Acute renal colic due to distal ureteric calculus — MSRA MCQ

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HardNephrolithiasisAcute renal colic due to distal ureteric calculusMSRA

A 71-year-old man presents to an acute assessment unit with CT-confirmed renal colic from a 6 mm distal ureteric calculus. He is afebrile, haemodynamically stable and has no pyuria. He continues to have severe pain and is vomiting despite oral paracetamol. His eGFR is 24 mL/min/1.73 m² (baseline 27 mL/min/1.73 m²). He has had 2 endoscopically confirmed bleeding gastric ulcers and takes apixaban for atrial fibrillation. He weighs 76 kg and has normal liver function. What is the most appropriate immediate analgesic treatment?

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Correct answer: B — Administer intravenous paracetamol

Explanation lettering: C = shown as B · D = shown as C · E = shown as D · B = shown as E

Intravenous paracetamol is the appropriate next analgesic. NICE recommends an NSAID first line for renal colic, but this patient has major reasons not to receive diclofenac: severe chronic kidney impairment and a history of recurrent ulcer haemorrhage; concomitant apixaban further increases concern about gastrointestinal bleeding. He is also vomiting, so oral analgesia is unreliable. Where NSAIDs are contraindicated or insufficient, NICE specifies intravenous paracetamol before considering an opioid. ([nice.org.uk](https://www.nice.org.uk/guidance/ng118/chapter/Recommendations?utm_source=openai)) A is inappropriate because diclofenac is contraindicated in renal failure and recurrent peptic ulceration or haemorrhage; anticoagulation compounds bleeding risk. B and E are opioids and are premature because intravenous paracetamol has not yet been given or shown to be ineffective. D is inappropriate because NICE advises against antispasmodics for suspected renal colic. The absence of fever, pyuria, haemodynamic instability or acute deterioration in renal function means that this question concerns analgesic sequencing rather than urgent treatment of infected obstruction.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Pain management recommendations (Published 8 January 2019; minor update May 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations Diclo-SR 75 — Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/14300/smpc