How should I treat an adult patient presenting with typical biliary colic due to gallstones, including immediate pain control and definitive management?

Treatment of Biliary Colic

For acute biliary colic, administer intramuscular diclofenac 75 mg immediately for pain control, followed by laparoscopic cholecystectomy within 7-10 days of symptom onset during the same hospital admission to prevent recurrent episodes and complications. 1, 2, 3

Immediate Pain Management

• Diclofenac 75 mg intramuscular is the first-line analgesic for biliary colic, providing complete pain relief in 91.7% of patients within 4 hours compared to only 69.4% with spasmolytics. 2

• Diclofenac demonstrates superior efficacy over hyoscine (spasmolytics), with significantly faster pain relief at 30 minutes, 1 hour, 2 hours, and 4 hours post-injection. 2

• Critically, diclofenac reduces progression to acute cholecystitis from 52.8% to only 16.7%, making it not just an analgesic but a disease-modifying intervention. 2

• A single 75 mg intramuscular dose decreases overall cholelithiasis-related complications substantially compared to placebo. 3

• Opioids may be used for severe acute pain when NSAIDs are insufficient or contraindicated. 4

Diagnostic Workup During Initial Presentation

• Obtain transabdominal ultrasound and liver function tests immediately to confirm gallstones and assess for common bile duct (CBD) stones. 1

• Assess for biliary obstruction markers: elevated bilirubin (particularly ≥4.7 mg/dL), alkaline phosphatase, GGT, and transaminases suggest CBD stones requiring ERCP. 5, 1

• Leukocytosis indicates infection and potential progression to acute cholecystitis or cholangitis. 1

• If CBD stones are suspected based on ultrasound findings, visible CBD stone, cholangitis, or bilirubin >4 mg/dL, proceed directly to ERCP; for moderate-risk patients, obtain MRCP or EUS for confirmation first. 6

Definitive Management: Laparoscopic Cholecystectomy

• Perform laparoscopic cholecystectomy within 7-10 days of symptom onset, ideally during the same hospital admission, achieving >97% success rate with immediate permanent stone removal. 1

• Early cholecystectomy (within 2 weeks) is mandatory to prevent recurrent biliary events; delaying beyond 2-4 weeks significantly increases risk of recurrent pancreatitis, cholangitis, and other complications. 7, 5, 6

• Laparoscopic cholecystectomy is the gold standard and only effective treatment for symptomatic gallstones, shortening total hospital stay and allowing return to work approximately 9 days sooner. 1, 8

Management When CBD Stones Are Present

This requires a two-stage approach:

• First stage: ERCP with biliary sphincterotomy and endoscopic stone extraction should be performed during the index admission without unnecessary delay. 5, 6

• The 72-hour window applies only to acute gallstone pancreatitis with predicted severe disease or cholangitis—not to uncomplicated retained CBD stones. 5

• ERCP achieves CBD clearance in 80-95% of cases, effectively decompressing the biliary system before surgery. 6

• Administer rectal NSAIDs at the time of ERCP to reduce post-ERCP pancreatitis risk (which occurs in 4-5.2% of cases). 1, 6

• Second stage: Laparoscopic cholecystectomy must still be performed within 2 weeks after CBD clearance if gallbladder stones remain, as leaving the gallbladder in situ results in 14.1% mortality versus 7.9% with cholecystectomy, plus 15-23.7% risk of recurrent CBD stones. 5

• Alternative single-stage approach: Laparoscopic cholecystectomy with laparoscopic CBD exploration is appropriate if surgical expertise is available. 5, 1

Critical Pitfalls to Avoid

• Do not adopt a "watch-and-wait" approach for proven CBD stones—conservative management results in 25.3% unfavorable outcomes (pancreatitis, cholangitis, biliary obstruction) versus 12.7% with planned stone extraction. 5

• Do not wait for fever or overt cholangitis before proceeding to ERCP; biochemical obstruction with symptoms is sufficient justification. 5

• Never use biliary stenting as definitive therapy in early post-operative patients; stenting is reserved only for temporary drainage while planning definitive stone extraction or for patients with limited life expectancy or prohibitive surgical risk. 5, 1

• Do not delay cholecystectomy beyond the index admission or 2-week window, as this dramatically increases recurrent biliary events including potentially fatal complications. 5, 6

Special Circumstances Requiring Urgent Intervention

• Patients with acute cholangitis who fail antibiotic therapy or have septic shock require urgent biliary decompression with endoscopic stone extraction and/or biliary stenting. 7

• Patients with gallstone pancreatitis plus cholangitis or persistent biliary obstruction require biliary sphincterotomy and stone extraction within 72 hours of presentation. 7

• For mild acute gallstone pancreatitis without cholangitis, perform cholecystectomy within 2 weeks of presentation, preferably during the same admission. 7