Urolithiasis: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
===Labs=== | ===Labs=== | ||
*UA | |||
*UCx | |||
**Consider for all patients<ref>Abrahamian FM, et al. "Association of Pyuria and Clinical Charateristics with Presence of Urinary Tract Infection Among Patietns with Acute Nephrolithiasis." Annals of EM. Novomber 2013. 62(5):526-533</ref> | |||
*Urine pregnancy | |||
*Chemistry | |||
*CBC (if concern for infection) | |||
===Imaging=== | ===Imaging=== | ||
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==Disposition== | ==Disposition== | ||
===Admission=== | ===Admission=== | ||
*Absolute | |||
**Intractable pain or vomiting | |||
**Urosepsis | |||
**Single or transplanted kidney with obstruction | |||
**Acute renal failure | |||
**[[Hypercalcemic Crisis]] | |||
**Severe medical comorbidities | |||
*Relative | |||
**[[Fever]] | |||
**Solitary kidney or transplanted kidney without obstruction | |||
**Obstructing stone with signs of urinary infection | |||
**Urinary extravasation | |||
**Significant medical comorbidities | |||
**Stone unlikely to pass (large stone (>5mm) in proximal ureter) | |||
===Consultation=== | ===Consultation=== | ||
*Renal insufficiency | |||
*Severe underlying disease | |||
*Stone >6 mm | |||
*Sloughed renal papillae | |||
*Associated UTI without sepsis | |||
*Infected stone | |||
===Discharge=== | ===Discharge=== | ||
Revision as of 20:02, 8 June 2015
Background[1]
- Peptic Ulcer Disease (PUD) increases risk for development
- Elevated oral calcium intake with calcium based treatments
- Renal damage
- Irreversible renal damage can occur w/in 3wk w/ complete obstruction
- Most pts have no rise in Cr b/c unobstructed kidney functions at up to 185% of its baseline capacity
- Rise in Cr suggests solitary kidney or preexisting renal disease (such that the unobstructed kidney is unable to compensate)
- Infection
Pass Rate
- <5mm - 98% will pass within 4wk
- 5-7mm - 60% will pase within 4wk
- >7mm - 39% will pass within 4wk
Types
- Calcium (75%)
- Hyperparathyroidism, hypercalcemia of malignancy, sarcoidosis, increased absorption, loop diuretics, IBD
- Struvite (magnesium-ammonium-phosphate) (15%)
- Proteus, klebsiella, pseudomonas, staph
- Uric Acid (10%)
- 25% of pts w/ gout develop kidney stones
Risk Factors for Poor Outcome
- Renal function at risk
- DM
- Hypertension
- Renal insufficiency
- Single kidney
- Horseshoe kidney
- Transplanted kidney
- History of difficulty with stones
- Extractions
- Stents
- Ureterostomy tubes
- Lithotripsy
- Symptoms of infection
- Fever
- Hypotension
- Systemic illness
- UTI
Clinical Features
- Pain
- Acute onset, crampy, intermittent
- Location of pain depends on location of stone:
- Upper ureter: flank pain
- Mid ureter: lower anterior quadrant of abdomen
- Distal ureter: groin pain
- UVJ: Can mimic a UTI (frequency, urgency, dysuria)
- N/V (50%)
- Hematuria (85%)
- Cannot be used to rule-in or rule-out stone (25% of pts w/ flank pain and hematuria do not have stone)
Differential Diagnosis
Nephrolithiasis is most common misdiagnosis given to patients with rupturing AAA
Flank Pain
- Vascular
- Abdominal aortic aneurysm
- Renal artery embolism
- Renal vein thrombosis
- Aortic dissection
- Mesenteric ischemia
- Renal
- Pyelonephritis
- Perinephric abscess
- Perinephric hematoma
- Papillary necrosis
- Renal cell carcinoma
- Obstructive uropathy
- May or may not be due to nephrolithiasis
- Renal infarction
- Renal hemorrhage
- Ureter
- Nephrolithiasis
- Blood clot
- Stricture
- Tumor (primary or metastatic)
- Bladder
- Tumor
- Varicose vein
- Cystitis
- GI
- Biliary colic
- Pancreatitis
- Perforated peptic ulcer
- Appendicitis (appendix may be pushed to RUQ in pregnancy)
- Inguinal Hernia
- Diverticulitis
- Cancer
- Bowel obstruction
- Gynecologic
- Ectopic Pregnancy
- PID/TOA
- Ovarian cyst
- Ovarian torsion
- Endometriosis
- Mittelschmerz or benign ovulatory pain
- GU
- Other
- Shingles
- Lower lobe pneumonia
- Retroperitoneal hematoma, abscess, or tumor
- Epidural abscess
- Epidural hematoma
- Rib contusion/fracture
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
- Renal disease
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- Other
Diagnosis
Labs
- UA
- UCx
- Consider for all patients[4]
- Urine pregnancy
- Chemistry
- CBC (if concern for infection)
Imaging
- Bedside Ultrasound
- Consider CT for:
- 1st time stone
- Consider formal US for:
- Pregnant pt
- Repeat stone (to avoid CT)
- In comparison of diagnosis by CT vs. U/S (by EP) vs. U/S (by radiologist):[5]
- No difference in rate of missed high-risk diagnoses that resulted in complications (pyelo/sepsis/diverticular abscess)
- No difference in rate of serious adverse events, pain scores, return emergency department visits, or hospitalizations
Management
Pain
first line agents
- Ketorolac 30mg IV
- Morphine
- Metoclopramide vs. ondansteron
Infection
- Inpatient:
- Gentamicin 1-2.5mg/kg + ampicillin 1-2gm q4hr OR
- Piperacillin-tazobactam 3.375 gm q6hr OR
- Cefepime 2gm q8hr OR
- Ciprofloxacin 400mg q12hr (if local sensitivities do not predict treatment failure)
- Outpatient:
- Ciprofloxacin 500mg PO BID x10-14d OR
- Levofloxacin 500mg PO daily x10-14d OR
- Cefpodoxime 200mg PO BID x10-14d
Expulsion
Although meta-analyses of previous randomized controlled trials concluded that the smooth muscle relaxant drugs tamsulosin and nifedipine assisted stone passage for people managed expectantly for ureteric colic, a randomized placebo-controlled trial demonstrated that no difference was noted between active treatment and placebo (p=0.78), or between tamsulosin and nifedipine (p=0.77).[6][7]
Surgery
- Considered for:
- Persistent obstruction
- Failure of stone progression
- Increasing or unremitting colic
- Staghorn calculi (abx penetration is poor)
Disposition
Admission
- Absolute
- Intractable pain or vomiting
- Urosepsis
- Single or transplanted kidney with obstruction
- Acute renal failure
- Hypercalcemic Crisis
- Severe medical comorbidities
- Relative
- Fever
- Solitary kidney or transplanted kidney without obstruction
- Obstructing stone with signs of urinary infection
- Urinary extravasation
- Significant medical comorbidities
- Stone unlikely to pass (large stone (>5mm) in proximal ureter)
Consultation
- Renal insufficiency
- Severe underlying disease
- Stone >6 mm
- Sloughed renal papillae
- Associated UTI without sepsis
- Infected stone
Discharge
- Small stone, adequate analgesia, able to arrange urology f/u w/in 7d
See Also
References
- ↑ Coe, F et al.The Pathogenesis and Treatment of Kidney StonesNew England Journal of Medicine, 1992; 327:1141-1152
- ↑ Abrahamian FM, et al. "Association of Pyuria and Clinical Charateristics with Presence of Urinary Tract Infection Among Patietns with Acute Nephrolithiasis." Annals of EM. Novomber 2013. 62(5):526-533
- ↑ Abrahamian FM, et al. "Association of Pyuria and Clinical Charateristics with Presence of Urinary Tract Infection Among Patietns with Acute Nephrolithiasis." Annals of EM. Novomber 2013. 62(5):526-533
- ↑ Abrahamian FM, et al. "Association of Pyuria and Clinical Charateristics with Presence of Urinary Tract Infection Among Patietns with Acute Nephrolithiasis." Annals of EM. Novomber 2013. 62(5):526-533
- ↑ Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med. 2014;371(12):1100–1110.
- ↑ Singh A, et al. A systematic review of medical therapy to facilitate the passage of ureteral calculi. Annals of Emerg Med. 2007; 552-563. fulltext
- ↑ Pickard, R et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. 2015; epub. [www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60933-3.pdf full text]