Anticholinergics Stop the Pain and the Motions – A Lesson for Surgeons

Background: Small bowel obstruction commonly presents to surgeons acutely. Adhesions and hernias are the commonest causes. However, medical ileus and gastroparesis are often overlooked.

Case report: This article presents a case of an 82year-old woman on orthopaedic ward referred to the general surgeons with symptoms of small bowel obstruction: bilious vomiting and abdominal distension. Despite all conservative measures, symptoms did not improve. Oral contrast on cross-sectional imaging and gastrograffin follow-through consistently illustrated a transition point at the base of jejunum. No mass or mural lesion was seen. The patient was prescribed regular orphenadrine for cramps over her right periprosthetic femoral fracture. Surgical intervention was then considered on suspicion of adhesional small bowel obstruction. A day before the planned laparotomy, the general surgical team stopped orphenadrine as the last attempt to relieve her symptoms. Ceasing orphenadrine reversed her obstructive symptoms and signs within hours.

Conclusion: Orphenadrine has a broad range of anticholinergic effects that is known to cause gastroparesis and ileus, which is often overlooked. This article discusses the learning points of this case and reviews literature regarding its pharmacologic effects.