# Biliary Colic (symptomatic gallstones) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary (ENDF) 2026 · Egyptian National Drug Formulary 2026 · Ibuprofen 100 mg/5 ml SmPC section 4.2 (eMC product 4560) · Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) · MSF Essential Drugs 2024 - paracetamol (oral) · NICE Guideline CG188: Gallstone disease: diagnosis and management 2014 · Diclofenac sodium 50 mg delayed-release (gastro-resistant) tablets US prescribing information, DOSAGE AND ADMINISTRATION (DailyMed SetID a57b897e-0cbe-4ac3-969f-b00357a0cfa8) for the oral dose; the intramuscular dose is from Voltarol Ampoules (diclofenac sodium 75 mg in 3 ml solution for injection) SmPC section 4.2 (eMC product 1043): "One ampoule once (or in severe cases twice) daily intramuscularly by deep intragluteal injection into the upper outer quadrant" - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary 2026 - Ibuprofen 100 mg/5 ml SmPC section 4.2 (eMC product 4560) - Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) - MSF Essential Drugs 2024 - paracetamol (oral) - Diclofenac sodium 50 mg delayed-release (gastro-resistant) tablets US prescribing information, DOSAGE AND ADMINISTRATION (DailyMed SetID a57b897e-0cbe-4ac3-969f-b00357a0cfa8) for the oral dose; the intramuscular dose is from Voltarol Ampoules (diclofenac sodium 75 mg in 3 ml solution for injection) SmPC section 4.2 (eMC product 1043): "One ampoule once (or in severe cases twice) daily intramuscularly by deep intragluteal injection into the upper outer quadrant" - Gallstones (Cholelithiasis) - disease-level clinical article (biliary-colic-full.txt) ## Treatment metadata - Diclofenac — 50 mg — oral.solid - Ibuprofen — 400 mg — oral.solid - Referral & safety-netting (no drug therapy) - Paracetamol — 500 mg — oral.solid - Hyoscine butylbromide — 10 mg — oral.solid ## Complete treatment card ```text BILIARY COLIC (SYMPTOMATIC GALLSTONES) Sources: Egyptian National Drug Formulary (ENDF) 2026 · Egyptian National Drug Formulary 2026 · Ibuprofen 100 mg/5 ml SmPC section 4.2 (eMC product 4560) · Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) · MSF Essential Drugs 2024 - paracetamol (oral) · NICE Guideline CG188: Gallstone disease: diagnosis and management 2014 · Diclofenac sodium 50 mg delayed-release (gastro-resistant) tablets US prescribing information, DOSAGE AND ADMINISTRATION (DailyMed SetID a57b897e-0cbe-4ac3-969f-b00357a0cfa8) for the oral dose; the intramuscular dose is from Voltarol Ampoules (diclofenac sodium 75 mg in 3 ml solution for injection) SmPC section 4.2 (eMC product 1043): "One ampoule once (or in severe cases twice) daily intramuscularly by deep intragluteal injection into the upper outer quadrant" Review status: REVIEWED against Egyptian National Drug Formulary 2026, Ibuprofen 100 mg/5 ml SmPC section 4.2 (eMC product 4560), Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020), MSF Essential Drugs 2024 - paracetamol (oral), Diclofenac sodium 50 mg delayed-release (gastro-resistant) tablets US prescribing information, DOSAGE AND ADMINISTRATION (DailyMed SetID a57b897e-0cbe-4ac3-969f-b00357a0cfa8) for the oral dose; the intramuscular dose is from Voltarol Ampoules (diclofenac sodium 75 mg in 3 ml solution for injection) SmPC section 4.2 (eMC product 1043): "One ampoule once (or in severe cases twice) daily intramuscularly by deep intragluteal injection into the upper outer quadrant", Gallstones (Cholelithiasis) - disease-level clinical article (biliary-colic-full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Cramping pain after eating, in the right upper abdomen or the pit of the stomach, boring through to the back or shoulder blade [abdominal pain · muscle cramps · right upper quadrant pain] - A fatty meal is the classic trigger, and sickness and vomiting usually come with the pain [vomiting] - Stones may cause nothing at all, or anything up to sepsis - the attack is only one point on that range [sepsis] - The pain can sit behind the breastbone or on the left instead, which is how it gets mistaken for the heart - Pain that has stopped being intermittent and become constant and worsening means the gallbladder is now inflamed SIGNS - what you find (7) - In a simple attack the belly is tender but the patient has no fever, and the pulse and blood pressure are normal - Pain caught by pressing under the right ribs as the patient breathes in points to acute cholecystitis [abdominal pain · right upper quadrant pain] - A palpable mass under the right ribs is the swollen, thick-walled gallbladder; fever and a fast pulse go with it [abdominal pain · fever · right upper quadrant pain] - Jaundice means the stone has moved into the common duct [jaundice] - Pain, fever and jaundice together are Charcot triad - the duct is infected and this is an emergency [fever · jaundice] - Add confusion and a falling blood pressure and it is Reynolds pentad, which is the untreated end of that road [confusion] - Pain in the middle of the upper abdomen with vomiting that will not stop suggests the stone has blocked the pancreas [vomiting] TESTS (10) - Ultrasound of the right upper abdomen is the test: 90 percent specific, and it picks up stones down to 2 mm - On ultrasound, inflammation shows as a wall over 3 mm thick, fluid around the gallbladder, and pain under the probe - Only about one stone in ten shows on a plain film, because most contain too little calcium - CT and MRI find stones but are poorer than ultrasound at showing an inflamed gallbladder - A widened common bile duct on imaging says a stone is sitting there, or has just passed through - Blood count, liver function, bilirubin and alkaline phosphatase measure what the stone is doing, not whether it is there - Normal bloods do not exclude stones - a stone that is not obstructing leaves no trace in the blood - With cholecystitis or obstruction the liver enzymes rise mildly and the direct bilirubin goes up - A HIDA scan tests how the gallbladder works, and separates cholecystitis from a lazy gallbladder - For a stone in the duct, MRCP looks and ERCP both looks and clears it IF NOT THIS - what else fits (8) - A heart attack - the one that must not be missed when upper abdominal pain is the complaint - Aortic dissection, which also radiates through to the back - Pancreatitis, or a peptic ulcer - Reflux, or spasm of the oesophagus - Hepatitis, or a cancer of the bile duct - Appendicitis, or gastroenteritis - Loss of blood supply to the gut, in an older patient with pain out of proportion - A kidney stone, or a pneumonia sitting at the base of the right lung Source StatPearls "Gallstones (Cholelithiasis)" - disease-level clinical article Status traced to the source above 1. DICLOFENAC [1st line] Adult 50 mg two to three times daily with or after food (or 75 mg IM deep intragluteal injection single dose for severe acute pain) x 1-3 days PRN during acute pain episode Peds Pediatric biliary colic is rare and requires urgent pediatric surgical / gastroenterology referral Choice Alternatives. Diclofenac is the NSAID the biliary colic evidence actually used, and it remains the one reached for in the Egyptian clinic. Source Diclofenac sodium 50 mg delayed-release (gastro-resistant) tablets US prescribing information, DOSAGE AND ADMINISTRATION (DailyMed SetID a57b897e-0cbe-4ac3-969f-b00357a0cfa8) for the oral dose; the intramuscular dose is from Voltarol Ampoules (diclofenac sodium 75 mg in 3 ml solution for injection) SmPC section 4.2 (eMC product 1043): "One ampoule once (or in severe cases twice) daily intramuscularly by deep intragluteal injection into the upper outer quadrant" Why NSAID that blocks prostaglandin synthesis; because prostaglandins drive gallbladder wall contraction against the obstructed cystic duct, blocking them is what relieves the pain of biliary colic, and it is why NSAIDs are first-line here. Caution First-line analgesia for biliary colic because NSAIDs inhibit prostaglandin-mediated gallbladder wall contraction. Contraindicated in active gastrointestinal ulceration, severe heart failure, established ischemic heart disease, or severe renal impairment. Refer urgently if pain persists >6 hours, accompanied by fever/chills (acute cholecystitis) or jaundice/dark urine (choledocholithiasis/cholangitis). Egypt DECLOFENAC 50MG 20 TAB. EL NASR 12.00 EGP (0.60/unit) RHEUMARENE 50MG 20 TAB. SEDICO 13.50 EGP (0.68/unit) DICLORAPID 50MG 30 F.C.TAB. SPIMACO MISR 37.50 EGP (1.25/unit) ZITOXANAL 50 MG 30 CAPS. ARAB CAPS > S... 69.00 EGP (2.30/unit) RHUMAQUICK 50 MG 20 DISP. TABS. MEDIZEN PHARM... 21.00 EGP OFLAM 50 MG 20 QUICKETAB. MUP > ACINO 48.00 EGP DECLOPHEN FAST 50MG GR. FOR ORAL SUSP. 30 SACHETS PHARCO 102.00 EGP ACTIFAST 50 MG 30 SACHETS SIGMA > OCTOB... 105.00 EGP CATAFLAM 15MG/ML ORAL DROPS 15 ML NOVARTIS 10.00 EGP -> ? strength differs, ? different route - not oral solid DOLPHIN K 15MG/ML ORAL DROPS 15 ML DELTA PHARMA 11.25 EGP -> ? strength differs, ? different route - not oral solid 2. IBUPROFEN [1st line] Adult 400 mg three to four times daily with or after food PRN during acute pain episodes (maximum 2400 mg/day) x 1-3 days PRN Peds Specialist pediatric evaluation required for gallstone symptoms. Source Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) Why NSAID with the same prostaglandin-blocking mechanism as diclofenac, used as an alternative first-line analgesic for biliary colic during acute pain episodes. Caution Take with or after food to reduce gastric mucosal irritation. Avoid in severe renal impairment, active peptic ulcer disease, or severe asthma triggered by NSAIDs. Refer to general surgery for elective laparoscopic cholecystectomy for recurrent symptomatic gallstones. Above 1200 mg a day is prescription territory, not the over-the-counter suspension. The tablet label allows up to 2400 mg in three or four divided doses, but only as a temporary increase in an acute severe episode, and no single dose above 800 mg. Egypt DAJUANOFEN 400 MG 20 F.C. TABS. COPAD PHARMA 5.00 EGP (0.25/unit) FLABU 400MG 10 F.C.TAB. DELTA PHARMA 3.75 EGP (0.38/unit) NOVA-PROFEN 400MG 30 F.C. TABLETS SANOFI 12.75 EGP (0.42/unit) IBUPROFEN 400 MG 10 TAB. SEDICO 6.00 EGP (0.60/unit) MAFO 400 MG 30 F.C.TABS EIPICO 42.00 EGP (1.40/unit) BRUFEN 400 MG 30 TABS. KAHIRA > ABBO... 78.00 EGP (2.60/unit) PROFUSOL 400MG 20 S.G CAPS. EUROPEAN EGYP... 31.00 EGP ANALGIPROF 400 MG 25 SACHETS EVA PHARMA 37.50 EGP NOVA-PROFEN 100MG/5ML ORAL SUSP. 100ML SANOFI 2.25 EGP -> ? strength differs, ? different route - not oral solid BRUFEMOL-N SUSP. 60 ML ARAB DRUG COM... 4.50 EGP -> ? strength differs, ? different route - not oral solid 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Gallstones (Cholelithiasis) - disease-level clinical article (biliary-colic-full.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Urgent hospital admission is needed for fever, sepsis, acute cholangitis, or cholecystitis. 4. PARACETAMOL [2nd line] Adult 500-1000 mg three or four times a day PRN when NSAIDs are contraindicated (maximum 4000 mg/24 hours) x 1-3 days PRN Peds Pediatric evaluation required for suspected biliary pain. Source MSF Essential Drugs 2024 - paracetamol (oral) Why Alternative non-opioid analgesic when NSAIDs are contraindicated due to peptic ulcer disease, asthma, or renal impairment. Caution Do not exceed 4000 mg total daily dose to prevent severe liver injury. Check co-formulated analgesics or cold remedies to avoid inadvertent paracetamol double- dosing. Egypt FEBRIMOL 500 MG 20 TAB. PHARCO 3.50 EGP (0.17/unit) CETAMOL 500 MG 20 TABS. MEMPHIS 8.00 EGP (0.40/unit) PARACETAMOL-MUP 500MG B.P. 20 TABS. MUP 13.00 EGP (0.65/unit) CETAL 500 MG 20 TABS. EIPICO 24.00 EGP (1.20/unit) ARKADOLOW 500 MG 30 F.C. TABS. UTOPIA 42.00 EGP (1.40/unit) PARAMOL 500MG 20 TAB. MISR 38.00 EGP (1.90/unit) ADOL 500MG 24 CAPLETS JULPHAR 32.00 EGP AUGICETAMIDE 500 MG 20 SACHETS AUG PHARMA 50.00 EGP FEBRIMOL ORAL DROPS 20 ML PHARCO 4.00 EGP -> ? strength differs, ? different route - not oral solid THERA-LO 3.2G/100ML ORAL SUSP. 100 ML PHAROPHARMA 5.00 EGP -> ? strength differs, ? different route - not oral solid 5. HYOSCINE BUTYLBROMIDE [add-on - not a substitute] Adult 10-20 mg three to four times daily PRN for acute visceral spasm x 1-3 days PRN Peds 6 to 12 years: 10 mg by mouth three times daily (Children (6 to 12 years): Oral: 10 mg three times daily.) Source Egyptian National Drug Formulary 2026 Why Antispasmodic targeting smooth muscle spasm of the biliary tract; widely used as an adjunct to NSAIDs in Egyptian primary care. Caution Use with caution in prostatic enlargement, urinary retention, narrow-angle glaucoma, or tachycardia. Egypt NU-SPASM 10 MG 20 TABS. EIPICO 4.00 EGP (0.20/unit) BUTACID 10MG 20 TAB. CID 20.00 EGP (1.00/unit) SPASMOCIN 10MG 20 TAB. MEMPHIS 34.00 EGP (1.70/unit) BUSCOPAN 10 MG 20 SUGAR C.TABS. SERVIER > Ope... 56.00 EGP SPASMOCIN 100MG/100ML SYRUP 120ML MEMPHIS 3.85 EGP -> ? strength differs, ? different route - not oral solid FARCORELAXIN 1MG/ML SYRUP 120ML PHARCO 4.50 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)