In an adult with acute calculous cholecystitis and normal renal function, is ketorolac more effective than hyoscine butylbromide (buscopan) for short‑term pain control?

Ketorolac vs Buscopan for Acute Cholecystitis Pain Control

Ketorolac is the superior choice for short-term pain control in acute calculous cholecystitis, as NSAIDs like ketorolac provide effective analgesia by reducing prostaglandin-mediated inflammation and gallbladder pressure, while hyoscine butylbromide (Buscopan) lacks evidence for efficacy in biliary pain and may mask important clinical signs needed for surgical decision-making.

Evidence-Based Rationale

Why Ketorolac is Preferred

NSAIDs are the appropriate analgesic class for acute cholecystitis because they address the underlying inflammatory pathophysiology. Ketorolac inhibits COX enzymes, reducing prostaglandin synthesis and thereby decreasing both pain and the inflammatory pressure within the gallbladder that causes biliary colic 1, 2. This mechanism directly targets the source of pain in cholecystitis.

• Ketorolac provides potent analgesia comparable to opioids (morphine, meperidine) in acute pain states, with analgesic effects that may persist longer than opioid alternatives 2
• In acute biliary colic specifically, ketorolac 60 mg IM achieved pain reduction of 3.8 points on a 10-point scale at 30 minutes, with only 12.5% of patients requiring rescue medication 3
• Ketorolac has demonstrated efficacy in multiple acute pain conditions including renal colic (which shares similar visceral pain mechanisms with biliary colic), with median pain scores dropping from 9 to 0 within 60 minutes 4

Why Buscopan is Not Recommended

Hyoscine butylbromide (Buscopan) is an antispasmodic that lacks robust evidence for biliary pain and may interfere with clinical assessment. The available evidence shows significant limitations:

• In renal colic (the closest comparable visceral pain condition studied), buscopan compositum showed a 62% pain relapse rate within 24 hours, requiring rescue opioid therapy 5
• Antispasmodics may mask important clinical signs that surgeons need to monitor when deciding on surgical timing for cholecystitis 6
• No high-quality studies support the use of antispasmodics specifically for acute cholecystitis pain 1

Practical Implementation Algorithm

Initial Pain Management Protocol

1. Administer ketorolac 30 mg IV over 1 minute (or 60 mg IM if IV access unavailable) 2, 3, 4
2. Reassess pain at 30 minutes using a validated pain scale (0-10 VAS) 3
3. If inadequate relief (<50% reduction), consider adding low-dose opioid rather than switching to buscopan 2
4. Continue ketorolac 15-30 mg IV/IM every 6 hours as needed until definitive surgical management 2

Critical Safety Considerations

Do not use ketorolac in patients with:

• Preexisting renal insufficiency (NSAIDs cause clinically significant renal dysfunction only in those with abnormal baseline function) 1
• Active peptic ulcer disease or recent GI bleeding 2, 4
• Known hypersensitivity to NSAIDs or aspirin 2, 4
• Concurrent anticoagulation or bleeding diathesis (though postoperative bleeding risk is not significantly increased with short-term use) 1, 2

Limit ketorolac duration to ≤5 days to minimize GI and renal risks, especially in elderly patients 2. Since acute cholecystitis requires early laparoscopic cholecystectomy within 72 hours to 7 days 1, 7, 6, this duration limitation aligns perfectly with the treatment timeline.

Integration with Definitive Management

Pain control with ketorolac should not delay surgical consultation or definitive treatment. The optimal management algorithm for acute cholecystitis is:

• Immediate initiation of IV antibiotics (amoxicillin/clavulanate 2g/0.2g every 8 hours for immunocompetent patients) 6
• Concurrent ketorolac for analgesia 7, 6
• Early laparoscopic cholecystectomy within 72 hours of diagnosis (or up to 7-10 days from symptom onset) 1, 7, 6

Ketorolac does not interfere with surgical decision-making because it provides analgesia without masking peritoneal signs or fever that indicate complications requiring urgent intervention 1, 2.

Common Pitfalls to Avoid

• Do not use buscopan as first-line therapy based on outdated assumptions about "antispasmodic" effects in biliary colic—the evidence does not support this approach 5
• Do not withhold NSAIDs in patients with normal renal function due to theoretical concerns; the evidence shows only transient, clinically unimportant renal effects 1
• Do not delay cholecystectomy to "optimize pain control"—definitive surgical source control is the treatment, and ketorolac provides adequate bridging analgesia 1, 7, 6
• Do not use high-dose or prolonged ketorolac (>5 days or >120 mg/day total) as this markedly increases GI bleeding risk, especially in elderly patients 2