Urolithiasis: Difference between revisions
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==Background==
==Background==
*Urolithiasis comprises 3 similar clinical entities:
Urolithiasis comprises 3 similar clinical entities:
**Nephrolithiasis
*Nephrolithiasis
**Ureterolithiasis
*Ureterolithiasis
**Cystolithiasis
*Cystolithiasis
*[[Peptic ulcer disease]] increases risk for development of kidney stones<ref>Coe F, et al. The pathogenesis and treatment of kidney stones. NEJM. 1992; 327:1141-1152.</ref>
 
**Elevated oral calcium intake with calcium based treatments
===Renal damage===
*Renal damage
*Irreversible renal damage can occur within 3 weeks in patients with a complete obstruction
**Irreversible renal damage can occur within 3wk with complete obstruction
*Most have no rise in creatinine because unobstructed kidney functions at up to 185% of its baseline capacity
**Most have no rise in Cr because 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===
*Infection
*8-15% of kidney stones have urinary co-infection<ref name="a">Abrahamian FM, et al. Association of pyuria and clinical characteristics with presence of urinary tract infection among patients with acute nephrolithiasis. Annals of EM. 2013; 62(5):526-533.</ref>
**8-15% of kidney stones have urinary co-infection<ref name="a">Abrahamian FM, et al. Association of pyuria and clinical characteristics with presence of urinary tract infection among patients with acute nephrolithiasis. Annals of EM. 2013; 62(5):526-533.</ref>
**Fever, pyuria >10 WBC/hpf, and peripheral WBC >11.3 (any one) best predictors of concomitant UTI<ref name="a"/>
**Fever, pyuria >10 WBC/hpf, and peripheral WBC >11.3 (any one) best predictors of concomitant UTI<ref name="a"/>


===Pass Rate===
===Stone Expulsion Rate===
*<5mm - 98% will pass within 4wk
{| {{table}}
*5-7mm - 60% will pass within 4wk
| align="center" style="background:#f0f0f0;"|'''Stone Size'''
*>7mm - 39% will pass within 4wk
| align="center" style="background:#f0f0f0;"|'''Passage Rate<ref>Coll DM et al. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol 2002 Jan; 178:101-3.</ref>'''
|-
| 1-4 mm||78%
|-
| 5 -7 mm||60%
|-
| >8mm||39%
|}


===Types===
===Types===
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**25% of patients with gout develop kidney stones
**25% of patients with gout develop kidney stones


===Risk Factors for Poor Outcome===
==Risk Factors for Complications==
*Renal function at risk   
*Renal function at risk   
**[[DM]]
**[[DM]]
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==Clinical Features==
==Clinical Features==
[[File:Pos-renal.png|thumb|Diagram showing the classic location of renal colic.]]
*Pain
*Pain
**Acute onset, crampy, intermittent, unable to find position of comfort
**Acute onset, crampy, intermittent, unable to find position of comfort
**Location of pain depends on location of stone:
**Location of pain depends on location of stone:
***Upper ureter: flank pain
***Upper ureter: [[flank pain]]
***Mid ureter: lower anterior quadrant of abdomen
***Mid ureter: lower anterior quadrant of [[abdominal pain|abdomen]]
***Distal ureter: groin pain  
***Distal ureter: groin pain  
***UVJ: Can mimic a UTI (frequency, urgency, dysuria)
***UVJ: Can mimic a [[UTI]] (frequency, urgency, [[dysuria]])
*[[Nausea/vomiting]] (50%)
*[[Nausea/vomiting]] (50%)
*[[Hematuria]] (85%)
*[[Hematuria]] (85%)


== Differential Diagnosis ==
==Differential Diagnosis==
''Nephrolithiasis is most common misdiagnosis given to patients with rupturing [[AAA]]''
''Nephrolithiasis is most common misdiagnosis given to patients with rupturing [[AAA]]''
{{Flank pain DDX}}
{{Flank pain DDX}}
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{{Lower back pain DDX}}
{{Lower back pain DDX}}


==Diagnosis==
==Evaluation==
===Labs===
===Labs===
*UA: hematuria
*[[Urinalysis]]: [[hematuria]]
**Hematuria cannot be used to rule-out or rule-in stone (sensitivity 71-95%; specificity 18-49%)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**Hematuria cannot be used to rule-out or rule-in stone (sensitivity 71-95%; specificity 18-49%)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**The abscence of pyuria cannot exclude a complicating UTI (sensitivity 86%; specificity 79%)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**The absence of pyuria cannot exclude a complicating UTI (sensitivity 86%; specificity 79%)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
*UCx:  
*Urine culture :  
**Consider for all patients<ref name="a"/> OR those at higher risk (female, pyuria, or [[cystitis]] symptoms)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**Consider for all patients<ref name="a"/> '''OR''' those at higher risk (female, pyuria, or [[cystitis]] symptoms)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
*Urine pregnancy
*Urine pregnancy
*Chemistry
*Chemistry
*CBC: If concern for infection
*CBC: If concern for infection (>15k concerning)


===Imaging===
===Imaging===
[[File:3mm renal stone2.png|thumb|Axial CT scan of abdomen without contrast, showing a 3-mm stone (marked by an arrow) in the proximal ureter.]]
*Bedside [[Renal ultrasound]]
*Bedside [[Renal ultrasound]]
[[File:Ultrasonography of renal stone located at the pyeloureteral junction.jpg|thumb|[[Renal ultrasound]] of a stone located at the pyeloureteral junction with accompanying hydronephrosis.]]
*Consider non-contrast CT abdomen and pelvis (KUB protocol) for:
*Consider non-contrast CT abdomen and pelvis (KUB protocol) for:
**1st time stone
**1st time stone
**Older patients with other possible diagnosis
**Avoid CT in young (<50 years old), health patients with known history of nephrolithiasis with presentation consistent with renal colic<ref>Part of [[Choosing wisely ACEP]]</ref>
**Avoid CT in young (<50 years old), health patients with known history of nephrolithiasis with presentation consistent with renal colic<ref>Part of [[Choosing wisely ACEP]]</ref>
*Consider formal US for:
*Consider formal [[ultrasound]] for:
**Pregnant pt
**Pregnant pt
**Repeat stone (to avoid CT)
**Repeat stone (to avoid CT)
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**No difference in rate of serious adverse events, pain scores, return emergency department visits, or hospitalizations
**No difference in rate of serious adverse events, pain scores, return emergency department visits, or hospitalizations


== Management ==
==Management==
===Pain===
===Pain===
'''ED/Inpatient''
*[[Ketorolac]] 30mg IV or  [[Ibuprofen]] 600mg PO Q6hrs PRN if the patient can tolerate oral medications<ref>Pathan, SA et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multi-group, randomised controlled trial. Lancet. 2016 May 14;387(10032): 1999-2007</ref>
*[[Ketorolac]] 30mg IV, AND
**Avoid high dose NSAIDS in patients with renal failure or insufficiency.
**Avoid in renal failure, bilateral stones, congenital stones (cysteine)
*[[Morphine]] or other [[Opioids]] are often needed due to severe pain
*[[Morphine]] or [[dilaudid]]
 
'''Outpatient'''
*[[Ibuprofen]] 600mg PO Q6hrs PRN pain, AND
*[[Norco]] 5/325 PO Q6hrs PRN pain x 3 days


===Antiemetic===
===Antiemetic===
*[[Metoclopramide]]
*[[Metoclopramide]]
*[[Ondansteron]]
*[[Ondansetron]]


===Infection===
===Expulsion Therapy===
*Inpatient:
*Consider [[Tamsulosin]] 0.4mg PO QHS (discontinued after successful expulsion; average 1-2 weeks)
**[[Gentamicin]] 1-2.5mg/kg + [[ampicillin]] 1-2gm q4hr OR
**See [[EBQ:Alpha-blockers for ureteral stone expulsion]] discussion of evidence
**[[Piperacillin-tazobactam ]]3.375 gm q6hr OR
**76% vs 48% passage rates in tamsulosin vs no treatment, respectively<ref>Hollingsworth JM et al. α-blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016;355:i6112.</ref>
**[[Cefepime]] 2gm q8hr OR
***Only patients with stones ≥ 5 mm benefited
**[[Ciprofloxacin]] 400mg q12hr (if local sensitivities do not predict treatment failure)
***Review of 55 RTCs, with NNT of 4
*Outpatient:
**Tamsulosin number needed to harm (orthostatic hypotension)= 19 (give at night, to reduce side effect rate)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**[[Ciprofloxacin]] 500mg PO BID x10-14d OR
*Use of IV fluids to "flush out" stone has NOT been shown to improve clinical outcomes<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**[[Levofloxacin]] 500mg PO daily x10-14d OR
**[[Cefpodoxime]] 200mg PO BID x10-14d


===Expulsion===
==Infected Urolithiasis==
*For large (>5mm) distal stones, consider [[tamulosin]] 0.4 mg PO QHS (discontinued after successful expulsion; average 1-2 weeks)
''Inpatient observation is often the safest disposition for patients with infected stones due to the risk of progressing to [[sepsis]]. All antibiotics should take into account patient's previous sensitivities and local antibiograms''
**Usage of [[tamulosin]] or [[nifedipine]] reflexively in all kidney stone patients has not been shown to be beneficial
{{Pyelonephritis antibiotics}}
**There is evidence that the subgroup of large distal stones >5mm benefit from tamulosin (passage rate of 83.3% with tamulosin versus 61.0% with placebo)<ref>Furyk, JS, et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Annals of Emergency Medicine. 2016; 67(1):86-95.e2.</ref>
**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).<ref>Singh A, et al. A systematic review of medical therapy to facilitate the passage of ureteral calculi. Annals of Emerg Med. 2007; 552-563.</ref><ref>Pickard R, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015; epub.</ref>
**Tamulosin number needed to harm (orthostatic hypotension)= 19 (give at night, to reduce side effect rate)<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
*Use of IV fluids to "flush out" stone has not been shown to improve clinical outcomes<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>


===Surgery===
===Surgical Removal===
*Considered for:
Considered for ureterolithiasis with:
**Persistent obstruction
*Persistent obstruction
**Failure of stone progression
*Failure of stone progression
**Increasing or unremitting colic
*Increasing or unremitting colic
**Staghorn calculi (abx penetration is poor)
*Staghorn calculi


==Disposition==
==Disposition==
===Admission===
===Admission===
*Absolute
'''Recommended for any of the following:'''
**Intractable pain or vomiting<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
*Intractable pain or vomiting<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**Proximal [[urinary tract infection]],<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref> as evidence by:
*Proximal [[urinary tract infection]],<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref> as evidence by:
***[[Urosepsis]]
*[[Urosepsis]]:
***[[Fever]]
**[[Fever]]
***Ill appearance, OR
**Ill appearance, '''OR'''
***Markedly elevated WBC
**Markedly elevated WBC
**Single or transplanted kidney with obstruction<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
*Single or transplanted kidney with obstruction<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**Acute renal failure<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
*Acute renal failure<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref>
**[[Hypercalcemic Crisis]]
*[[Hypercalcemic Crisis]]
*Relative
 
**Solitary kidney or transplanted kidney without obstruction
'''Also consider admission for patients with:'''
**Urinary extravasation
*Solitary kidney or transplanted kidney without obstruction
**Significant medical comorbidities
*Urinary extravasation
*Significant medical comorbidities


===Consultation===
===Consultation===
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===Discharge===
===Discharge===
*Small stone, adequate analgesia, able to arrange urology f/u w/in 7d
*Small stone, adequate analgesia, able to arrange urology follow up within 7d


==See Also==
==See Also==
*[[Flank pain]]
*[[Flank pain]]
*[[EBQ:Hematuria in Renal Colic]]


== References ==
==References==
<references/>
<references/>


[[Category:Renal]]
[[Category:Renal]]

Revision as of 23:15, 17 October 2019

Background

Urolithiasis comprises 3 similar clinical entities:

  • Nephrolithiasis
  • Ureterolithiasis
  • Cystolithiasis

Renal damage

  • Irreversible renal damage can occur within 3 weeks in patients with a complete obstruction
  • Most have no rise in creatinine because unobstructed kidney functions at up to 185% of its baseline capacity

Infection

  • 8-15% of kidney stones have urinary co-infection[1]
    • Fever, pyuria >10 WBC/hpf, and peripheral WBC >11.3 (any one) best predictors of concomitant UTI[1]

Stone Expulsion Rate

Stone Size Passage Rate[2]
1-4 mm 78%
5 -7 mm 60%
>8mm 39%

Types

Risk Factors for Complications

  • 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

Clinical Features

Diagram showing the classic location of renal colic.
  • Pain
    • Acute onset, crampy, intermittent, unable to find position of comfort
    • 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)
  • Nausea/vomiting (50%)
  • Hematuria (85%)

Differential Diagnosis

Nephrolithiasis is most common misdiagnosis given to patients with rupturing AAA

Flank Pain

Lower Back Pain

Evaluation

Labs

  • Urinalysis: hematuria
    • Hematuria cannot be used to rule-out or rule-in stone (sensitivity 71-95%; specificity 18-49%)[3]
    • The absence of pyuria cannot exclude a complicating UTI (sensitivity 86%; specificity 79%)[3]
  • Urine culture :
    • Consider for all patients[1] OR those at higher risk (female, pyuria, or cystitis symptoms)[3]
  • Urine pregnancy
  • Chemistry
  • CBC: If concern for infection (>15k concerning)

Imaging

Axial CT scan of abdomen without contrast, showing a 3-mm stone (marked by an arrow) in the proximal ureter.
Renal ultrasound of a stone located at the pyeloureteral junction with accompanying hydronephrosis.
  • Consider non-contrast CT abdomen and pelvis (KUB protocol) for:
    • 1st time stone
    • Older patients with other possible diagnosis
    • Avoid CT in young (<50 years old), health patients with known history of nephrolithiasis with presentation consistent with renal colic[4]
  • Consider formal ultrasound 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

  • Ketorolac 30mg IV or Ibuprofen 600mg PO Q6hrs PRN if the patient can tolerate oral medications[6]
    • Avoid high dose NSAIDS in patients with renal failure or insufficiency.
  • Morphine or other Opioids are often needed due to severe pain

Antiemetic

Expulsion Therapy

  • Consider Tamsulosin 0.4mg PO QHS (discontinued after successful expulsion; average 1-2 weeks)
    • See EBQ:Alpha-blockers for ureteral stone expulsion discussion of evidence
    • 76% vs 48% passage rates in tamsulosin vs no treatment, respectively[7]
      • Only patients with stones ≥ 5 mm benefited
      • Review of 55 RTCs, with NNT of 4
    • Tamsulosin number needed to harm (orthostatic hypotension)= 19 (give at night, to reduce side effect rate)[3]
  • Use of IV fluids to "flush out" stone has NOT been shown to improve clinical outcomes[3]

Infected Urolithiasis

Inpatient observation is often the safest disposition for patients with infected stones due to the risk of progressing to sepsis. All antibiotics should take into account patient's previous sensitivities and local antibiograms Treatment is targeted at E. coli, Enterococcus, Klebsiella, Proteus mirabilis, S. saprophyticus.

Outpatient

Consider one dose of Ceftriaxone 1g IV or Gentamycin 7mg/kg IV if the regional susceptibility of TMP/SMX or Fluoroquinolones is <80%

Adult Inpatient Options

Pediatric Inpatient Options

Surgical Removal

Considered for ureterolithiasis with:

  • Persistent obstruction
  • Failure of stone progression
  • Increasing or unremitting colic
  • Staghorn calculi

Disposition

Admission

Recommended for any of the following:

Also consider admission for patients with:

  • Solitary kidney or transplanted kidney without obstruction
  • Urinary extravasation
  • Significant medical comorbidities

Consultation

  • Renal insufficiency
  • Severe underlying disease
  • Stone >10 mm[3]
  • Sloughed renal papillae
  • Unclear/distal UTI
  • Ruptured renal capsule causing urinoma

Discharge

  • Small stone, adequate analgesia, able to arrange urology follow up within 7d

See Also

References

  1. ↑ 1.0 1.1 1.2 Abrahamian FM, et al. Association of pyuria and clinical characteristics with presence of urinary tract infection among patients with acute nephrolithiasis. Annals of EM. 2013; 62(5):526-533.
  2. ↑ Coll DM et al. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol 2002 Jan; 178:101-3.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454
  4. ↑ Part of Choosing wisely ACEP
  5. ↑ Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. NEJM. 2014; 371(12):1100–1110.
  6. ↑ Pathan, SA et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multi-group, randomised controlled trial. Lancet. 2016 May 14;387(10032): 1999-2007
  7. ↑ Hollingsworth JM et al. α-blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016;355:i6112.
  8. ↑ Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women. Clinical Infectious Diseases. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257
  9. ↑ Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
  10. ↑ Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
  11. ↑ Sandberg T. et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4;380(9840):484-90.
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