Acute Pain is one of the key reasons why patients present to Emergency Department and we should be experts at managing any sort of acute pain. Renal Colic is one such pathology that presents with sudden onset intermittent severe crampy flank pain a/w nausea and vomiting. NSAIDs are the drugs of choice as they inhibit prostaglandin synthesis and result in relaxation of ureteral spasm and decrease of renal capsular distension and associated pain. Here is a quick review of Renal Colic:
Risk Factors for Renal Stones
- Obesity
- Diabetes
- Metabolic Abnormalities
- Hyperparathyroidism
- Immobilisation
- Excess intake of meat and Na
- Gout
- Inflammatory Bowel Disease
- Family History
Up to 15-30% patients with Nephrolithiasis may not show blood in urine. Do not exclude tis diagnosis based on the absence of hematuria.
Things that you should not miss (Mimics):
- Dissection/Aneurysm (most common misdiagnosis given to patients with a rupturing or expanding abdominal aortic aneurysm)
- Renal Infarct
- Pyelonephritis
- Biliary Colic
- Pancreatitis
- Diverticulitis
- Ovarian Torsion
- Ectopic Pregnancy
- Lower Lobe Pneumonia
- Testicular Torsion
- Herpes Zoster
Investigations:
- Urine Dip (look for infection)
- Full Blood Count (WCC is elevated due to stress demargination)
- Uric Acid, CA (Helps in further evaluation as an out-patient)
- Renal Function (Normal creatinine does not rule out obstruction)
- Imaging (CT KUB, Bedside USG, Formal USG) - read more on imaging at aliem
- Beta hCG
Consider adding amylase, LFT, CXR if history or examination findings are atypical.
Management
- Pain Relief (IM/IV/PR NSAIDs, Opioids, Antispasmodics are of uncertain benefit)
- Anti-emetics (Metocloperamide)
- Medical Expulsion Therapy (No proven benefit. Prescribe only for >5mm distal ureteric stones)
- Antibiotics if febrile, systemically unwell (WCC is elevated due to stress demargination)
IV Fluids do not expedite stone expulsion
Consult Urology in cases of:
- Refractory Pain
- Obstruction and Acute Renal Failure
- Urosepsis
- Advanced age and co-morbidities
- Solitary/Transplanted Kidney
- Pregnancy
Take Home
- Look for risk factors and potential mimics (aortic dissection and renal infarct)
- Do not rule out kidney stones based on the absence of hematuria
- Provide pain relief and arrange follow up
Further Reading
- Core EM - Renal Colic
- REBEL EM - Does Use of Tamsulosin in Renal Colic Facilitate Stone Passage?
- Golzari, S. E., Soleimanpour, H., Rahmani, F., Zamani Mehr, N., Safari, S., Heshmat, Y., & Ebrahimi Bakhtavar, H. (2014). Therapeutic Approaches for Renal Colic in the Emergency Department: A Review Article. Anesthesiology and Pain Medicine, 4(1), e16222. http://doi.org/10.5812/aapm.16222
- Stewart A, Joyce A. Modern management of renal colic. Trends in Urology & Men's Health. 2008 May 1;13(3):14-7.
Posted by:
Lakshay Chanana
Speciality Doctor
Northwick Park Hospital
Department of Emergency Medicine
England
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