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Acute renal colic with NSAID contraindication — MSRA MCQ

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HardNephrolithiasisAcute renal colic with NSAID contraindicationMSRA

A 57-year-old man attends the emergency department with CT-confirmed left renal colic caused by a 4 mm distal ureteric calculus. He is afebrile, haemodynamically stable, has normal renal function and no features of urinary infection. He has severe ongoing pain despite 1 g oral paracetamol taken 2 hours earlier. He has an endoscopically confirmed actively bleeding duodenal ulcer and is receiving high-dose proton-pump inhibitor treatment. He has no hepatic impairment and weighs 82 kg. Which is the most appropriate immediate pharmacological management?

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Correct answer: D — Give intravenous paracetamol

Intravenous paracetamol is the appropriate next analgesic step. NSAIDs are first-line for renal colic, but diclofenac is inappropriate here because of the actively bleeding peptic ulcer. NICE recommends intravenous paracetamol when NSAIDs are contraindicated or do not provide adequate relief. The prior use of oral paracetamol does not replace this step: the recommendation specifically specifies intravenous paracetamol before escalating to an opioid. Intravenous morphine is therefore premature; opioids are considered only when both NSAIDs and intravenous paracetamol are contraindicated or insufficient. Tamsulosin may be considered as medical expulsive therapy for a distal ureteric stone smaller than 10 mm, but it does not provide immediate analgesia and should not displace acute pain control. Hyoscine butylbromide is not recommended for renal colic. The small distal stone, absence of infection and preserved renal function do not create an indication for emergency decompression; the immediate priority is guideline-sequenced analgesia.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (Published 2019; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations