Urolithiasis: Difference between revisions

(Text replacement - " US " to " ultrasound ")
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==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 [[Opiods]] 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===
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*[[Ondansteron]]
*[[Ondansteron]]


===Infection===
===Expulsion Therapy===
*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===
*Consider [[Tamsulosin]] 0.4mg PO QHS (discontinued after successful expulsion; average 1-2 weeks)
*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  
**See [[EBQ:Alpha-blockers for ureteral stone expulsion]] discussion of evidence  
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*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>
*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===
==Infected Ureterolithiasis==
*Considered for:
''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''
{{Pyelonephritis antibiotics}}
 
===Surgical Removal===
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 (antibiotic penetration is poor)
**Staghorn calculi


==Disposition==
==Disposition==

Revision as of 02:32, 23 November 2016

Background

  • Urolithiasis comprises 3 similar clinical entities:
    • Nephrolithiasis
    • Ureterolithiasis
    • Cystolithiasis
  • Peptic ulcer disease increases risk for development of kidney stones[1]
    • Elevated oral calcium intake with calcium based treatments
  • Renal damage
    • 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
      • Rise in creatinine suggests solitary kidney or preexisting renal disease (such that the unobstructed kidney is unable to compensate)
  • Infection
    • 8-15% of kidney stones have urinary co-infection[2]
    • Fever, pyuria >10 WBC/hpf, and peripheral WBC >11.3 (any one) best predictors of concomitant UTI[2]

Pass Rate

  • <5mm - 98% will pass within 4wk
  • 5-7mm - 60% will pass within 4wk
  • >7mm - 39% will pass within 4wk

Types

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

Clinical Features

  • 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 abscence of pyuria cannot exclude a complicating UTI (sensitivity 86%; specificity 79%)[3]
  • Urine culture :
    • Consider for all patients[2] OR those at higher risk (female, pyuria, or cystitis symptoms)[3]
  • Urine pregnancy
  • Chemistry
  • CBC: If concern for infection

Imaging

  • Bedside Renal ultrasound
  • Consider non-contrast CT abdomen and pelvis (KUB protocol) for:
    • 1st time stone
    • 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 Opiods are often needed due to severe pain

Antiemetic

Expulsion Therapy

  • Consider Tamsulosin 0.4mg PO QHS (discontinued after successful expulsion; average 1-2 weeks)
  • Use of IV fluids to "flush out" stone has not been shown to improve clinical outcomes[3]

Infected Ureterolithiasis

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

  • Absolute
  • Relative
    • 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. ↑ Coe F, et al. The pathogenesis and treatment of kidney stones. NEJM. 1992; 327:1141-1152.
  2. ↑ 2.0 2.1 2.2 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.
  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. ↑ 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
  8. ↑ Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
  9. ↑ Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
  10. ↑ 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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