Renal Calculi

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Author

Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Carolinas Medical Center

Nothing to disclose.

Specialty Editor(s)

David S Howes, MD, Professor of Medicine and Pediatrics, Section Chief and Residency Program Director, Emergency Medicine, University of Chicago/Pritzker School of Medicine

Nothing to disclose.

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine

eMedicine Salary Employment

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

Nothing to disclose.

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Nothing to disclose.

Background

Acute passage of a kidney stone from the renal pelvis through the ureter gives rise to pain at times so excruciating that it has been likened to the discomfort of childbirth. The often sudden, extremely painful episode of renal colic prompts more than 450,000 visits to EDs annually and places emergency physicians on the front line of management of acute nephrolithiasis. ED management is focused on excluding other serious diagnoses and providing adequate pain relief.

Pathophysiology

Most calculi arise in the kidney when urine becomes supersaturated with a salt that is capable of forming solid crystals. Symptoms arise as these calculi become impacted within the ureter as they pass toward the urinary bladder.

Epidemiology

Frequency

United States

The lifetime prevalence of nephrolithiasis is approximately 12% for men and 7% for women in the United States, and it is rising. Recurrence rates after the first stone episode are 14%, 35%, and 52% at 1, 5, and 10 years, respectively. An increased incidence has been noted in the southeastern United States, prompting the term "stone belt" for this region of the country.[1]

International

Nephrolithiasis occurs in all parts of the world, with a lower lifetime risk of 2-5% in Asia, 8-15% in the West, and 20% in Saudi Arabia.

Mortality/Morbidity

Race

Sex

Age

Peak onset of symptomatic nephrolithiasis is in the third and fourth decades of life.

History

Most calculi originate within the kidney and proceed distally, creating various degrees of urinary obstruction as they become lodged in narrow areas, including the ureteropelvic junction, pelvic brim, and ureterovesical junction. Location and quality of pain are related to position of the stone within the urinary tract. Severity of pain is related to the degree of obstruction, presence of ureteral spasm, and presence of any associated infection.

Physical

The classic patient with renal colic is writhing in pain, pacing about, and unable to lie still, in contrast to a patient with peritoneal irritation, who remains motionless to minimize discomfort.

Causes

The formation of the 4 basic chemical types of renal calculi is associated with more than 20 underlying etiologies. Stone analysis, together with serum and 24-hour urine metabolic evaluation, can identify an etiology in more than 95% of patients. Specific therapy can result in a remission rate of more than 80% and can decrease the individual recurrence rate by 90%. Therefore, emergency physicians should stress the importance of urologic follow-up, especially in patients with recurrent stones, solitary kidneys, or previous kidney or stone surgery and in all children.[2]

Laboratory Studies

Imaging Studies

Procedures

Emergency Department Care

Consultations

Medication Summary

Pain of renal colic is mediated locally primarily by prostaglandin E2. Ureteral obstruction stimulates synthesis of prostaglandin E2 in the renal medulla, which increases ureteral contractility and renal blood flow, leading to increased ureteral pressures and painful renal colic.

Class Summary

These agents act at the CNS mu receptors and are the standard of care for treatment of renal colic. They are inexpensive and proven effective. Disadvantages include sedation, respiratory depression, smooth muscle spasm, and potential for abuse and addiction.

Butorphanol (Stadol)

Clinical Context:  Mixed agonist-antagonist narcotic with central analgesic effects for moderately severe to severe pain. Causes less smooth muscle spasm and respiratory depression than morphine or meperidine. Weigh these advantages against increased cost of butorphanol.

Class Summary

These agents inhibit synthesis of prostaglandin E2 and are at least as effective as narcotic analgesics in numerous randomized controlled trials. NSAIDs cause less nausea and less sedation than narcotic analgesics, do not cause respiratory depression, and have no abuse potential. Principal disadvantage is cost. Potential adverse effects on renal function, GI mucosa, and platelet aggregation do not appear clinically important when used for short-term pain relief.

Ketorolac (Toradol)

Clinical Context:  Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases formation of prostaglandin precursors. Only NSAID approved for IV or IM use in adults in United States. Single IM dose of 30 mg provides pain relief comparable to meperidine 100 mg IM with fewer adverse effects. Also can be administered IV. Onset of analgesic action is evident within 10 min of IM administration. Efficacy of PO formulation for outpatient treatment of renal colic has not yet been studied.

Ketorolac intranasal (Sprix)

Clinical Context:  NSAID; inhibits cyclooxygenase (COX), an early component of the arachidonic acid cascade, resulting in reduced synthesis of prostaglandins, thromboxanes, and prostacyclin. Elicits anti-inflammatory, analgesic, and antipyretic effects. Indicated for short-term (up to 5 d) management of moderate to moderately severe pain. Bioavailability of 31.5-mg intranasal dose (2 sprays) is approximately 60% of 30-mg IM dose. Intranasal spray delivers 15.75 mg per 100-μ L spray; each 1.7-g bottle contains 8 sprays.

Class Summary

Patients with acute renal colic frequently experience intense nausea and/or vomiting. Effective pain control often is accompanied by resolution of nausea and vomiting, but some patients may require antiemetics in addition to analgesics. Various antiemetic medications are used, including phenothiazines and butyrophenones.

Metoclopramide (Reglan)

Clinical Context:  Only antiemetic that has been studied specifically in treatment of renal colic. In 2 small double-blinded studies, provided relief of nausea and pain relief equal to that of narcotic analgesics.

Antiemetic effect due to blockade of dopaminergic receptors in chemoreceptor trigger zone in CNS. Does not possess antipsychotic or tranquilizing activity and is less sedating than other central dopamine antagonists. Onset of action is 1-3 min after IV injection and 10-15 min after IM injection.

Class Summary

Infected hydronephrosis mandates IV antibiotic therapy in addition to urgent drainage via percutaneous nephrostomy or urethral stent placement. Aerobic gram-negative enteric organisms, including E coli and Klebsiella, Proteus, Enterobacter, and Citrobacter species, are typical pathogens. Enterococcal infection occasionally is seen in patients recently on antibiotics. Candida albicans sometimes is responsible in diabetic or immunosuppressed patients. Initial empiric antibiotic therapy should cover common bacterial pathogens.

Ampicillin (Omnipen) plus gentamicin (Garamycin)

Clinical Context:  Ampicillin is beta-lactam aminopenicillin antibiotic. Non–penicillinase-producing staphylococci and most streptococci are susceptible. Ampicillin is effective against E coli and Proteus and Enterococcus species, but most Klebsiella, Serratia, Acinetobacter, indole-positive Proteus, and Pseudomonas species and Bacteroides fragilis are resistant.

Gentamicin is aminoglycoside antibiotic, which is active against Staphylococcus aureus and Enterobacteriaceae organisms including E coli and Proteus, Klebsiella, Serratia, Enterobacter, and Citrobacter species. Pseudomonas aeruginosa is usually sensitive, although its sensitivity varies somewhat. When used in combination with ampicillin, gentamicin also effective against Enterococcus faecalis.

Ticarcillin and clavulanic acid (Timentin)

Clinical Context:  Ticarcillin is extended-spectrum penicillin, beta-lactam antibiotic. Clavulanic acid is beta-lactamase inhibitor that, in combination with ticarcillin, extends spectrum of ticarcillin to include many beta-lactamase–producing bacteria.

Timentin active against most staphylococci and streptococci and gram-negative organisms including E coli, Morganella morganii, Proteus mirabilis, Proteus vulgaris, Neisseria gonorrhoeae, and Pseudomonas and Providencia species. Anaerobic spectrum includes Peptococcus and Peptostreptococcus species, Clostridium perfringens, Clostridium tetani, and Bacteroides species, including many strains of B fragilis. Timentin not effective against Enterococcus species or methicillin-resistant staphylococci.

Timentin excreted via urinary tract.

Ciprofloxacin (Cipro)

Clinical Context:  Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and Streptococcus pneumoniae. Not effective against anaerobes. Variably effective against E faecalis, though ampicillin and gentamicin likely to be more effective.

Levofloxacin (Levaquin)

Clinical Context:  Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and S pneumoniae. Not effective against anaerobes. Variably effective against E faecalis, though ampicillin and gentamicin likely to be more effective.

Ofloxacin (Floxin)

Clinical Context:  Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and S pneumoniae.

Not effective against anaerobes. Variably effective against E faecalis, though ampicillin and gentamicin likely to be more effective.

Class Summary

These agents are strong anti-inflammatory drugs that reduce ureteral inflammation. They also have profound metabolic and immunosuppressive effects.

Prednisolone (Econopred, Pediapred, Delta-Cortef, Articulose-50, AK-Pred)

Clinical Context:  In combination with nifedipine or tamsulosin, proven to facilitate spontaneous passage of a ureteral stone in several small prospective studies. Only a short course of therapy (5-10 d) should be administered.

Class Summary

These agents are smooth muscle relaxants that, in combination with prednisolone, facilitate ureteral stone passage in several small prospective studies.

Nifedipine (Procardia)

Clinical Context:  Sustained-release (SR) formulation simplifies treatment and encourages compliance. Only short-term therapy (5-10 d) should be considered for this indication.

Class Summary

These agents promote smooth muscle relaxation and, in combination with prednisolone, facilitate spontaneous passage of a ureteral stone.

Tamsulosin (Flomax)

Clinical Context:  Alpha-adrenergic blocker specifically targeted to alpha1-receptors. Has advantage of relatively less orthostatic hypotension and requires no gradual up-titration from initial introductory dosage. Inhibits postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles and decrease in total peripheral resistance and blood pressure. Improves irritative and obstructive voiding symptoms. Only short-term therapy (5-10 d) should be considered for this indication.

Further Inpatient Care

Further Outpatient Care

Inpatient & Outpatient Medications

Deterrence/Prevention

Complications

Prognosis

References

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Noncontrast helical CT scan of the abdomen demonstrating a stone at the right ureterovesical junction.

Intravenous pyelogram (IVP) demonstrating dilation of the right renal collecting system and right ureter consistent with right ureterovesical stone.

Renal sonogram showing a dilated renal collecting system consistent with ureteral obstruction.

Transabdominal sonogram revealing a ureteral stone at the ureterovesical junction.