Therapy of gallstone disease: What it was, what it is, what it will be

Table 2 Major features of the uncomplicated biliary colic

Pathogenesis	Visceral pain caused by the impaction of the stone in the cystic duct or the ampulla of Vater, followed by distension of the gallbladder and/or biliary tract with activation of visceral sensory neurons[161]
Onset	Not exclusively postprandial, typically intermittent
Intensity	Mean visual analogue scale of 9 cm on a 0-10 cm scale
Localization	Most frequently right upper quadrant of the abdomen and/or the epigastrium (representative dermatomes T8/9)
Duration	Generally longer than 15-30 min. Can last several hours and be associated non-specific symptoms of indigestion
Radiation	Angle of the right scapula and/or shoulder (about 60% of cases), retrosternal area (less than 10% of cases)
Associated features	Urgency to walk[162] (two-third of patients), nausea or vomit[42,161,162]
Relief	If the stone returns into the gallbladder lumen, passes through the ampulla of Vater into the duodenum or migrates back to the common bile duct[26]
First-line therapy	Fast-acting narcotic analgesics (meperidine[163]) or non-steroidal anti-inflammatory drugs (NSAIDs) (im or iv ketorolac or ibuprofen po) which could also reduce the risk of evolution towards acute cholecystitis[164-167]
Second-line therapy	Antispasmodic (anticholinergic) agents like hyoscine (scopolamine). Less effective than NSAIDs[164]
Recommendations	Fasting, to avoid release of endogenous cholecystokinin and further gallbladder contraction

Adapted from[25,63,148] with permission.