Management of Renal Management of Renal Colic in A&E departmentColic in A&E department

Protocol presented during A&E Protocol presented during A&E medical meetingmedical meeting

20/06/201220/06/2012Dr David / Dr TienDr David / Dr Tien

Typical presentationTypical presentation The pain lasts minutes to hours, and occurs in The pain lasts minutes to hours, and occurs in

spasms with intervals of no pain or dull ache.spasms with intervals of no pain or dull ache. The The person is restless and cannot lie still (which helps to person is restless and cannot lie still (which helps to differentiate from inflammatorydifferentiate from inflammatory causes, such as causes, such as peritonitis).peritonitis).

The pain may radiate to the groin, scrotum, testis, The pain may radiate to the groin, scrotum, testis, labia, and anterior thigh.labia, and anterior thigh.

The pain is often accompanied by nausea, vomiting, The pain is often accompanied by nausea, vomiting, hypotension, frequent urination,hypotension, frequent urination, dysuria, oliguria, dysuria, oliguria, and haematuria.and haematuria.

There may be a history of previous episodes.There may be a history of previous episodes. There is often a history of precipitating factors, which There is often a history of precipitating factors, which

include dehydration with reduced urine output, include dehydration with reduced urine output, increased protein intake, heavy physical exercise, increased protein intake, heavy physical exercise, and use of drugs associated with stone formationand use of drugs associated with stone formation

Physical examinationPhysical examination

Examination may reveal loin Examination may reveal loin

tenderness or tenderness of the lower tenderness or tenderness of the lower

quadrant quadrant

Peritoneal signs are absent.Peritoneal signs are absent.

Fever suggests either a separate Fever suggests either a separate

diagnosis of urinary tract infection or diagnosis of urinary tract infection or

coexisting urinarycoexisting urinary tract infection.tract infection.

Interest of urine test (BU)Interest of urine test (BU)

Urine testUrine test: look for blood : look for blood (to confirm the (to confirm the diagnosis)diagnosis) and leucocytes and leucocytes (to look for infectious (to look for infectious complication)complication)

Absence of haematuria makes the diagnosis Absence of haematuria makes the diagnosis of renal colic less likely of renal colic less likely ((but does notbut does not exclude exclude the diagnosisthe diagnosis).).

Presence of haematuria supports the Presence of haematuria supports the diagnosis, but specificity and positive diagnosis, but specificity and positive predictivepredictive value are poor.value are poor.

Presence of nitrite and leucocytes indicates Presence of nitrite and leucocytes indicates possible urinary tract infection possible urinary tract infection (may be the(may be the primary diagnosis or coexistent with renal colic).primary diagnosis or coexistent with renal colic).

Differential diagnosisDifferential diagnosis Pyelonephritis Pyelonephritis (can also be associated with kidney (can also be associated with kidney

stone)stone)

Ectopic pregnancy: Woman of reproductive age Ectopic pregnancy: Woman of reproductive age

and recent delayed menstrual period and recent delayed menstrual period (Beta HCG)(Beta HCG)

Endometriosis, Ovarian cystEndometriosis, Ovarian cyst

Leaking abdominal aortic aneurysm: Leaking abdominal aortic aneurysm: People older People older

than 60 years of age, especially men with left-sided painthan 60 years of age, especially men with left-sided pain

Biliary colic, Pancreatitis, Bowel ischemia Biliary colic, Pancreatitis, Bowel ischemia

Pneumonia, pleuretic painPneumonia, pleuretic pain

Confirmation by imagingConfirmation by imagingo Uroscanner Uroscanner (Unenhance CT scanner): Unenhanced (Unenhance CT scanner): Unenhanced

helical CT is fast and accurate in determining the helical CT is fast and accurate in determining the cause of colic and is highly accurate for emergency cause of colic and is highly accurate for emergency situations. situations.

o Most often, CT confirmed a ureteral stone and allowed Most often, CT confirmed a ureteral stone and allowed appropriate discharge or urologic intervention. In a appropriate discharge or urologic intervention. In a smaller subset of patients, CT established a significant smaller subset of patients, CT established a significant alternative diagnosis that allowed the prompt alternative diagnosis that allowed the prompt initiation of appropriate treatment (aortic aneuvrism).initiation of appropriate treatment (aortic aneuvrism).

o Ultrasound (US):Ultrasound (US): US is inferior to spiral CT in the US is inferior to spiral CT in the demonstration of ureteral calculi in patients with renal demonstration of ureteral calculi in patients with renal colic. US should be limited to the situation where CT colic. US should be limited to the situation where CT scan is not available or contra-indicated. scan is not available or contra-indicated.

Uroscanner / Ultrasound ?Uroscanner / Ultrasound ?

o Uroscanner CTUroscanner CT allows a rapid, contrast- allows a rapid, contrast-medium-free, anatomically accurate medium-free, anatomically accurate diagnosis of urinary tract calculi and has a diagnosis of urinary tract calculi and has a sensitivity of 98% and a specificity of 97%. sensitivity of 98% and a specificity of 97%. CT provides an alternative diagnosis in 6% CT provides an alternative diagnosis in 6% of patients. Helical CT should be the first of patients. Helical CT should be the first choice in imaging a patient with renal colic. choice in imaging a patient with renal colic.

o If this technique is not available or contra-If this technique is not available or contra-indicated (eg: pregnant women), indicated (eg: pregnant women), ultrasonography should be considered.ultrasonography should be considered.

Initial treatment in A&EInitial treatment in A&E VoltarenVoltaren (Diclofenac) (Diclofenac) 75 mg75 mg intravenous (unless intravenous (unless

contraindication ofcontraindication of non-steroidal anti-inflammatory drug non-steroidal anti-inflammatory drug

NSAID like pregnant women 3NSAID like pregnant women 3rdrd trimestre or renal failure) trimestre or renal failure)

Consider an opioid Consider an opioid (for example morphine) (for example morphine) if diclofenac if diclofenac

is not suitable or is insufficient to control the pain:is not suitable or is insufficient to control the pain:

MorphineMorphine 2 to 3 mg intravenous injection (IV) bolus 2 to 3 mg intravenous injection (IV) bolus

following Morphin titration protocole (up to a cumulative following Morphin titration protocole (up to a cumulative

dose 10 mg if pain is not relieved after the first bolus). dose 10 mg if pain is not relieved after the first bolus).

ParacetamolParacetamol IV or an antispasmodic drug like IV or an antispasmodic drug like SpasfonSpasfon

can also be prescribed in association with Voltarencan also be prescribed in association with Voltaren

If complications > If complications > Hospitalization Hospitalization

o They are in shock or have They are in shock or have fever or signs of systemic infectionfever or signs of systemic infection (which can lead to life-threatening sepsis).(which can lead to life-threatening sepsis).

They are at increased risk from They are at increased risk from loss of renal functionloss of renal function (and (and require emergency imaging and drainage to prevent irreversible require emergency imaging and drainage to prevent irreversible loss of renal function): Solitary or transplanted kidney, Pre-loss of renal function): Solitary or transplanted kidney, Pre-existing renal impairment, Bilateral obstructing stones are existing renal impairment, Bilateral obstructing stones are suspected.suspected.

They do They do not respond to appropriate analgesicnot respond to appropriate analgesic and anti-emetic and anti-emetic treatment within 1 hour treatment within 1 hour

They have They have abrupt recurrence of severe painabrupt recurrence of severe pain despite initial despite initial analgesia (analgesia (Consider admission if pain is persisting beyond 24 Consider admission if pain is persisting beyond 24 hourshours))

They are dehydrated and They are dehydrated and cannot take oral fluids due to cannot take oral fluids due to vomitingvomiting — they require intravenous fluids. — they require intravenous fluids.

There is There is uncertainty regarding the diagnosisuncertainty regarding the diagnosis (for example if a (for example if a leaking abdominal aortic aneurysm cannot be excluded).leaking abdominal aortic aneurysm cannot be excluded).

Pregnant women.Pregnant women. Patient Patient more than 60 years with chronic diseasesmore than 60 years with chronic diseases / Patient / Patient

preference for admission.preference for admission. Contact by telephone is not possible or no reliable social Contact by telephone is not possible or no reliable social

support.support.

No complication > No complication > DischargeDischarge

o Give patient the prescription with Non-Give patient the prescription with Non-

Steroidal Anti-inflammatory drugs and Steroidal Anti-inflammatory drugs and

painkillers by mouth: painkillers by mouth: Voltaren 75mg x 2 + Voltaren 75mg x 2 +

Efferalgan Codein 2 tab x 3Efferalgan Codein 2 tab x 3 Advise the person to contact Advise the person to contact A&E on-dutyA&E on-duty

doctor if there is an abrupt recurrence of doctor if there is an abrupt recurrence of

severesevere painpain or sign of seriousness like fever, or sign of seriousness like fever,

shiver, vomiting++ (food of drink intolerance) shiver, vomiting++ (food of drink intolerance)

> come back in emergency to A&E.> come back in emergency to A&E. Offer referralOffer referral to urologist in OPD to urologist in OPD so that so that

investigations can be carried out withininvestigations can be carried out within 3 3 days. days.

Prognostic Prognostic

Most symptomatic renal stones are small Most symptomatic renal stones are small (less (less than 5 mm in diameterthan 5 mm in diameter) and pass) and pass spontaneously.spontaneously. Spontaneous passage is less likely for larger Spontaneous passage is less likely for larger stones:stones:

Stones less than Stones less than 5 mm5 mm in diameter pass in diameter pass spontaneously in up to 80% of people.spontaneously in up to 80% of people.

Stones between Stones between 5 mm and 10 mm5 mm and 10 mm in in diameter pass spontaneously in about 50% ofdiameter pass spontaneously in about 50% of people.people.

Stones larger than Stones larger than 1 cm1 cm in diameter usually in diameter usually require intervention require intervention (urgent intervention is(urgent intervention is required required if complete obstruction or infection is present).if complete obstruction or infection is present).

Urological expertise if Urological expertise if complication:complication:

Renal colic with feverRenal colic with fever Rupture of urinary tract (CT scanner)Rupture of urinary tract (CT scanner) Obstructive renal insufficiency (unique Obstructive renal insufficiency (unique

kidney or bilateral migration of calculi) kidney or bilateral migration of calculi) Hyperalgic renal colic (not responding to Hyperalgic renal colic (not responding to

initial treatment NIAS + Morphin)initial treatment NIAS + Morphin)

Urological expertise if Urological expertise if particular context:particular context:

Chronic Renal failure or pre-existing Chronic Renal failure or pre-existing

uropathyuropathy

Single kidney (anatomical or fonctionnal)Single kidney (anatomical or fonctionnal)

PregnancyPregnancy

Bilateral stone migrationBilateral stone migration

Calculi > 6mmCalculi > 6mm

Probability of spontaneous Probability of spontaneous elimination of the stoneelimination of the stone

Look for complications / risk factors > admission in hospital

o Fever or sign of sepsis (CRP, WBC, BU) > start antibiotics after ECBUo Severe pain despite initial treatment (after 1 hour)o Recurrence of severe pain within 24hourso Risk of loss of renal function* / anuriao Risk of dehydration due to drink and food intolerance (vomiting++)o Stone more than 6mmo Pregnant womeno Patient lives far from an hospital, social isolationo Patient > 60 years with chronic diseases / Patient preference for admission

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)

Suspicion of renal colic:o Loin pain / Back paino On & Off evolutiono Past history of kidney stone

Confirmation by Imaging:

1. Uroscanner (without contrast)2 Ultrasound (if CT contra-indicated)

YESYES NONO

Management of renal colicManagement of renal colic(ASP + Echography)(ASP + Echography)

Management of renal colic in Management of renal colic in A&EA&E

(Uro-scanner)(Uro-scanner)