Renal and Biliary Colic
Andrew Worster
Rahim Valani
Renal Colic
Renal colic occurs when calculi are formed in the renal collecting system.
Risk factors include family history, bowel disease, increased sodium or oxalate intake, dietary habits, gout, obesity, immobilization, and low urine output.
The urinary tract migration of calculi causes local tissue irritation, bleeding and increased tension to the ureteral wall, and submucosal edema.
These factors cause local prostaglandin secretion that, in turn, causes smooth muscle spasm and vasodilatation.
The latter that causes diuresis, which again increases the tension to the ureteral wall and renal pelvis. As the stone migrates through the urinary tract, the character and location of the pain may change from muscle spasm-type flank pain to ipsilateral groin and genital discomfort and symptoms of cystitis.
If the stone is large enough, it will cause partial or complete obstruction of the ureter and, eventually, urinary tract and renal capsule distension (hydronephrosis).
In the industrialized world, urolithiasis typically affects young, healthy adults.
Seventy percent are between 20 and 50 years of age with a peak incidence in males at 30 years and two peaks in women at 35 and 55 years.
It also affects 1–2% of the Western pediatric population.
White populations > Black irrespective of geographical region.
Men > women in White and Asian populations.
Women > men in Black and Hispanic populations.
Diagnosis:
Urinalysis may reveal hematuria.
Computed tomography (CT) is the imaging of choice.
Advantages of CT include no intravenous contrast, visualization of radiolucent calculi, visualization of pathology outside the urinary tract, and shorter examination time.
Ultrasound (US) should be considered as the first choice for imaging test in patients with suspected ureteric colic for whom there is concern over the potentially harmful cumulative long-term effect of radiation.
US has been reported to overestimate stone size and, overall, might not be as accurate as CT although the differences between the two may not be clinically significant.
Plain radiographs of the kidneys, ureters, and bladder (KUB) have little value in the diagnosis of acute ureteric colic.
Management:
Most (70%) stones 5 mm or less in diameter and half of those from 5.1 to 10.1 mm can be expected to pass spontaneously.
The length of time from symptom onset to spontaneous stone passage can vary from hours to days and patients may remain symptomatic throughout.
Extracorporeal shock wave lithotripsy (ESWL) and observation with analgesia with or without adjuvant medications to facilitate stone passage, that is, medical expulsive therapy (MET) are the noninvasive management options for patients with a newly diagnosed ureteral stone smaller than 10 mm diameter.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac and cyclooxygenase-2 (COX-2) inhibitors, which interfere with prostaglandin synthesis and release can reduce the associated pain of acute ureteric colic by blocking the mechanism of action.
Opioids have long served as the analgesic of choice by these patients and their attending emergency physicians.
The combination of opioids and NSAIDs has been found to have an additive analgesic effect greater than either medication alone.
Calcium channel blockers, alpha-adrenergic blockers, beta-adrenergic blockers, prostaglandin-synthesis inhibitors, glyceryl trinitrate, and steroids have all been used as MET.Related posts:
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