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Analgesia in biliary colic

Three Part Question

In [patients with acute biliary colic] is [non-steroidal anti-inflammatory better than/equal to opiates] at [pain reduction]?

Clinical Scenario

A 34 year old female is brought into the ED with RUQ abdominal pain. She has previously been diagnosed as having symptomatic gallstones (Chronic cholecystitis) and is awaiting a cholesystectomy. You diagnose her as having biliary colic and wonder if giving her an IM NSAID (eg.40mg of piroxicam) would be appropriate instead of an opiate (IV Morphine titrated to pain with IV 10mg metoclopramide).

Search Strategy

Medline 1966-09/2000 using OVID interface.
[exp biliary tract diseases/ or exp cholecystitis/ or exp cholelithiasis/ or exp colic/ or "biliary colic".mp.] AND [{ exp analgesics, opioid/ or "analgesics,opioid".mp.} OR{exp narcotics/ or "opiates".mp.} OR{exp morphine/ or exp morphine derivatives/ or"morphine".mp.}OR{exp.meperidine/ or "pethidine".mp.} OR{ exp analgesics/ or exp analgesics, non-narcotic/ or "analgesics".mp.} OR {exp analgesics/ or exp anti-inflammatory agents, non-steroidal/ or analgesics, nonsteroidal".mp} OR. { exp diclofenac/ or exp diclofenac sodium/ or "diclofenac".mp.} OR {"diclofenac".mp. 9 exp diclofenac sodium/ or "voltarol".mp.} {exp ibuprofen/ or "ibuprofen".mp. } OR{ exp ibuprofen/ or "brufen".mp} OR{ exp piroxicam/ or "feldene".mp.} OR {exp piroxicam/ or "piroxicam".mp.}] – maximally sensitive RCT filter, limit to human and English language

Search Outcome

264 papers were found none of which were relevant to the question.


Biliary colic – intermittent bouts of RUQ pain – a symptom of chronic cholecystitis and cholelithiasis is traditionally treated with pethidine ("less spasm of sphincter of Oddi") but is associated with the potential common side effects of nausea, vomiting, drowsiness and postural hypotension. Use of a NSAID parenterally eg. IM Feldene could avoid these problems. Though no RCTs were found comparing the pain reliving efficacy of NSAIDs to opiates 2 placebo–controlled trials of diclofenac in biliary colic were found (1997 & 1984): (1,2) One of them (the more recent one) concluded that in patients with cholelithiasis who present with biliary colic, a single 75-mg intramuscular dose of diclofenac can provide satisfactory pain relief and decrease substantially the rate of progression to acute cholecystitis (1) Another double–blind study. (3) showed that NSAIDs have a favourable effect on the clinical course of acute cholecystitis, and was useful for patients awaiting operation or scheduled for later elective surgery. This was because in acute obstructive cholecystitis the increased intraluminal pressure in the gallbladder is reduced by nonsteroid anti-inflammatory drugs which effectively relieve biliary pain (4). 1. Akriviadis EA. Hatzigavriel M. Kapnias D. Kirimlidis J. Markantas A. Garyfallos A. Treatment of biliary colic with diclofenac: a randomized, double-blind,placebo- controlled study. Gastroenterology. 113(1):225-31, 1997 Jul 2. Broggini M. Corbetta E. Grossi E. Borghi C. Diclofenac sodium in biliary colic: a double blind trial. British Medical Journal Clinical Research Ed.. 288(6423):1042, 1984 Apr 7. 3. Thornell E. Nilsson B. Jansson R. Svanvik J. Effect of short-term indomethacin treatment on the clinical course of acute obstructive cholecystitis. European Journal of Surgery. 157(2):127-30, 1991 Feb. 4. Goldman G. Kahn PJ. Alon R. Wiznitzer T. Biliary colic treatment and acute cholecystitis prevention by prostaglandin inhibitor. Digestive Diseases & Sciences. 34(6):809-11, 1989 Jun.

Clinical Bottom Line

A parenteral NSAID could be used to provide pain relief in biliary colic (as is the practice for renal colic.) with probable additional benefits.