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AIP: Abdominal pain > Renal colic > Flashcards

Renal colic Flashcards

1
Q

In which gender and age group are renal tract stones (urolithiasis) most common?

A

males, typically <65 years

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2
Q

What are 2 locations where renal tract stones can form?

A

renal stones within kidney, or ureteric stones within ureter

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3
Q

What is the most common type of urinary tract stone?

A

80% made of calcium (calcium oxalate, calcium phosphate or mixed oxalate and phosphate)

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4
Q

What are the 3 types of calcium renal tract stones that form 80% of all stones?

A
  1. Calcium oxalate- 35%
  2. Calcium phosphate - 10%
  3. Mixed oxalate and phosphate - 35%
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5
Q

What are 4 types of renal tract stones?

A
  1. Calcium stones (oxalate, phosphate or mixed)
  2. Struvite stones (magnesium ammonium phosphate)
  3. Urate stones
  4. Cystine stones
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6
Q

Which type of renal tract stone are large and soft and most commonly cause ‘staghorn calculi’?

A

struvite stones (magnesium ammonium phosphate)

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7
Q

What is the only type of radiolucent renal tract stone?

A

urate stones

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8
Q

What are cystine stones usually associated with?

A

typically homocystinuria, an inherited defect that affects absorption and transport of cystine in the bowel and kidneys

as citrate is a stone inhibitor, hypocitraturia from the condition can predispose affected indivudals to recurrent stone formation

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9
Q

What is shown in the plain film abdominal radiograph?

A

large staghorn calculus

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10
Q

What is the overall basis for the pathophysiology of renal tract stones?

A

over-saturation of urine

certain stone types that form may also be caused by a specific underlying pathology

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11
Q

What leads to the formation of urate stones?

A

high levels of purine in the blood, either from diet (e.g. red meats) or through haematological disorders (such as myeloprliferative disease)

results in increase of urate formation and subsequent crystallisation in the urine

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12
Q

For stones that enter the drainage system of the urinary tract, where are stones likely to impact? 3 points

A

3 natural narrowed points where lkely to impact:

  1. Pelvi-ureteric junction (PUJ) where the renal pelvis becomes the ureter
  2. Crossing the pelvic brim, where the iliac vessels travel across the ureter in the pelvis
  3. Vesicoureteric junction (VUJ), where the ureter enters the bladder
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13
Q

What is the pelvic brim?

A

point where iliac vessels travel across ureter in the pelvis

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14
Q

What are 5 clinical features of renal tract stones?

A
  1. Sudden onset, severe ureteric colic (pain)
  2. Nausea and vomiting
  3. Haematuria - typically non-visible
  4. Tenderness in affected flank on examination
  5. Signs of dehydration - due to vomiting
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15
Q

What is the nature of the pain with renal tract stones?

A

occurs from increased peristalsis from around site of obstruction

sudden onset, severe, radiating from flank to pelvis (loin to groin)

often associated with nausea and vomiting

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16
Q

In what proportion of cases of renal tract stones does haematuria occur?

A

90% of cases

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17
Q

When assessing urine for haematuria in renal tract stones, what else should you assess for?

A

signs of concurrent infection - symptoms such as rigors, fevers, lethargy

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18
Q

What are 5 investigations to perform in suspected cases of renal tract stones?

A
  1. Urine dip: microscopic haematuria, evidence of infection (always ensure to send a urine culture as well in such cases)
  2. Blood tests: FBC, CRP, U+Es, urate + calcium levels
  3. If pass stone in urine - retrieval of stone and send for analysis
  4. Imaging: gold standard = non-contrast CT-KUB
  5. Ultrasound scans of renal tract to assess for hydronephrosis - sometimes performed
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19
Q

What should always be done if there is evidence of infection on the urine dip?

A

send a urine culture

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20
Q

What are 5 blood tests to take in suspected renal tract stones?

A
  1. FBC
  2. CRP
  3. U+Es
  4. Calcium levels
  5. Urate levels
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21
Q

What is the gold standard investigation for diagnosis of renal stones?

A

non-contrast CT scan of renal tract (KUB)

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22
Q

What are the advantages of performing CT-KUB to diagnose renal tract stones?

A

high sensitivity and specificity to identify stone disease, as well as concurrent assessment of any alternative pathology

23
Q

What is the disadvantage of performing plain film abdominal radiographs (AXR) i.e. intravenous urograms in suspected renal tract stones?

A

not all stones are radio-opaque so limits their use

plus high radiation exposure

24
Q

What are intravenous urograms?

A

take seriousof abdominal x-rays following injection of contrast, to demonstrate any filling defect (but rarely used)

25
Q

What is the initial management of patients with renal tract stones?

A
  • adequate fluid resuscitation if required
  • analgesia - opiates analgesia and NSAIDs per rectum
  • evidence of significant infection/sepsis - IV antibiotic therapy, urgent referral to urology
  • usually pass spontaneously without further intervention
26
Q

What are 2 factors that favour spontaneous passing of renal stones?

A
  1. Stones in the lower ureter
  2. Stones <5mm in diameter
27
Q

What are the 2 most effective options for analgesia in renal tract stones?

A
  1. Opiates
  2. PR NSAIDs (diclofenac/ indomethacin)

can also give IV paracetamol

28
Q

What is the imaging modality of choice for renal tract stones in pregnant women?

A

ultrasound

29
Q

What is medical expulsive therapy for renal tract stones?

A

use of an alpha-blocker e.g. tamsulosin to facilitate spontaneous stone passage during the observation period

30
Q

When are alpha receptor antagonists (e.g. tamsulosin) used for renal tract stones?

A

said to large have limited benefit, but NICE says use if distal ureteric stones <10mm

31
Q

What are 4 examples of criteria that warrant the need for hospital admission for renal tract stones?

A
  1. Post-obstructive acute kidney injury
  2. Uncontrollable pain from simple analgesics
  3. Evidence of an infected stone(s)
  4. Large stones (>5mm)
32
Q

What are the 2 non-definitive surgical options for patients with obstructive nephrophathy or significant infection from renal tract stones?

A
  1. Retrograde stent insertion
  2. Nephrostomy
33
Q

When is non-definitive surgical intervention to prevent renal damage in kidney stones warranted?

A

in obstructive nephropathy or significant infection, to temporarily relieve obstruction prior to definitive management

34
Q

How does retrograde stent insertion work to prevent renal damage in renal tract stones?

A

placement of a stent within the ureter, approaching from distal to proximal via cystoscopy

keeps ureter patent and temporarily relieves obstruction

35
Q

How does nephrostomy work to temporarily relieve obstruction in renal tract stones?

A

tube placed directly into the renal pelvis and collecting system, relieving the obstruction proximally

anterograde stent can subsequent be pased via the same tract made

36
Q

When is definitive surgical management indicated for renal tract stones?

A

within 48 hours of diagnosis or readmission if pain ongoing and not tolerated, or stone unlikely to pass spontaneously

37
Q

What are 5 considerations for the type of definitive surgery chosen for renal tract stone treatment?

A
  1. Age of patient
  2. Size of stone
  3. Contraindications
  4. If previous procedure has failed in past
  5. Anatomical considerations
38
Q

What are 3 key options for definitive surgical management of renal tract stones?

A
  1. Extracorporeal shock wave lithotripsy (ESWL)
  2. Percutaneous nephrolithotomy (PCNL)
  3. Flexible uretero-renoscopy (URS)
39
Q

What does extracorporeal shock wave lithotripsy (ESWL) involve?

A

targeted sonic waves break up stone to then be passed spontaneously

performed via radiological guidance - x-ray or USS

40
Q

Which type of renal tract stones is extracorporeal shock wave lithotripsy (ESWL) typically used for?

A

small stones (<2cm)

41
Q

What are 2 contraindications to extracorporeal shock wave lithotripsy (ESWL)?

A
  1. Pregnancy
  2. Stone positioned over bony landmark e.g. pelvis
42
Q

Which type of renal tract stones is percutaneous nephrolithotomy used for?

A

renal stones only - preferred method for large renal stones, including stahorn calculi (usually struvite stones)

43
Q

What does percutaneous nephrolithotomy (PCNL) involve?

A

percutaneous access to the kidney is performed, with nephroscope passed into the renal pelvis

stones can then be fragmented using various forms of lithotripsy

44
Q

What does flexible uretero-renoscopy (URS) involve?

A

passing scope retrograde up into the ureter allowing stones to be fragmented through laser lithotripsy and fragments subsequently removed

45
Q

What are the 2 key complications of renal tract stones?

A
  1. Infection
  2. Post-renal acute kidney injury
46
Q

What is the risk of recurrent renal stones?

A

can lead to scarring and loss of kidney function

47
Q

What is the general management of recurrent stone formers? 4 aspects

A
  1. Specialised management
  2. Underlying cause identified and managed
  3. Advise to stay hydrates
  4. Ensure serum urate and calcium levels checked if patient unable to retrieve any passed stones
48
Q

What are 4 examples of specific management options depending on the underlying stone composition for recurrent stone formers?

A
  1. Oxalate: avoid high purine foods and high oxalate foods (nuts, rhubarb, sesame)
  2. Calcium: check PTH levels to exclude primary hyperparathyroidism, avoid excess salt
  3. Urate: avoid high purine foods (red meat, shellfish), consider for urate-lowering meds e.g. allopurinol
  4. Cystine: genetic testing for underlying familial disease
49
Q

What is typically the cause of bladder stones?

A

typically form from urine stasis within the bladder - commonly seen in chronic urine retention

50
Q

What are 3 things that bladder stones can occur secondary to?

A
  1. Chronic urinary retention
  2. Infections, classically schistosomiasis
  3. Passed ureteric stones
51
Q

How do bladder stones typically present?

A

lower urinary tract symptoms

52
Q

What is the definitive management of bladder stones?

A

cystoscopy - allowing stones to drain or fragmenting them through lithotrispy if required

53
Q

What can happen if the underlying cause of baldder stones is not addressed?

A

can often recur - chronic irritation of bladder epithelium can predispose to development of squamous cell carcinoma bladder cancer

AIP: Abdominal pain (20 decks)

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