What is the treatment for biliary colic?

Treatment of Biliary Colic

For acute biliary colic, administer intramuscular diclofenac 75 mg as first-line analgesic therapy, which provides superior pain relief compared to opioids or spasmolytics and significantly reduces progression to acute cholecystitis. 1

Acute Pain Management

First-Line Analgesic Therapy

• Diclofenac 75 mg intramuscular is the optimal choice for immediate pain relief in biliary colic 1
• This NSAID provides complete pain relief in approximately 78% of patients within 30 minutes 1
• Critically, diclofenac reduces progression to acute cholecystitis from 42% (placebo) to only 15%, representing a substantial protective effect 1
• The mechanism involves prostaglandin inhibition, which addresses both pain and inflammatory progression 2

Alternative NSAID Options

• Tenoxicam 20 mg intravenous provides significant pain relief in 63% of patients at 30 minutes and prevents acute cholecystitis development 3
• Tenoxicam demonstrates superior efficacy compared to spasmolytics, with no pain relapse over 24 hours in responders 3

Opioid-Based Regimens (Second-Line)

• If NSAIDs are contraindicated, use paracetamol 1000 mg IV combined with morphine 0.05 mg/kg rather than higher-dose morphine alone 4
• This combination provides equivalent analgesia to morphine 0.1 mg/kg while reducing opioid-related side effects 4
• Pain scores decrease from approximately 8.7 to 1.7 within 30 minutes with either regimen 4

Avoid Spasmolytics as Monotherapy

• Hyoscine N-butylbromide shows inferior efficacy, with only 44% achieving pain relief at 30 minutes and 25% experiencing pain relapse requiring rescue analgesia 3
• Four out of six non-responders to hyoscine progressed to acute cholecystitis 3

Definitive Treatment

Surgical Management

• Laparoscopic cholecystectomy is the definitive treatment for symptomatic cholelithiasis and should be performed within 7-10 days of symptom onset for uncomplicated cases 5
• Early cholecystectomy significantly reduces mortality compared to expectant management (7.9% vs 14.1%) and decreases recurrent pain, jaundice, and cholangitis 6
• Approximately 30% of patients may not experience recurrent episodes even without surgery, but this unpredictability supports definitive intervention 5

Management of Choledocholithiasis

• ERCP with sphincterotomy and stone extraction is the standard treatment for common bile duct stones 5
• ERCP must be performed within 72 hours for patients with biliary obstruction or cholangitis 5
• For patients with septic shock or clinical deterioration despite antibiotics, perform urgent ERCP within 24 hours 5

Management of Complications

Acute Cholangitis/Biliary Sepsis

• Initiate broad-spectrum antibiotics immediately upon recognition of cholangitis or biliary sepsis 5
• For severe infections with septic shock, use piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem 5
• Alternative regimen: aztreonam combined with amikacin for patients in shock 5
• First-line agents for mild-moderate cases include aminopenicillin/beta-lactamase inhibitors due to oral administration capability 7
• Third-generation cephalosporins with anaerobic coverage are appropriate for severe cases requiring IV therapy 7
• Avoid fluoroquinolones as first-line due to high resistance rates and unfavorable side effects; reserve for specific cases only 7

Biliary Drainage Procedures

• Endoscopic internal biliary catheter with removable plastic stent is the preferred initial approach for most biliary obstruction scenarios 7
• Percutaneous internal/external biliary catheter is appropriate for hilar obstruction from malignancy or when endoscopic access fails 7
• Biliary stents must be removed within 1-2 weeks to prevent complications; longer duration significantly increases risk 6

High-Risk Surgical Patients

• Percutaneous cholecystostomy is an option for acute cholecystitis in patients with multiple comorbidities who cannot tolerate surgery 5
• For prohibitive surgical risk, biliary sphincterotomy with endoscopic duct clearance alone may be considered as an alternative to cholecystectomy 6

Special Diagnostic Considerations

Functional Gallbladder Disorders

• When ultrasound is unremarkable but biliary colic persists, obtain HIDA scan to evaluate gallbladder ejection fraction (GBEF) 8
• Biliary hyperkinesia (GBEF >80%) is an underrecognized cause of biliary colic that responds to cholecystectomy 8
• Laparoscopic cholecystectomy provides complete symptom resolution in functional gallbladder disorders including both hypokinesia and hyperkinesia 8

Critical Pitfalls to Avoid

• Do not routinely place biliary stents before assessing resectability except for acute cholangitis, severe malnutrition, or specific technical indications 7
• Do not delay cholecystectomy beyond 4 weeks in biliary pancreatitis, as this increases risk of recurrent attacks 5
• Do not assume atypical or ambiguous symptoms will resolve with cholecystectomy; these patients have lower success rates 5
• Do not use routine postoperative antibiotics when the infectious focus is controlled by cholecystectomy in uncomplicated cases 7
• Do not rely on spasmolytics alone for biliary colic management given high failure rates and progression to complications 3