What is the recommended pain reliever for cholelithiasis (gallstones)?

Pain Management for Cholelithiasis

First-Line Analgesic Recommendation

NSAIDs, specifically intramuscular diclofenac 75 mg or intravenous ketorolac, are the recommended first-line pain relievers for biliary colic from cholelithiasis, providing superior pain control compared to placebo and potentially reducing progression to acute cholecystitis. 1, 2, 3

Evidence-Based Pain Management Algorithm

Initial Pain Control

• Administer NSAIDs as first-line therapy for acute biliary colic pain, with diclofenac 75 mg intramuscularly or ketorolac intravenously showing the strongest evidence 1, 2, 3
• NSAIDs achieve complete pain relief in approximately 78% of patients compared to 27% with placebo 3
• A single dose of diclofenac 75 mg IM provides satisfactory pain relief and decreases progression to acute cholecystitis by approximately 60% (from 42% with placebo to 15% with diclofenac) 3

Alternative NSAID Options

• Intravenous tenoxicam and injectable flurbiprofen are equally effective alternatives when diclofenac or ketorolac are unavailable 2
• NSAIDs demonstrate superior efficacy with lower number of doses required and longer duration of action compared to opioids 2

When NSAIDs Are Insufficient or Contraindicated

• Opioids can be used as second-line agents when NSAIDs fail to provide adequate pain control or are contraindicated 1
• No significant difference exists between NSAIDs and opioids for complete pain relief (RR 0.98), though the evidence quality is very low 1
• Spasmolytic drugs are less effective than NSAIDs, with NSAIDs showing better pain control (RR 0.51) 1

Critical Clinical Considerations

Disease-Modifying Effects of NSAIDs

• NSAIDs not only control pain but may reduce disease progression, decreasing complications such as mild acute cholecystitis, jaundice, cholangitis, and acute pancreatitis 1, 3
• The complication rate is significantly lower with NSAIDs compared to placebo (RR 0.66) 1

Safety Profile

• No severe adverse events were reported in the trials evaluating NSAIDs for biliary colic 1
• Minor adverse events (abdominal pain, drowsiness, headache, dizziness, cutaneous manifestations) were infrequently reported 1
• Standard NSAID contraindications apply: avoid in patients with gastrointestinal bleeding risk, renal impairment, or cardiovascular disease 1

Common Pitfalls to Avoid

Symptom Recognition

• Do not attribute chronic, intermittent pain lasting less than 15 minutes to gallstone disease - true biliary colic presents as sudden, severe, steady pain unaffected by position change or household remedies 4
• Belching, bloating, fatty food intolerance, and chronic pain are NOT attributable to cholelithiasis and will not resolve with treatment 4
• Atypical symptoms (indigestion, flatulence, heartburn, nausea) are less likely to resolve following cholecystectomy compared to classic biliary pain 4, 5

Treatment Timing

• Refer all patients with confirmed symptomatic cholelithiasis to surgery/gastroenterology within 2 weeks of initial presentation regardless of symptom severity 6
• Early laparoscopic cholecystectomy (within 7-10 days) is the definitive treatment for symptomatic disease 5, 7

Medication Limitations

• NSAIDs provide symptomatic relief but do not treat the underlying gallstones 1, 2
• Oral bile acid therapy (ursodeoxycholic acid) is reserved only for highly select patients who refuse surgery or are poor surgical candidates with small, radiolucent stones 5, 7