Renal Colic Investigation and Management
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Renal Colic Investigation and Management
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Renal Colic Investigation and Management
- 1. Investigation and Management of Renal Colic CME 30/10/14 Kate Goodwin
- 2. Nephrolithiasis Majority (approx 80%) are calcium stones Others include uric acid, struvite and cystine
- 3. Risk Factors PMhx of renal calculi Fhx of renal calculi consider hereditary diseases ass with stones Enhanced enteric oxalate absorption Gastric bypass, short bowel syndrome Patient factors HTN, obesity, gout, DM, extreme exercise, poor oral fluid intake Persistantly acidic urine Chronic diarrhoea, metabolic disorders (gout, DM, obesity) Recurrent upper UTIs UTI due urease-producing organisms (Protease, Klebsiella) increases risk of struvite stones
- 4. Renal Colic Symptoms most at passage of stone from renal pelvis into ureter Thought to be due to obstruction and distention of the renal capsule Colicky (due to ureteric spasm) and migratory as the stone travels down the ureter Passage of a stone usually associated with haematuria Other Sx may include N&V, dysuria and urgency Significant complications include obstruction, infection and ARF
- 5. Differential Diagnosis Renal cell carcinoma Pyelonephritis Gynae - ectopic pregnancy/cyst accident, dymenorrhoea Surgical - bowel obstruction, mesenteric ischaemia, appendicitis, diverticulitis Biliary colic/cholecystitis Herpes zoster AAA
- 6. Diagnosis Non-con helical CT 3-5mm cuts May identify alternative diagnosis Some information regarding stone compostiosn Radiation dose Low dose CT have similar sensitivity and specificity expect with small (<2mm) stones and in obese patients USS No radiation Sensitive for obstruction May be able to identify radiolucent stones Harder to detect smaller stones and distal ureteric stones
- 9. USS v CT in the ED Smith-Bindman, Aubin, Bailitz, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. NEJM 2014;371:1100. Pts with clinical suspicion of renal colic randomised to non-con CT, USS by radiologist, bedside USS by trained ED physician Sensitivity USS 57% (radiologist), 54% (ED physician) CT 88% Radiation dose higher in CT group Significant missed diagnoses similar USS 0.5%, CT 0.3% Adverse events & repeat visits to ED similar Length of stay in ED longer when USS performed by Radiologist
- 10. Other imaging modalities AXR/XR KUB Will detect large radiopaque stones Potential to miss uric acid stones, smaller stones and stones overlying bone Does not detect signs of obstruction IVP More specific and sensitive the plain XR Detects obstruction Potential for contrast reactions, significant radiation dose MRI Some role in pregnancy
- 14. Department of Health Diagnostic Imaging Pathway - loin pain (renal colic) QuickTime™ and a decompressor are needed to see this picture.
- 15. Further investigation Bloods Inflammatory markers, calcium, urate Urine pH, crystals, oxalate Straining urine for stones Genetic testing Dent’s disease, adenine phosphoribosyltransferase deficiency, cystinuria
- 16. Management Analgesia and hydration NSAIDs v opiates NSAIDs can reduce smooth muscle tone in the ureter Possibly best in combination NSAIDs should be avoided/used with care in severe dehydration and impaired renal function
- 17. Passing a stone <5mm likely to pass without intervention >10mm unlikely to pass without intervention Increased intervention requirements with larger stones Likelihood of stone passing also affected by position Stones at the vesicoureteric junction more likely to be passed than those in the proximal ureter
- 18. Medical Expulsive Therapy Alpha-blockers - prazosin, tamsulosin (tamsulosin is a selective a1A receptor blocker so less SEs than with prazosin but cost implications as not on PBS) (Calcium channel blockers - nifedipine)
- 19. Urological referral Urosepsis ARF Anuria Uncontrolled pain Stones not passed after trial of medical therapy (usually about 4 weeks)
- 20. Intervention Emergency infected obstructed kidney, bilat obstruction with AKI or obstructed single kidney with AKI requires urgent decompression via percutaneous drainage or ureteric stenting Shock wave lithotripsy Ureterscopic lithotripsy Percutaneous nephrolithotomy with laparoscopic stone removal Open surgical removal
- 21. Prevention of stone recurrence Stone analysis Increased fluid intake Dietary and lifestyle factors Obesity, diabetes, exercise Low sodium diet for calcium stones
- 23. Additional treatments Thiazide diuretics in combination with low sodium diet for calcium stones Potassium citrate for hypocitraturia and to alkalinise the urine in uric acids stones (also some role for allopurinol in uric acid stone prevention) Increased fluid intake, urinary alkalinisation and tiopronin (thiol drug which decreases the precipitation of cystine in the urine) for cystine stones
- 24. In summary Renal colic usually presents as unilateral, colicky, loin/flank pain Haematuria present in majority of cases 1st line imaging either CT or USS Smaller (<10mm) stones usually managed conservatively Fluids, analgesia & MET Surgical options include SWL and ureteroscopy Emergency decompression indicated for infected obstructed kidney, bilat obstruction with AKI & obstructed single kidney with AKI