Renal colic

Question 1

A 65 year old man presents to the Emergency Department with a twenty four hour history of right loin to groin colicky pain and intermittent fevers. His BP is 120/72 mmHg, PR 64/min and T 38.4°C. Can you outline your management plan?

Answer 1

Impression
My impression is for this stem given the classical clinical with loin-to-groin colicky pain, Provisionally I think this is renal colic (nephrolithiasis). Given the man does have an elevated temperature, I would also be concerned about a superimposed urosepsis/pyelonephritis as with urinary stasis this man is at increased risk for infection. This would comprise a medical emergency demanding immediate management. However, nice

Fever is uncomplicated in common nephrolithiasis.

DDx

• Renal: other causes of obstruction (intraluminal, intramural, extramural) RCC (rare to cause pain).
• Testicular: torsion, epididymitis
• GI: appendicitis, diverticulitis, bowel obstruction
• Gynae causes in female.

Goals

• Call for help, assess patient for HD instability with sepsis, and initiate emergent management of urosepsis/pyelonephritis if indicated
• Full septic work-up, assess size of likely ureteric stone, decide on conservative vs surgical management for stone removal, manage pain symptoms appropriately in meantime.

Question 2

Renal colic - Assessment

Answer 2

Assessment

• call for senior input
• conduct A to E assessment, assess for HD instability, institute appropriate resus/temporising measure in the immediate term
• likely HD stable given normal vitals in stem, just need to keep high index of suspicion regarding this elevated temperature and investigate thoroughly

Question 3

Renal Colic - History

Answer 3

History

• Sx: pain, onset, duration, nature, location. Infective sx (fevers, sweats, rigors, tachy, palps, etc)
• HPI: had before? renal disease, fluid intake (low = risk factor),
• PMHx, PSHx, fam Hx, meds, allergies, SNAP, last meal

Question 4

Renal colic - Examination

Answer 4

Examination

• General appearance + vitals
• Abdominal exam: exquisite renal angle tenderness, focal tenderness. nil massess
• systems review for evidence of systemic infection

Question 5

Renal colic - Investigations

Answer 5

Investigations
Key/diagnostic
- KUB Xray, CT-KUB, renal tract US (for pyelonephritis and obstruction)
- septic workup (blood cultures, urine, sputum, etc)

• bedside: UA, Urine MCS, VBG (lactate for ?sepsis)
• bloods: FBC, UEC, LFT + lipase, CRP/ESR, pre-ops, CMP + uric acid,
• Imaging: as above

Question 6

Renal colic - Management

Answer 6

Management
- Consult urology

For pyelonephritis/urosepsis

• PO Augmentic if non-severe, then with directed ABx
• IV gent + amp if severe (ceftriaxone if gent CI)

For nephrolithiasis
- Urology consult
Definitive mx depends on the size of the stone. <5mm can be passed with analgesia and medical therapy, or smooth muscle relaxers (alpha blockers - tamsulosin, or CCBs - nifedipine) to speed up the passage of the stone.
- can be managed as an outpatient if tolerative fluids

If not able to be passed with non-surgical mx

• shock wave lithotripsy
• ureteroscopy + lithotripsy, +/- ureteric stenting
• percutaneous lithotomy (stones >20mm)
• laparoscopic stone removal

Ongoing mx depending on the type of stone;

• Calcium: reduce animal protein, reduce salt intake
• Urate: allopurinol, avoid red meats
• Mx of other comorbidites: diabetes, obesity,