including morphine, pethidine, and fentanyl
were also tried to relieve her retrosternal pain along with
Figure 1: An anomalous dilated longitudinal vein along the luminal wall
of the lower one-third of the esophagus with multiple ulcerations and
oozing of blood
204
imipramine. Yet, the symptoms were not relieved satisfactorily.
However, we found excellent result instantaneously while used
intravenous nalbuphine.
Case 2
A 58‑year‑old male  with severe retrosternal pain and
melena was received. He was a known case of achalasia
cardia. There was bleeding from a large organized blood clot
observed endoscopically in the luminal wall of the lower
third of the esophagus. This patient was also attempted with
all conventional analgesics and antispasmodics but relieved
significantly when we used intravenous nalbuphine.
Case 3
A 31‑year‑old female  developed severe peritonitis following
hysterosalpingography with dye for investigation of her
primary sterility. Within hours, she suffered from severe
dyspepsia and intractable retrosternal pain due to esophageal
spasm. Her upper GI endoscopy revealed normal, but she was
a known case of gastroesophageal reflux disease. This patient
was also tried with varieties of antispasmodics and analgesics,
but there was a remarkable relief of symptoms following
intravenous administration of nalbuphine.
Initially, we used 5 mg of nalbuphine intravenously, and
then, we added 5 mg as increment at an interval of 15 min
up to a total of 20 mg within 1 h. The possible mechanism
of relaxation and analgesia may be explained by the direct
actions of opioids on the opioid receptors (i.e., mu, kappa,
and delta) in enteric neurons of esophagus [Figure 2].[3] When
the esophageal receptors are activated, the propulsive activity,
secretions, and peristalsis decrease, resulting relaxations and
analgesia as well.[4] Moreover, the agonist‑antagonists causes
fewer adverse effects of pure agonist opioids such as nausea,
constipation, and biliary spasm.[5]
The patients experienced a little drowsiness and sweating for
a while just after administration of the drug and following
that, there were no other complications which conforms to
other reports.[6] The respiration and hemodynamics were
stable. These reports show that intravenous nalbuphine
has a significant role on relieving retrosternal pain due to
esophageal spasm when other remedies failed. Our limitations
were – we did not perform and monitor the esophageal
manometry and the pain scoring system. Large‑scale studies
are recommended to advocate the routine use of nalbuphine
for the relief of esophageal spasmodic pain.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
© 2018 Indian Journal of Pain | Published by Wolters Kluwer ‑ Medknow
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Letter to the Editor

Address for correspondence: Dr. Md Rabiul Alam,

Department of Anaesthesiology, Combined Military Hospital, Dhaka
Cantonment, Dhaka 1206, Bangladesh.
E‑mail: rabiuldr@gmail.com

References
1. Achem SR. Management of esophageal chest pain. Gastroenterol
Hepatol (N Y) 2007;3:765‑7.
2. Fox M, Sweis R, Wong T, Anggiansah A. Sildenafil relieves symptoms
and normalizes motility in patients with oesophageal spasm: A report of
two cases. Neurogastroenterol Motil 2007;19:798‑803.
3. Pergolizzi JV Jr. Opioid-Induced Constipation: Treating the Patient
Holistically. Pain Medicine News: 27  August, 2015. Available
from: http://www.painmedicinenews.com/Review-Articles/
Article/08-15/Opioid-Induced-Constipation-Treating-the-Patient-nbsp-
Holistically/33226/ses=ogst. [Last accessed on 2017 Dec 06].
4. Lacy BE. Effects of opioids on esophageal dysfunction. Gastroenterol
Hepatol (N Y) 2016;12:323‑5.
5. Rosow CE. The clinical usefulness of agonist‑antagonist analgesics in
acute pain. Drug Alcohol Depend 1987;20:329‑37.
6. Greif R, Laciny S, Rajek AM, Larson MD, Bjorksten AR, Doufas AG,
et al. Neither nalbuphine nor atropine possess special antishivering
activity. Anesth Analg 2001;93:620‑7.

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DOI:
Nil. 10.4103/ijpn.ijpn_62_17

Conflicts of interest
There are no conflicts of interest.
How to cite this article: Alam MR, Rahman SM, Karim KI, Haque M.
Md Rabiul Alam, SM Mizanur Rahman1, Kh Iqbal Karim, Mozibul Haque Nalbuphine relieves esophageal spasmodic pain: A report of three cases.
Indian J Pain 2017;31:204-5.
Departments of Anaesthesiology and 1Gastroenterology, Combined Military
Hospital, Dhaka, Bangladesh © 2017 Indian Journal of Pain | Published by Wolters Kluwer - Medknow

Indian Journal of Pain  ¦  Volume 31  ¦  Issue 3  ¦  September‑December 2017 205