What can be given to a patient with Choledocholithiasis (presence of gallstones in the common bile duct) who is experiencing right upper abdominal cramping and is NPO (nil per os, nothing by mouth) after an ERCP (Endoscopic Retrograde Cholangiopancreatography) and prior to a laparoscopic cholecystectomy (surgical removal of the gallbladder)?

Management of Right Upper Abdominal Cramping Post-ERCP in a Patient with Choledocholithiasis

For a patient with right upper abdominal cramping after ERCP for choledocholithiasis who is NPO prior to laparoscopic cholecystectomy, intravenous ketorolac (15-30 mg depending on age and renal function) is recommended for pain management.

Assessment and Initial Management

• Right upper quadrant cramping after ERCP is common and may be related to residual gas, post-procedural inflammation, or transient biliary spasm 1
• Since the patient is NPO (nothing by mouth) in preparation for laparoscopic cholecystectomy, oral medications are contraindicated 1
• The patient has already received Percocet (oxycodone/acetaminophen) but is still experiencing pain, indicating need for additional analgesia 2

Recommended Pharmacological Management

First-line option:

• Intravenous ketorolac (Toradol) is recommended as it:
  • Provides effective analgesia for moderate to severe pain 2
  • Has been shown to be effective for biliary pain 1
  • Has the additional benefit of reducing risk of post-ERCP pancreatitis 1
  • Dosing should be:
    • 30 mg IV for patients under 65 years without renal impairment 2
    • 15 mg IV for patients ≥65 years, with renal impairment, or <50 kg 2
    • Administered slowly over at least 15 seconds 2

Alternative options if NSAIDs are contraindicated:

• IV opioid analgesics may be considered if ketorolac is contraindicated 2
• Low-dose IV antispasmodics (such as hyoscine butylbromide) may help relieve biliary spasm 1

Important Considerations and Monitoring

• Assess for potential complications of ERCP that could cause pain:

  • Post-ERCP pancreatitis (occurs in 2-5% of therapeutic ERCPs) 1
  • Cholangitis (especially if complete biliary drainage was not achieved) 1
  • Perforation (rare but serious complication) 1

• Monitor for warning signs requiring urgent attention:

  • Fever, which may indicate cholangitis 1
  • Severe, worsening, or changing character of pain 1
  • Signs of peritonitis or perforation 1

• Ensure adequate IV hydration while the patient remains NPO 1

Timing of Cholecystectomy

• The planned laparoscopic cholecystectomy should proceed as scheduled, as definitive management of gallstone disease is recommended during the same hospital admission after ERCP for choledocholithiasis 1
• Early laparoscopic cholecystectomy (within 72 hours) is associated with better outcomes and shorter hospital stays 3, 4

Post-Procedural Care

• After successful removal of common bile duct stones via ERCP, laparoscopic cholecystectomy is the definitive treatment to prevent recurrent biliary symptoms 3, 5
• Ensure adequate pain control post-cholecystectomy with appropriate analgesics 2

Remember that right upper quadrant pain after ERCP is common but should be monitored carefully to distinguish between expected post-procedural discomfort and potential complications requiring further intervention.