What is the best analgesia for biliary colic?

Best Analgesia for Biliary Colic

Intramuscular diclofenac 75 mg is the recommended first-line treatment for biliary colic when the diagnosis is clear and there are no signs of complications. 1

Initial Management

• Analgesia should be administered quickly to provide pain relief within 30 minutes of assessment 1
• The intramuscular route is preferred for initial treatment as oral and rectal administration are considered unreliable, and intravenous administration may be impractical in certain settings 1
• Complete or acceptable pain control should be maintained for at least six hours 1

First-Line Treatment

• NSAIDs are the preferred first-line treatment for biliary colic 2, 3
• Diclofenac 75 mg intramuscular injection provides faster and more effective pain relief compared to alternatives 2, 4
• NSAIDs not only provide symptom control but may also prevent disease progression to acute cholecystitis 2, 4
• Studies show that diclofenac can prevent progression to acute cholecystitis in a significant number of patients (16.66% progression with diclofenac vs. 52.77% with hyoscine) 2

Alternative Options

• When NSAIDs are contraindicated, an opiate combined with an antiemetic (such as morphine sulfate and cyclizine) should be given 1
• Other NSAIDs that have shown efficacy include:
  • Intravenous tenoxicam 20 mg 5
  • Injectable flurbiprofen 3
  • Ketorolac 3
• Paracetamol combined with low-dose morphine may be effective, but evidence suggests it is not superior to standard morphine dosing 6

Monitoring and Follow-up

• If pain is not alleviated within 60 minutes of initial treatment, hospital admission should be arranged 1
• Patients should be followed up (via telephone call) one hour after initial assessment and administration of analgesia 1
• Abrupt recurrence of severe pain warrants immediate hospital admission 1

Important Considerations

• Patients with shock or fever must be admitted to hospital immediately 1
• Patients should be instructed to drink plenty of fluids and, if possible, void urine into a container to catch any identifiable calculus 1
• Alternative diagnoses should be considered in patients over 60 years of age (leaking abdominal aortic aneurysm) or women with delayed menses (ectopic pregnancy) 1

Common Pitfalls and Caveats

• Avoid delaying analgesia while waiting for diagnostic tests 1
• Be cautious with NSAIDs in patients with renal impairment, history of peptic ulcer disease, or allergies to NSAIDs 3
• Some clinicians may be tempted to use spasmolytics like hyoscine N-butylbromide, but evidence shows they are less effective than NSAIDs and associated with higher rates of progression to acute cholecystitis 2, 5
• Avoid issuing limited quantities of oral or rectal analgesics for patients with recurrent pain due to potential for drug misuse 1