A 40 year old female with a history of hyperlipidemia presents for abdominal pain. She has been having intermittent pain in her right upper quadrant after meals without vomiting or change in her bowel habits. Vital signs are within normal limits. She has mild tenderness to palpation to the right upper quadrant on exam with a negative Murphy’s sign. Point of care pregnancy test is negative. Her workup including CBC, BMP, LFTs, and lipase are unremarkable. A right upper quadrant ultrasound demonstrates numerous gallstones without evidence of cholecystitis. Which of the following is recommended for first line treatment of this patient’s suspected condition?
A: Acetaminophen
B: Gabapentin
C: Ketorolac
D: Morphine
Answer: Ketorolac
This patient is presenting with biliary colic which occurs by a gallstone causing periodic obstruction of the cystic duct. Management includes symptom control and outpatient surgical referral for cholecystectomy. NSAIDs are first line therapy. When administered parenterally, NSAIDs have similar analgesic effect compared to opioids for biliary colic. In addition, NSAIDs reduce the rate of short term complications such as acute cholecystitis.
Acetaminophen is an antipyretic that has analgesic properties but is not first line for biliary colic. Gabepentin is typically used for neuropathic pain such as diabetic neuropathy or shingles. Opioids such as morphine are reserved for when NSAIDs are not effective in reducing pain but are not first line due to safety and side effects such as hypoventilation. It is known that opioids cause sphincter of Oddi spasm, but the clinical significance of this is unclear.
References:
Besinger B, Stehman CR. Pancreatitis and Cholecystitis. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.
Colli A, Conte D, Valle SD, Sciola V, Fraquelli M: Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic. Aliment Pharmacol Ther 35: 1370, 2012. [PubMed: 22540869]
