Urolithiasis: Difference between revisions
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==Background== | ==Background== | ||
[[File:Urinary system.png|thumb|'''(1) Human urinary system:''' (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra. <Br>'''Additional structures:''' (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.]] | |||
Urolithiasis comprises 3 similar clinical entities: | |||
*Nephrolithiasis | |||
*Ureterolithiasis | |||
*Cystolithiasis | |||
The most common cause is infection of residual bladder urine with urea-spliting organisms (proteus, pseudomonas, klebsiella, staphlococcus and mycoplasm) | |||
===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<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"/> | ||
=== | ===Stone Expulsion Rate=== | ||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Stone Size''' | |||
| 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=== | ||
Line 27: | Line 36: | ||
**25% of patients with gout develop kidney stones | **25% of patients with gout develop kidney stones | ||
==Risk Factors for Complications== | |||
*Renal function at risk | *Renal function at risk | ||
**[[DM]] | **[[DM]] | ||
Line 47: | Line 56: | ||
==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}} | ||
Line 63: | Line 73: | ||
{{Lower back pain DDX}} | {{Lower back pain DDX}} | ||
== | ==Evaluation== | ||
===Labs=== | ===Labs=== | ||
* | *[[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 | **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> | ||
*Urine culture : | *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=== | ||
*Consider tailoring your choice of imaging based upon the patient's age, clinical likelihood of stones, risk factors, and prior history of stones<ref>Imaging in suspected renal colic: systematic review of the literature and multispecialty consensus Moore CL, Carpenter CR, Heilbrun ME, et al. Ann Emerg Med. 2019;74(3):391-399.</ref> | |||
**In young patients, even with no prior history of kidney stones, reasonable approaches may be bedside ultrasound or no imaging | |||
**In middle aged patients with prior history of stones, it may be reasonable to perform a bedside ultrasound although no imaging can be appropriate as well | |||
**In middle aged patients with no prior history of stones, CT imaging is reasonable | |||
**In elderly patients, even with prior history of stones, CT is recommended in order to avoid missing alternative etiologies such as dissection, AAA, or diverticulitis. | |||
[[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 | *Consider formal [[ultrasound]] for: | ||
**Pregnant pt | **Pregnant pt | ||
**Repeat stone (to avoid CT) | **Repeat stone (to avoid CT) | ||
Line 86: | Line 104: | ||
**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=== | ||
*[[Ketorolac]] 15mg 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]] | **Avoid high dose NSAIDS in patients with renal failure or insufficiency. | ||
**Avoid in renal failure, | **Ketorolac 15 mg has similar effects to the traditional 30 mg dosage. <ref> Motov S, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017 Aug;70(2):177-184. doi: 10.1016 </ref> | ||
*[[Morphine]] or [[ | *[[Morphine]] or other [[Opioids]] may be needed if severe pain | ||
===Antiemetic=== | ===Antiemetic=== | ||
*[[Metoclopramide]] | *[[Metoclopramide]] | ||
*[[ | *[[Ondansetron]] | ||
=== | ===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<ref>Hollingsworth JM et al. α-blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016;355:i6112.</ref> | ||
** | ***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)<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> | ||
** | |||
* | |||
== | ==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'' | |||
{{Pyelonephritis antibiotics}} | |||
=== | ===Surgical Removal=== | ||
Considered for ureterolithiasis with: | |||
*Persistent obstruction | |||
*Failure of stone progression | |||
*Increasing or unremitting colic | |||
*Staghorn calculi | |||
==Disposition== | ==Disposition== | ||
===Admission=== | ===Admission=== | ||
'''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> | |||
*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]]: | |||
**[[Fever]] | |||
**Ill appearance, '''OR''' | |||
**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> | |||
*Acute renal failure<ref name="Wang RC">Wang RC. Managing Urolithiasis. Annals of EM. April 2016. 67(4):449-454</ref> | |||
*[[Hypercalcemic Crisis]] | |||
'''Also consider admission for patients with:''' | |||
*Solitary kidney or transplanted kidney without obstruction | |||
*Urinary extravasation | |||
*Significant medical comorbidities | |||
===Consultation=== | ===Consultation=== | ||
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===Discharge=== | ===Discharge=== | ||
*Small stone, adequate analgesia, able to arrange urology follow up | *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 01:25, 13 October 2020
Background
Urolithiasis comprises 3 similar clinical entities:
- Nephrolithiasis
- Ureterolithiasis
- Cystolithiasis
The most common cause is infection of residual bladder urine with urea-spliting organisms (proteus, pseudomonas, klebsiella, staphlococcus and mycoplasm)
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
- Calcium (75%)
- Hyperparathyroidism, hypercalcemia of malignancy, sarcoidosis, increased absorption, loop diuretics, IBD
- Struvite (magnesium-ammonium-phosphate) (15%)
- Uric Acid (10%)
- 25% of patients with gout develop kidney stones
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
- Fever
- Hypotension
- Systemic illness
- UTI
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
- Vascular
- Abdominal aortic aneurysm
- Renal artery embolism
- Renal vein thrombosis
- Aortic dissection
- Mesenteric ischemia
- Renal
- Pyelonephritis
- 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
- GU
- Other
- Shingles
- Lower lobe pneumonia
- Retroperitoneal hematoma/abscess/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
Evaluation
Labs
- Urinalysis: hematuria
- Urine culture :
- Urine pregnancy
- Chemistry
- CBC: If concern for infection (>15k concerning)
Imaging
- Consider tailoring your choice of imaging based upon the patient's age, clinical likelihood of stones, risk factors, and prior history of stones[4]
- In young patients, even with no prior history of kidney stones, reasonable approaches may be bedside ultrasound or no imaging
- In middle aged patients with prior history of stones, it may be reasonable to perform a bedside ultrasound although no imaging can be appropriate as well
- In middle aged patients with no prior history of stones, CT imaging is reasonable
- In elderly patients, even with prior history of stones, CT is recommended in order to avoid missing alternative etiologies such as dissection, AAA, or diverticulitis.
- Bedside Renal ultrasound
- 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[5]
- 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):[6]
- 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 15mg IV or Ibuprofen 600mg PO Q6hrs PRN if the patient can tolerate oral medications[7]
- Avoid high dose NSAIDS in patients with renal failure or insufficiency.
- Ketorolac 15 mg has similar effects to the traditional 30 mg dosage. [8]
- Morphine or other Opioids may be needed if 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[9]
- 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%
- Ciprofloxacin 500mg PO BID x7 days OR
- Trimethoprim-Sulfamethoxazole DS 160/800mg PO BID x14 days OR[10]
- Cephalexin 500mg QID PO x 10-14 days (OR consider 1000mg BID if difficulty with QID regimen) OR
- Cefdinir 300mg BID PO x 10-14 days OR
- Cefpodoxime 200mg PO BID x 10 days OR[11]
- Cefixime 400mg PO daily x 10 days OR[12]
- Levofloxacin 750mg PO QD x7 days[13]
Adult Inpatient Options
- Ciprofloxacin 400mg IV q12hr OR
- Ceftriaxone 1gm IV QD (Preferred in pregnancy) OR
- Cefotaxime 1-2gm IV q8hr OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr OR
- Cefepime 2gm IV q8hr OR
- Imipenem 500mg IV q8hr
Pediatric Inpatient Options
- Ceftriaxone 75mg/kg IV QD OR
- Cefotaxime 50mg/kg IV q8hrs OR
- Ampicillin 25mg/kg IV q6hrs + Gentamicin 2.5mg/kg IV q8hrs
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:
- Intractable pain or vomiting[3]
- Proximal urinary tract infection,[3] as evidence by:
- Urosepsis:
- Fever
- Ill appearance, OR
- Markedly elevated WBC
- Single or transplanted kidney with obstruction[3]
- Acute renal failure[3]
- Hypercalcemic Crisis
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
- ↑ 1.0 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.
- ↑ 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.
- ↑ 3.0 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
- ↑ Imaging in suspected renal colic: systematic review of the literature and multispecialty consensus Moore CL, Carpenter CR, Heilbrun ME, et al. Ann Emerg Med. 2019;74(3):391-399.
- ↑ Part of Choosing wisely ACEP
- ↑ Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. NEJM. 2014; 371(12):1100–1110.
- ↑ 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
- ↑ Motov S, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017 Aug;70(2):177-184. doi: 10.1016
- ↑ Hollingsworth JM et al. α-blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016;355:i6112.
- ↑ 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
- ↑ Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
- ↑ Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
- ↑ 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.