Urolithiasis: Difference between revisions
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===Expulsion=== | ===Expulsion=== | ||
*Consider [[Tamsulosin]] 0. | *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 | ||
**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> | **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> |
Revision as of 16:57, 26 July 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 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
Pass Rate
- <5mm - 98% will pass within 4wk
- 5-7mm - 60% will pass 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%)
- Uric Acid (10%)
- 25% of patients with 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, 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
- UA: hematuria
- Urine culture :
- 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 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
ED & Inpatient
- Ketorolac 30mg IV, AND
- Avoid in renal failure, bilateral stones, congenital stones (cysteine)
- Morphine or dilaudid
Outpatient
Antiemetic
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
- 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
- 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]
Surgery
- Considered for:
- Persistent obstruction
- Failure of stone progression
- Increasing or unremitting colic
- Staghorn calculi (antibiotic penetration is poor)
Disposition
Admission
- Absolute
- Intractable pain or vomiting[3]
- Proximal urinary tract infection,[3] as evidence by:
- Single or transplanted kidney with obstruction[3]
- Acute renal failure[3]
- Hypercalcemic Crisis
- 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
- ↑ Coe F, et al. The pathogenesis and treatment of kidney stones. NEJM. 1992; 327:1141-1152.
- ↑ 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.
- ↑ 3.0 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
- ↑ 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.