Urolithiasis: Difference between revisions

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==Background==
==Background==
*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)
*Types
*Types
**Calcium (75%)
**Calcium (75%)
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**Uric Acid (10%)  
**Uric Acid (10%)  
***25% of pts w/ gout develop kidney stones
***25% of pts w/ gout develop kidney stones
*Pass Rate
**<5mm - 98% will pass w/in 4wk
**5-7mm - 60% will pase w/in 4wk
**>7mm - 39% will pass w/in 4wk


If unrelieved, irreversible renal damage occurs within 3 weeks with complete obstruction. During acute obstruction, most patients have no rise in serum creatinine because the unobstructed kidney functions at up to 185% of its baseline capacity. A rise in serum creatinine in acute obstruction suggests a solitary kidney or preexisting renal disease such that the unobstructed kidney is unable to compensate completely. Fortunately, most patients have incomplete ureteral obstruction, and many patients can be safely observed over weeks. Irreversible renal damage from an obstructive kidney stone is rare if obstruction has not been present for >1 month.
==Diagnosis==
===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)


==Clinical Features==
==Work-Up==
acute onset of a crampy intermittent pain that originates in the flank and radiates toward the groin. As pain originates from a hollow viscus (ureter), the pain is visceral in nature without associated peritoneal irritation. Patients writhe in pain, unable to find a position of comfort. However, patients with renal colic may demonstrate rebound tenderness (29%), guarding (61%), and rigidity (8%).13 Pain is commonly accompanied by nausea and vomiting (50%). The adrenergic response to pain can result in tachycardia, hypertension, and diaphoresis. Hematuria is present in approximately 85% of patients with renal colic, whereas only 30% have gross hematuria.
===Labs===
 
#UA
The location of the pain correlates somewhat with the location of the stone. Stones in the upper ureter refer pain to the flank, whereas those in the mid-ureter radiate to the lower anterior quadrant of the abdomen. A distal ureter stone, which is where 75% of stones are diagnosed, refers pain to the groin. Stones positioned at the UVJ can mimic a urinary tract infection (UTI) by causing frequency, urgency, and dysuria in 3% to 24% of patients.13
#UCx (obtain if UA c/w infection)
#Urine pregnancy
#Chemistry
#CBC (if concern for infection)
===Imaging===
*Consider CT for:
**1st time stone
*Consider US for:
**Pregnant pt
**Repeat stone (to avoid CT)




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Systemic illness  
Systemic illness  
Urinary tract infection  
Urinary tract infection  
Diagnosis
The laboratory evaluation centers on evaluating for infection, kidney dysfunction, and possibility of pregnancy. Test all females of childbearing potential for pregnancy when considering renal colic.
Urinalysis is needed to rule out infection. If infection is found, obtain urine culture and sensitivities, as requirement for antibiotic therapy may be prolonged,14 and sensitivities help guide therapy if the empiric antibiotic fails.


Although 10% to 15% of patients with nephrolithiasis will have no hematuria, approximately 24% of patients with flank pain and hematuria have no radiographic evidence of ureterolithiasis.15 Therefore, although hematuria may contribute to diagnostic decision making, it should not be used alone to exclude or confirm the diagnosis of ureterolithiasis.15
Check renal function with both blood urea nitrogen and creatinine level, as the overwhelming majority of stone formers have reduced creatinine clearance.16 These studies allow for identification of renal failure due to obstruction and establish a baseline for future evaluations. Unless febrile or systemically ill, a white blood cell count does not aid in the evaluation
==Imaging==
It is unclear whether all patients with first time stones require ED imaging for suspected renal colic. For young, healthy patients in whom the diagnosis is clinically clear, one study suggested imaging could be conducted later on an outpatient basis.18 However, another study showed that clinicians are often wrong based on clinical suspicion alone.19 In patients for whom the initial clinical suspicion of stone was 0% to 50%, a stone was present in 29%. In patients for whom the physician had a high pretest clinical suspicion (90% to 100%) of a stone, a stone was present in only 80%. In this same study, CT scanning revealed an alternative diagnosis in 33% of the patients. Thus, these authors strongly advise imaging for patients presenting with a first time stone, with a CT scan to both confirm the suspicion and identify alternative diagnoses.19 As for patients with repeat stones, the issue of imaging hinges on several items. Did the patient have a complication with the previous stone that imaging would aid in preventing? Is the diagnosis in question (i.e., drug seeker, >50)? And finally, for type of evaluation, what is the patient's previous radiation load?
CT
In combination, unilateral ureteral dilatation and perinephric stranding have a PPV of 96% for stone disease.21 If both are absent, the NPV is 93% to 97%
US
Although useful in the detection of larger stones (Figure 97-3), it may miss smaller (<5 mm in diameter) ureteral stones.27 US is helpful in diagnosing stones in the proximal and distal ureters but is insensitive for mid-ureteral stones. Overall, US has only modest sensitivity and specificity for detecting renal stones (Table 97-3) but is 98% sensitive for detecting hydronephrosis (see Figure 91-2B). However, of hydronephrosis diagnosed by US, up to 22% of studies do not represent obstruction, but rather, normal anatomic variation, full bladder, and renal cysts.24 Rapid bolus infusion of crystalloid can result in a false positive finding of hydroureter.
=== Pass Rates ===
Based on stone size alone, 98% of stones <5 mm will pass within 4 weeks without intervention. Sixty percent of stones 5 to 7 mm and 39% of stones >7 mm will pass within 4 weeks. Stone size on plain radiographs is magnified by up to 20%, and a measured stone on CT is 88% of actual stone size
'''Size'''
*4mm ~75%
*4-6mm ~50%
*&gt;6mm ~10%
'''Location in Ureter'''
#Distal ~70%
#Middle ~50%
#Proximal ~20%


== DDx  ==
== DDx  ==
#[[Cholelithiasis]] (5%)
#Vascular
#Appy (4%)
##Aortic dissection
#Pyelonephitis (3%)
##AAA
#Ovarian cyst (2%)
##Renal artery embolism  
#Renal mass (1.4%)
##Renal vein thrombosis  
#[[AAA]] w/or w/o rupture (1.4%)
##Mesenteric ischemia  
 
#Renal
Differential Diagnoses for Ureterolithiasis
##Pyelonephritis  
##Papillary necrosis  
Vascular Aortic dissection
##Renal cell carcinoma  
Abdominal aortic aneurysm
##Renal infarct  
Renal artery embolism  
##Renal hemorrhage  
Renal vein thrombosis  
#Ureter
Mesenteric ischemia  
##Blood clot  
Renal Pyelonephritis  
##Stricture  
Papillary necrosis  
##Tumor (primary or metastatic)  
Renal cell carcinoma  
#Bladder
Renal infarct  
##Tumor  
Renal hemorrhage  
##Varicose vein  
Ureter Blood clot  
##Cystitis  
Stricture  
#GI
Tumor (primary or metastatic)  
##Biliary colic  
Bladder Tumor  
##Pancreatitis  
Varicose vein  
##Perforated peptic ulcer
Cystitis  
##Appendicitis  
GI Biliary colic  
##Inguinal hernia  
Pancreatitis  
##Diverticulitis  
Perforated peptic ulcer disease
##Cancer  
Appendicitis  
##Bowel obstruction  
Inguinal hernia  
#Gynecologic
Diverticulitis  
##Ectopic pregnancy  
Cancer  
##PID/TOA
Bowel obstruction  
##Ovarian cyst  
Gynecologic Ectopic pregnancy  
##Ovarian torsion  
Pelvic inflammatory disease/tubo-ovarian abscess
##Endometriosis  
Ovarian cyst  
#GU
Ovarian torsion  
##Testicular torsion  
Endometriosis  
##Epididymitis  
GU Testicular torsion  
#Other
Epididymitis  
##Shingles  
Other Drug-seeking behavior
##Retroperitoneal hematoma/abscess/tumor  
Shingles  
Retroperitoneal hematoma/abscess/tumor  
   
   


== Treatment  ==
== Treatment  ==
#ED
*Pain
##Toradol 30mg IV/IM
**NSAIDs are agent of choice
##Morphine 3-5mg IV
***Ketorolac 30mg IV
#Outpt
**Morphine
##NSAIDS PO
**Metoclopramide (provides pain relief equivalent to morphine)
##Vicodin PO
*Infection
##Smooth muscle relaxant (alpha-adrenergic blocker)
**Inpatient:
###Tamsulosin (Flomax) 0.4mg PO QHS x 21 days, OR
***Gentamicin 1-2.5mg/kg + ampicillin 1-2gm q4hr OR
###Terazosin (Hytrin) 1mg PO QHS x 21 days
***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
**Alpha blockers a/w increased rate of expulsion, decreased time to expulsion, and decreased pain
***Tamsulosin 0.4mg PO daily up to 4wk
*Surgery
**Consider for:
***Persistent obstruction
***Failure of stone progression
***Increasing or unremitting colic
***Staghorn calculi (abx penetration is poor)




primary choice of analgesics in the treatment of stone disease, as they have a direct action on the ureter by inhibiting prostaglandin synthesis.31,32 IV administration achieves more rapid relief than IM or PO dosing33 (for example, ketorolac, 30 milligrams IV). NSAIDs should be used with caution in patients with GI bleeding risks and renal impairment. Narcotics (for example, hydromorphone, 0.5 to 2.0 milligrams IV) are good analgesics but do not affect the cause of pain. As both the pain of the stone and narcotics can cause nausea and vomiting, address these symptoms as well.


Metoclopramide is the only antiemetic that has been specifically studied in the treatment of renal colic. In two double-blinded studies, metoclopramide provided pain relief equivalent to narcotic analgesics in addition to relieving nausea. Metoclopramide works by blocking dopaminergic receptors in the central nervous system, but is less sedating than other centrally acting dopamine antagonists.34
Patients who have a known stone who return for continued pain should be evaluated for worsening renal function (blood urea nitrogen/creatinine), evidence of obstruction (US to limit radiation exposure), evidence of infection (repeat urinalysis and review for systemic symptoms), movement of stone (repeat KUB), and clear evidence that a stone was the original cause of the pain. If all of these issues do not suggest a urologic emergency, the patient's pain management regimen should be altered. Consider metoclopramide, NSAIDs, opioids, -blockers, and, possibly, steroids.


For patients in whom admission is anticipated, recommended IV antibiotics for the treatment of stones associated with infection include gentamicin or tobramycin, 3.0 milligrams/kg/day divided every 8 hours, plus ampicillin, 1 to 2 grams every 4 hours; piperacillin-tazobactam, 3.375 grams IV every 6 hours; cefepime, 2 grams IV every 8 hours; ticarcillin-clavulanic acid, 3.1 grams every 6 hours; or ciprofloxacin, 400 milligrams every 12 hours, if local sensitivities do not predict treatment failure. Patients who have a ureteral stone with an associated UTI but no evidence of significant obstruction, fever, or systemic illness can be treated as outpatients. Provide urologic follow-up in 48 to 72 hours, as well as detailed discharge instructions to return to the ED for fever, nausea, and systemic illness. The choice of antibiotic should cover gram-negative rods and be appropriate for antibiotic sensitivity at your institution. Resistance rates of >10% to 20% should preclude use of that antibiotic. Choices include: ciprofloxacin, 500 milligrams PO twice a day for 10 to 14 days; levofloxacin, 500 milligrams PO once a day for 10 to 14 days; cefpodoxime, 200 milligrams PO twice a day for 10 to 14 days; or others predicted to be successful based on local sensitivities.


-Blockers are associated with increased rate of expulsion, decreased time to expulsion, and decreased pain, with a number needed to treat of 3.3 and a 2- to 6-day improvement in time to expulsion.35 Approximately 4% of patients have associated adverse effects. The benefit is limited to stones in the distal third of the ureter, because it is thought that there are an increased number and density of -receptors in the distal ureter. The most commonly used agent is tamsulosin (0.4 milligrams PO daily for up to 4 weeks), but terazosin (5 to 10 milligrams daily) and doxazosin (4 milligrams daily) are also as effective


=== Surgical Treatment===
Persistent obstruction, failure of stone progression, or increasing or unremitting colic
Antibiotic penetration into staghorn calculi is poor, and the potential for urosepsis exists as long as the stones remain. Consequently, surgical treatment is recommended for staghorn calculi.


Shock wave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy
In severe concurrent underlying disease (e.g., angina or chronic obstructive pulmonary disease) or in the fragile elderly who may be unable to tolerate the stress of renal colic, a lower admission threshold is indicated. There is also a subset of patients who may require emergent decompression. Examples include those with a solitary kidney and complete obstruction, ureterolithiasis with hydronephrosis and fever, and urosepsis with obstruction. In addition, disposition should be discussed with a urologist and follow-up within 1 week obtained if there is (1) renal insufficiency, (2) severe underlying disease, (3) an IV urogram showing extravasation or complete obstruction, (4) multiple ED visits, (5) a stone >6 mm, (6) sloughed renal papillae, or (7) associated UTI without sepsis.


==Disposition==
==Disposition==
Admit for:
===Admission===
#Intractable pain (on orals)
#Absolute
#Solitary or transplanted kidney
##Intractable pain or vomiting
#Presence of urinary tract infection (UTI), fever, sepsis, or pyonephrosis
##Urosepsis
 
##Single or transplanted kidney with obstruction
Most patients with stones are discharged with urologic or primary care follow-up, at which time preventive therapy may be considered based on stone type.36 Because of lower rates of spontaneous passage, patients with large (>5 mm), irregular, or proximal stones should be considered for admission (Table 97-5). In severe concurrent underlying disease (e.g., angina or chronic obstructive pulmonary disease) or in the fragile elderly who may be unable to tolerate the stress of renal colic, a lower admission threshold is indicated. There is also a subset of patients who may require emergent decompression. Examples include those with a solitary kidney and complete obstruction, ureterolithiasis with hydronephrosis and fever, and urosepsis with obstruction. In addition, disposition should be discussed with a urologist and follow-up within 1 week obtained if there is (1) renal insufficiency, (2) severe underlying disease, (3) an IV urogram showing extravasation or complete obstruction, (4) multiple ED visits, (5) a stone >6 mm, (6) sloughed renal papillae, or (7) associated UTI without sepsis.
##Acute renal failure
 
##Hypercalcemic crisis
Table 97-5 Indications for Admission
##Severe medical comorbidities
 
#Relative
##Fever
##Solitary kidney or transplanted kidney without obstruction
Absolute Indications for Admission Relative Indications for Admission
##Obstructing stone with signs of urinary infection  
Intractable pain or vomiting
##Urinary extravasation
Fever
##Significant medical comorbidities
##Stone unlikely to pass (large stone (>5mm) in proximal ureter)
Urosepsis
===Discharge===
Solitary kidney or transplanted kidney without obstruction
*Stone w/ associated UTI but no e/o obstruction, fever, or systemic illness can be treated as outpt
**Provide urologic follow-up in 48 to 72 hours
Single or transplanted kidney with obstruction
*Consider d/c for:
**Small stone
Obstructing stone with signs of urinary infection  
**Adequate analgesia
*Arrange urology f/u w/in 7d
Acute renal failure
Hypercalcemic crisis
Urinary extravasation
Severe medical comorbidities
Significant medical comorbidities
  Stone unlikely to pass—large stone in proximal ureter
 
 
Discharge is appropriate in those with smaller stones; in the absence of infection; and when pain is controlled by oral analgesics. Give patients a urinary strainer with instructions to save any stones they pass for pathologic evaluation. Average time for stone passage varies according to size and location, but may range up to 7 to 20 days for stones 5 to 6 mm in diameter. Patients should be counseled to return promptly for fever, vomiting, or uncontrolled pain. A prescription for an oral opiate and NSAIDs should be provided, as well as for medical expulsive therapy if used. Follow-up with a urologist within 7 days should be recommended.
 
If the stone passes in the ED, no further treatment is required. Elective urologic consultation is recommended so that the etiology of the stone is evaluated and a prophylactic strategy can be arranged. Patients with hematuria, negative imaging studies, and no other source require outpatient urologic follow-up to determine the cause of hematuria.
 
 
==Prognosis==
=== Recurrence Rates  ===
 
1 yr ~33%
 
5yr ~50%
 
#Increasing H2O intake decreases rate
#Protease inhibitors and diuretics increases rate
 
 
Patients who have a known stone who return for continued pain should be evaluated for worsening renal function (blood urea nitrogen/creatinine), evidence of obstruction (US to limit radiation exposure), evidence of infection (repeat urinalysis and review for systemic symptoms), movement of stone (repeat KUB), and clear evidence that a stone was the original cause of the pain. If all of these issues do not suggest a urologic emergency, the patient's pain management regimen should be altered. Consider metoclopramide, NSAIDs, opioids, -blockers, and, possibly, steroids.




Revision as of 04:17, 18 August 2011

Background

  • 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)
  • Types
    • Calcium (75%)
      • Hyperparathyroidism, hypercalcemia of malignancy, sarcoidosis, increased absorption, thiazides, IBD
    • Struvite (magnesium-ammonium-phosphate) (15%)
      • Proteus, klebsiella, pseudomonas, staph
    • Uric Acid (10%)
      • 25% of pts w/ gout develop kidney stones
  • Pass Rate
    • <5mm - 98% will pass w/in 4wk
    • 5-7mm - 60% will pase w/in 4wk
    • >7mm - 39% will pass w/in 4wk

Diagnosis

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)

Work-Up

Labs

  1. UA
  2. UCx (obtain if UA c/w infection)
  3. Urine pregnancy
  4. Chemistry
  5. CBC (if concern for infection)

Imaging

  • Consider CT for:
    • 1st time stone
  • Consider US for:
    • Pregnant pt
    • Repeat stone (to avoid CT)


During the interview, elucidate three separate items of history. Ask about risk factors for stone development (Table 97-1), risk factors for a poor stone-related outcome, and risk factors for important mimickers. The risk factors for a poor outcome with stones include three categories: renal function is at risk (diabetes, hypertension, preexisting renal insufficiency, single kidney or transplant), history of difficulty with stones (extractions, stents, ureterostomy tubes), and infection (fever, systemic illness, and UTI symptoms; Table 97-2). Two mimickers that are very important to exclude are abdominal aortic aneurysm (AAA) and renal artery infarction. Nephrolithiasis is the most common misdiagnosis given to patients with a rupturing or expanding AAA. Recall that stones don't usually present in men older than age 60 and do not cause hypotension, even transiently. Renal artery thrombosis can mimic stone symptoms due to swelling of the infarcted kidney and can also be associated with hematuria. However, early in the course, CT will not necessarily show inflammation around the kidney, and, because no contrast is used, the function of the kidney is not assessed.


Important Historical Features for Poor Outcome with Stone Renal function at risk Diabetes 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 Urinary tract infection


DDx

  1. Vascular
    1. Aortic dissection
    2. AAA
    3. Renal artery embolism
    4. Renal vein thrombosis
    5. Mesenteric ischemia
  2. Renal
    1. Pyelonephritis
    2. Papillary necrosis
    3. Renal cell carcinoma
    4. Renal infarct
    5. Renal hemorrhage
  3. Ureter
    1. Blood clot
    2. Stricture
    3. Tumor (primary or metastatic)
  4. Bladder
    1. Tumor
    2. Varicose vein
    3. Cystitis
  5. GI
    1. Biliary colic
    2. Pancreatitis
    3. Perforated peptic ulcer
    4. Appendicitis
    5. Inguinal hernia
    6. Diverticulitis
    7. Cancer
    8. Bowel obstruction
  6. Gynecologic
    1. Ectopic pregnancy
    2. PID/TOA
    3. Ovarian cyst
    4. Ovarian torsion
    5. Endometriosis
  7. GU
    1. Testicular torsion
    2. Epididymitis
  8. Other
    1. Shingles
    2. Retroperitoneal hematoma/abscess/tumor


Treatment

  • Pain
    • NSAIDs are agent of choice
      • Ketorolac 30mg IV
    • Morphine
    • Metoclopramide (provides pain relief equivalent to morphine)
  • 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
    • Alpha blockers a/w increased rate of expulsion, decreased time to expulsion, and decreased pain
      • Tamsulosin 0.4mg PO daily up to 4wk
  • Surgery
    • Consider for:
      • Persistent obstruction
      • Failure of stone progression
      • Increasing or unremitting colic
      • Staghorn calculi (abx penetration is poor)


Patients who have a known stone who return for continued pain should be evaluated for worsening renal function (blood urea nitrogen/creatinine), evidence of obstruction (US to limit radiation exposure), evidence of infection (repeat urinalysis and review for systemic symptoms), movement of stone (repeat KUB), and clear evidence that a stone was the original cause of the pain. If all of these issues do not suggest a urologic emergency, the patient's pain management regimen should be altered. Consider metoclopramide, NSAIDs, opioids, -blockers, and, possibly, steroids. 



In severe concurrent underlying disease (e.g., angina or chronic obstructive pulmonary disease) or in the fragile elderly who may be unable to tolerate the stress of renal colic, a lower admission threshold is indicated. There is also a subset of patients who may require emergent decompression. Examples include those with a solitary kidney and complete obstruction, ureterolithiasis with hydronephrosis and fever, and urosepsis with obstruction. In addition, disposition should be discussed with a urologist and follow-up within 1 week obtained if there is (1) renal insufficiency, (2) severe underlying disease, (3) an IV urogram showing extravasation or complete obstruction, (4) multiple ED visits, (5) a stone >6 mm, (6) sloughed renal papillae, or (7) associated UTI without sepsis.

Disposition

Admission

  1. Absolute
    1. Intractable pain or vomiting
    2. Urosepsis
    3. Single or transplanted kidney with obstruction
    4. Acute renal failure
    5. Hypercalcemic crisis
    6. Severe medical comorbidities
  2. Relative
    1. Fever
    2. Solitary kidney or transplanted kidney without obstruction
    3. Obstructing stone with signs of urinary infection
    4. Urinary extravasation
    5. Significant medical comorbidities
    6. Stone unlikely to pass (large stone (>5mm) in proximal ureter)

Discharge

  • Stone w/ associated UTI but no e/o obstruction, fever, or systemic illness can be treated as outpt
    • Provide urologic follow-up in 48 to 72 hours
  • Consider d/c for:
    • Small stone
    • Adequate analgesia
  • Arrange urology f/u w/in 7d


See Also

EBQ Medical Treatment for Nephrolithiasis

Source

Tintinalli

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