Transcript Management of Renal Colic in A&E department

Management of Renal Colic in
A&E department
Protocol presented during A&E
medical meeting
20/06/2012
Dr David / Dr Tien
Typical presentation
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The pain lasts minutes to hours, and occurs in spasms with
intervals of no pain or dull ache. The person is restless and
cannot lie still (which helps to differentiate from
inflammatory causes, such as peritonitis).
The pain may radiate to the groin, scrotum, testis, labia, and
anterior thigh.
The pain is often accompanied by nausea, vomiting,
hypotension, frequent urination, dysuria, oliguria, and
haematuria.
There may be a history of previous episodes.
There is often a history of precipitating factors, which
include dehydration with reduced urine output, increased
protein intake, heavy physical exercise, and use of drugs
associated with stone formation
Physical examination
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Examination may reveal loin tenderness or
tenderness of the lower quadrant
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Peritoneal signs are absent.
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Fever suggests either a separate diagnosis
of urinary tract infection or coexisting
urinary tract infection.
Interest of urine test (BU)
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Urine test: look for blood (to confirm the diagnosis)
and leucocytes (to look for infectious complication)
Absence of haematuria makes the diagnosis of
renal colic less likely (but does not exclude the
diagnosis).
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Presence of haematuria supports the diagnosis,
but specificity and positive predictive value are
poor.
Presence of nitrite and leucocytes indicates
possible urinary tract infection (may be the primary
diagnosis or coexistent with renal colic).
Differential diagnosis
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Pyelonephritis (can also be associated with kidney stone)
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Ectopic pregnancy: Woman of reproductive age
and recent delayed menstrual period (Beta HCG)
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Endometriosis, Ovarian cyst
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Leaking abdominal aortic aneurysm: People older
than 60 years of age, especially men with left-sided pain
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Biliary colic, Pancreatitis, Bowel ischemia
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Pneumonia, pleuretic pain
Confirmation by imaging
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Uroscanner (Unenhance CT scanner): Unenhanced
helical CT is fast and accurate in determining the cause of
colic and is highly accurate for emergency situations.
Most often, CT confirmed a ureteral stone and allowed
appropriate discharge or urologic intervention. In a smaller
subset of patients, CT established a significant alternative
diagnosis that allowed the prompt initiation of appropriate
treatment (aortic aneuvrism).
Ultrasound (US):
US is inferior to spiral CT in the
demonstration of ureteral calculi in patients with renal
colic. US should be limited to the situation where CT scan
is not available or contra-indicated.
Uroscanner / Ultrasound ?
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Uroscanner CT allows a rapid, contrast-mediumfree, anatomically accurate diagnosis of urinary
tract calculi and has a sensitivity of 98% and a
specificity of 97%. CT provides an alternative
diagnosis in 6% of patients. Helical CT should be
the first choice in imaging a patient with renal
colic.
If this technique is not available or contraindicated
(eg:
pregnant
women),
ultrasonography should be considered.
Initial treatment in A&E
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Voltaren (Diclofenac) 75 mg intravenous (unless
contraindication of non-steroidal anti-inflammatory drug
NSAID like pregnant women 3rd trimestre or renal failure)
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Consider an opioid (for example morphine) if diclofenac
is not suitable or is insufficient to control the pain:
Morphine 2 to 3 mg intravenous injection (IV) bolus
following Morphin titration protocole (up to a cumulative
dose 10 mg if pain is not relieved after the first bolus).
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Paracetamol IV or an antispasmodic drug like Spasfon
can also be prescribed in association with Voltaren
If complications > Hospitalization
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They are in shock or have fever or signs of systemic infection
(which can lead to life-threatening sepsis).
They are at increased risk from loss of renal function (and require
emergency imaging and drainage to prevent irreversible loss of
renal function): Solitary or transplanted kidney, Pre-existing renal
impairment, Bilateral obstructing stones are suspected.
They do not respond to appropriate analgesic and anti-emetic
treatment within 1 hour
They have abrupt recurrence of severe pain despite initial analgesia
(Consider admission if pain is persisting beyond 24 hours)
They are dehydrated and cannot take oral fluids due to vomiting —
they require intravenous fluids.
There is uncertainty regarding the diagnosis (for example if a
leaking abdominal aortic aneurysm cannot be excluded).
Pregnant women.
Patient more than 60 years with chronic diseases / Patient
preference for admission.
Contact by telephone is not possible or no reliable social support.
No complication > Discharge
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Give patient the prescription with Non-Steroidal
Anti-inflammatory drugs and painkillers by mouth:
Voltaren 75mg x 2 + Efferalgan Codein 2 tab x 3
Advise the person to contact A&E on-duty doctor
if there is an abrupt recurrence of severe pain or
sign of seriousness like fever, shiver, vomiting++
(food of drink intolerance) > come back in
emergency to A&E.
Offer referral to urologist in OPD so that
investigations can be carried out within 3 days.
Prognostic
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Most symptomatic renal stones are small (less than
5 mm in diameter) and pass spontaneously.
Spontaneous passage is less likely for larger
stones:
Stones less than 5 mm in diameter pass
spontaneously in up to 80% of people.
Stones between 5 mm and 10 mm in diameter
pass spontaneously in about 50% of people.
Stones larger than 1 cm in diameter usually
require intervention (urgent intervention is required if
complete obstruction or infection is present).
Urological expertise if complication:
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Renal colic with fever
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Rupture of urinary tract (CT scanner)
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Obstructive renal insufficiency (unique
kidney or bilateral migration of calculi)
Hyperalgic renal colic (not responding to
initial treatment NIAS + Morphin)
Urological expertise if particular
context:
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Chronic Renal failure or pre-existing uropathy
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Single kidney (anatomical or fonctionnal)
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Pregnancy
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Bilateral stone migration
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Calculi > 6mm
Probability of spontaneous
elimination of the stone
Confirmation by Imaging:
Suspicion of renal colic:
o Loin pain / Back pain
o On & Off evolution
o Past history of kidney stone
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Uroscanner (without contrast)
Ultrasound (if CT contra-indicated)
Look for complications / risk factors > admission in hospital
o Fever or sign of sepsis (CRP, WBC, BU) > start antibiotics after ECBU
o Severe pain despite initial treatment (after 1 hour)
o Recurrence of severe pain within 24hours
o Risk of loss of renal function* / anuria
o Risk of dehydration due to drink and food intolerance (vomiting++)
o Stone more than 6mm
o Pregnant women
o Patient lives far from an hospital, social isolation
o Patient > 60 years with chronic diseases / Patient preference for admission
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Admission in hospital
1Surgical ward if stable (inform urologist on call)
2ICU if unstable (severe sepsis / shock)
Discharge the patient
1Medical treatment by mouth (NSAI + Efferalgan Codein)
2Follow up J3 by urologist
3Give advices (discharge form with advices)
Management of renal colic
(ASP + Echography)
Management of renal colic in A&E
(Uro-scanner)