Can ceftriaxone (Ceftriaxone) cause abdominal pain?

Ceftriaxone Can Cause Abdominal Pain Through Multiple Mechanisms

Yes, ceftriaxone can cause abdominal pain through several mechanisms, most notably biliary pseudolithiasis (gallbladder sludge/stones) and gastrointestinal side effects. 1

Mechanisms of Ceftriaxone-Associated Abdominal Pain

1. Gastrointestinal Side Effects

• According to the FDA drug label, gastrointestinal adverse reactions occur in approximately 2.7% of patients receiving ceftriaxone 1
• Common GI symptoms include:
  • Diarrhea/loose stools (2.7%)
  • Nausea and vomiting (<1%)
  • Abdominal pain (reported as a rare adverse reaction <0.1%)
  • Pseudomembranous colitis (can occur during or after treatment)

2. Biliary Complications

• Biliary pseudolithiasis/sludge: Ceftriaxone can precipitate with calcium in the gallbladder, forming sludge or stones
  • Occurs in approximately 45% of treated patients 2
  • Symptomatic in about 19% of those affected 2
  • Typically presents as right upper quadrant colicky pain
  • More common with:
    • Higher doses
    • Longer duration of treatment
    • Children (but can occur in adults)

3. Renal Complications

• Ceftriaxone can cause nephrolithiasis (kidney stones) 3, 4
  • Can present with flank pain, abdominal pain, or renal colic
  • May lead to post-renal acute kidney injury in severe cases
  • More likely with high-dose therapy

4. Pancreatic Complications

• Rare cases of ceftriaxone-induced acute pancreatitis have been reported 5
  • Presents with severe abdominal pain, nausea, vomiting
  • Associated with elevated lipase and amylase

Clinical Evaluation of Abdominal Pain in Patients on Ceftriaxone

When a patient on ceftriaxone presents with abdominal pain:

1. Assess pain characteristics:

   • Location (right upper quadrant pain suggests biliary involvement)
   • Timing (relation to ceftriaxone administration)
   • Quality (colicky pain suggests stone/sludge)

2. Diagnostic workup:

   • Right upper quadrant ultrasound (first-line imaging) to evaluate for gallbladder disease 6
   • Liver function tests to assess for hepatobiliary involvement
   • Serum lipase/amylase if pancreatitis is suspected
   • Urinalysis and renal imaging if nephrolithiasis is suspected

Management Recommendations

1. For mild gastrointestinal symptoms:

   • Symptomatic treatment
   • Consider continuing ceftriaxone if infection requires it and symptoms are tolerable

2. For biliary pseudolithiasis:

   • If symptomatic and severe, consider discontinuing ceftriaxone
   • Switch to alternative antibiotic therapy if needed
   • Reassurance that stones typically dissolve spontaneously after discontinuation of ceftriaxone, especially if treatment was short-term 2

3. For nephrolithiasis or urinary tract obstruction:

   • Discontinue ceftriaxone
   • Urological consultation may be needed
   • In severe cases with obstruction, stent placement may be required 3

4. For suspected pancreatitis:

   • Immediately discontinue ceftriaxone
   • Provide supportive care
   • Consider hospitalization if severe 6

Prevention

• Use appropriate dosing of ceftriaxone
• Consider alternative antibiotics in patients with history of gallbladder disease
• Ensure adequate hydration during therapy
• Monitor patients receiving high-dose or prolonged therapy for symptoms

Important Caveats

• The risk of biliary complications increases with higher doses and longer duration of treatment
• Children appear more susceptible to biliary pseudolithiasis, but adults can also be affected
• Most cases of biliary sludge/stones resolve spontaneously after discontinuation of ceftriaxone
• When treating serious infections, the benefits of ceftriaxone may outweigh the risk of these complications

In summary, abdominal pain is a recognized adverse effect of ceftriaxone therapy, with multiple potential mechanisms including direct gastrointestinal effects, biliary pseudolithiasis, nephrolithiasis, and rarely pancreatitis.