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Renal Colic

Renal colic is an acute, severe pain commonly caused by nephrolithiasis.


Presentation

The clinical presentation is highly variable. Most patients with renal stone disease are asymptomatic, whereas others present with pain, hematuria, urinary tract infection (UTI) or urinary tract obstruction. A common presentation is acute loin pain radiating to the anterior abdominal wall, together with hematuria, termed as renal colic. This is most commonly caused by ureteric obstruction by a calculus but the same symptom can occur in association with sloughed renal papilla, tumor or blood clot. The patient is suddenly aware of pain in the loin which radiates round the flank to the groin and often into the testes or labium in the sensory distribution of the first lumbar nerve. The pain steadily increases in intensity to reach the peak in a few minutes. The patient is restless and tries unsuccessfully to obtain relief by changing position or pacing the room. There is pallor, sweating and often vomiting. Frequency, dysuria and hematuria may occur. The intense pain usually subsides within 2 hours but may continue unabated for hours or days. It is usually constant during attacks, although slight fluctuation in severity may be seen. Intermittent dull pain in the loin or back may persist for several hours following the attack of renal colic. Other symptoms that may be present include fever with rigors and chills, urinary retention, abdominal bloating, loss of appetite and abnormally colored urine.

Severe Pain
  • In both groups, the severity of the pain was graded between 0 (no pain) and 10 (severe pain) by using the visual analogue scale (VAS).[ncbi.nlm.nih.gov]
  • Symptoms An extremely severe pain is felt suddenly, originating at the lumbar and moving towards the genitals. One side is affected and the pain often radiates to the flank, genitals and inner thigh.[health.ccm.net]
  • In renal colic there is generally severe pain leading from the kidneys down through the abdomen and groin.[britannica.com]
  • BACKGROUND: Renal colic is typically characterized by the sudden onset of severe pain radiating from the flank to the groin and its acute management in emergency departments essentially aims at rapid pain relief.[ncbi.nlm.nih.gov]
  • Kidney stones can cause severe pain when it passes into the ureter. This pain is referred to by doctors as renal colic. Renal colic is caused by distension of the kidney because of the blockage of urine flow down the ureter.[melbourneurologist.com.au]
Malingering
  • RESULTS: We identified 12 patients who presented with renal colic and had a final diagnosis of Munchausen's syndrome or malingering. The incidence of factitious renal colic was 0.6%.[ncbi.nlm.nih.gov]
Soft Tissue Mass
  • CT-KUB revealed a soft tissue mass at the left vesico-ureteric junction. Flexible cystoscopy demonstrated a mass intruding into the posterior bladder.[ncbi.nlm.nih.gov]
Colic
  • , associated conditions for Renal colic, risk factors for Renal colic, or other related conditions.[cureresearch.com]
  • Adult randomized controlled trial evidence supports using POCUS as the initial approach to imaging and management of suspected renal colic. However, there remain limited data on POCUS in children for renal colic.[ncbi.nlm.nih.gov]
  • Convert to ICD-10-CM : 788.0 converts directly to: 2015/16 ICD-10-CM N23 Unspecified renal colic Approximate Synonyms Renal colic (pain from kidney stone) Ureteral colic Ureteric colic Applies To Colic (recurrent) of: kidney ureter ICD-9-CM Volume 2 Index[icd9data.com]
  • The primary outcome was daily number of renal colic emergency department admissions. A distributed lag nonlinear model with 21 days of lag was applied to estimate the cumulative effect of temperature on colic admissions.[ncbi.nlm.nih.gov]
  • CONCLUSION: This small sample suggests that in younger patients with uncomplicated renal colic, the benefit of immediate CT for suspected renal colic should be questioned.[ncbi.nlm.nih.gov]
Vomiting
  • Opioids are associated with a higher incidence of adverse events, particularly vomiting.[ncbi.nlm.nih.gov]
  • Abstract Intravenously administered ketorolac tromethamine provided complete pain relief to a 54-year-old man with right-sided testicular pain and nausea and vomiting. The patient had a ureteral calculus documented by computed tomography.[ncbi.nlm.nih.gov]
  • Pain in the small of the back Lower abdominal pain Genital pain Inner thigh pain Other commonly associated symptoms include: Nausea Vomiting Swollen abdomen Fever Chills Blood in urine See also symptoms of urinary stones More symptoms of Renal colic:[cureresearch.com]
  • Vomiting is also considered an important adverse effect of opioids, mainly with pethidine. Oral narcotic medications are also often used.[en.wikipedia.org]
  • The pain is often described as the worst pain the patient has ever experienced and may be associated with nausea, vomiting, hypertension and haematuria.[doi.org]
Nausea
  • CONCLUSIONS: Using lidocaine may be recommended as an effective, safe, and inexpensive adjuvant to morphine in improving nausea and reducing the time needed to achieve pain and nausea relief in patients visiting the ED with acute RC.[ncbi.nlm.nih.gov]
  • Abstract Intravenously administered ketorolac tromethamine provided complete pain relief to a 54-year-old man with right-sided testicular pain and nausea and vomiting. The patient had a ureteral calculus documented by computed tomography.[ncbi.nlm.nih.gov]
  • Appendicitis caused more often nausea (81 vs 11%), fever and localized pain in the McBurney (97 vs 59%) than renal colic. The patients with ureteral stone had tenderness in 16% in the right lower quadrant.[ncbi.nlm.nih.gov]
  • According to these results, male sex, presence of microscopic hematuria, stone history in the family, nausea and emesis in addition to pain and accompanying urinary symptoms were detected as predictive factors in diagnosing urinary stone disease by multivariate[ncbi.nlm.nih.gov]
  • Median age 47 years vs 49 years, males 76.4% vs 66.5% and medianSex, Timing, Origin, Nausea, Erythrocytes (STONE) score 10 vs 10 for Monash and Dandenong, respectively.[ncbi.nlm.nih.gov]
Abdominal Pain
  • METHODS: A total of 215 patients who presented with abdominal pain and who were histopathologically diagnosed as AA, and 200 patients who presented with abdominal pain and who were diagnosed as renal colic were included into the study.[ncbi.nlm.nih.gov]
  • Abstract Renal colic can be a challenging cause of abdominal pain in the military population. This review highlights the management of renal colic in the Royal Navy's operational setting.[ncbi.nlm.nih.gov]
  • The result may help in the differential diagnosis of patients with abdominal pain.[ncbi.nlm.nih.gov]
  • We retrospectively identified 491 patients in our emergency department computer database who complained of back, flank, or lower abdominal pain during 2007-2015.[ncbi.nlm.nih.gov]
  • A statement on the website continued: “Leo Messi will not be playing after waking up on Thursday morning with renal colic, a type of abdominal pain commonly caused by kidney stones.[theguardian.com]
Right Flank Pain
  • We present a case in which a male patient presented with simultaneous right flank pain and ipsilateral scrotal pain.[ncbi.nlm.nih.gov]
  • We report a patient with severe right flank pain initially diagnosed as renal colic. She was brought to our emergency department because of persistent pain. After further investigation, ovarian torsion caused by teratoma was diagnosed.[ncbi.nlm.nih.gov]
  • Abstract A 31 year old man with prosthetic aortic valve replacement presented with sudden onset of colic right flank pain. Analysis of the urine revealed haematuria, and the international normalised ratio was suboptimal.[ncbi.nlm.nih.gov]
  • Clinical Scenario A 24 year old male presents to the emergency department with sudden onset of right flank pain radiating to the groin. A clinical diagnosis of renal colic is made. However, the patient is allergic to opioids.[bestbets.org]
  • He develops waves of right flank pain associated with vomiting. One of the relatives suggests it might be food poisoning. This does not go over well with the matriarch of the family.[thesgem.com]
Hyperkeratosis
  • Her history of chronic irritation of the collecting system has resulted in keratinizing squamous metaplasia (KSM) with hyperkeratosis that has sloughed from the upper urinary tract and has become lodged in the ureter.[ncbi.nlm.nih.gov]
Back Pain
  • pain. patient history, physical exam can provide valuable clues to the cause of back pain.[newyorkurologyspecialists.com]
  • .- ) back pain ( M54.9 ) breast pain ( N64.4 ) chest pain ( R07.1- R07.9 ) ear pain ( H92.0- ) eye pain ( H57.1 ) headache ( R51 ) joint pain ( M25.5- ) limb pain ( M79.6- ) lumbar region pain ( M54.5 ) pelvic and perineal pain ( R10.2 ) shoulder pain[icd10data.com]
  • Renal colic is pain in right or left lower abdomen or low back pain due to disease in the kidney, ureter or bladder. Causes of Renal Colic . Renal stones are main reason for renal colic. .[specialityclinic.com]
  • Prevalence and clinical importance of alternative causes of symptoms using a renal colic computed tomography protocol in patients with flank or back pain and absence of pyuria. Acad Emerg Med. 2013;20(5):470-8. (Level III evidence).[imagingpathways.health.wa.gov.au]
Low Back Pain
  • Renal colic is pain in right or left lower abdomen or low back pain due to disease in the kidney, ureter or bladder. Causes of Renal Colic . Renal stones are main reason for renal colic. .[specialityclinic.com]
Flank Pain
  • Abstract The case of a patient with acute onset of flank pain and hematuria is presented. Initial therapy was directed toward relief of pain believed to be caused by renal colic.[ncbi.nlm.nih.gov]
  • We sought to examine the validity of this score in younger, noninfected flank pain patients.[ncbi.nlm.nih.gov]
  • A 25-year-old single female affected by recurrent episodes of renal colic was admitted to our institution, reporting right acute flank pain and at least two previous periods of hospitalization due to bilateral acute flank pain with no evidence of urinary[ncbi.nlm.nih.gov]
  • High clinical suspicion is necessary on an old patient who has thromboembolic risk factors with the complaint of abrupt-onset flank pain.[ncbi.nlm.nih.gov]
  • However not all the patients with flank pain really suffer for renal colic, although painful somatic irradiation refers to the same areas. CASE REPORT: A seventy years old male patient was admitted from the casualty ward for left renal colic.[ncbi.nlm.nih.gov]
Flank Pain Radiating to the Groin
  • Clinical Scenario A 24 year old male presents to the emergency department with sudden onset of right flank pain radiating to the groin. A clinical diagnosis of renal colic is made. However, the patient is allergic to opioids.[bestbets.org]
Agitation
  • The patient will become pale, anxious and agitated and no position manages to relieve the pain. Urine usually remains normal in appearance, but can sometimes contain blood.[health.ccm.net]

Workup

Patients with symptoms of renal colic should be investigated to determine the presence of the stone(s), to identify its location and to assess whether it is causing obstruction.

  • Complete blood count: White blood count may be elevated in the presence of infection.
  • 24-hour urine profile: The most common findings on 24-hour urine studies include hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia and low urinary volume.
  • X-ray KUB: It is a very good initial investigation. The KUB film shows kidney, ureter and bladder. Over 90% of stones are radio-opaque so they are visible on plain X-ray. Calcium oxalate, struvite and phosphate stones are radio-opaque whereas uric acid stones are radiolucent.
  • Ultrasonography: Majority of the stones can be diagnosed on ultrasonography.
  • Intravenous urography: Renal function tests should be normal before performing intravenous urography. It provides the anatomical detail and functional status of the entire renal tract. If the renal function is disturbed, then intravenous urography should not be performed as contrast agent can further enhance renal injury. In such patients, renal function is assessed by measuring glomerular filtration rate via a 99Tc-DTPA renal scan.
  • Non contrast enhanced helical CT KUB: This is currently the imaging modality of choice for renal tract stones. It accurately picks up almost all types of radiolucent and radio-opaque stones anywhere in the renal tract [10] [11].
  • Retrograde pyelography: It can be performed safely in patients allergic to intravenous contrast media. It shows both radiolucent and radio-opaque stones, ureteral kinks and structures that may not be visualized easily on other studies.

Since most stones pass spontaneously through the urinary tract, the urine should be sieved for a few days after an episode of colic in order to collect the calculus for analysis.

Treatment

The immediate treatment of renal colic is represented by the use of analgesia and antiemetics. Renal colic is often unbearably painful and demands powerful analgesia. Diclofenac 100mg given orally is often very effective. It can be followed by an intramuscular injection of 10-20mg morphine. There are various options for the treatment depending upon size, site and composition of the stones.

  • Observation: 90% of stones which are less than 5mm usually pass spontaneously. Analgesia, antibiotics and plenty of fluid (3litres/day) is all that are needed.
  • Medical expulsive therapy: 70% of stones which are 6-8mm in diameter can pass with medication. Tamsulosin 0.4mg given once at night, in addition to analgesics, is prescribed to ease the passage of the stone.
  • Extracorporeal shock wave lithotripsy: This is a non-surgical modality for the treatment of stones. In extracorporeal shock wave lithotripsy, the stone is focused and bombarded with shock waves of sufficient energy to disintegrate the stone into fragments. These small fragments are then passed down the ureter into bladder and then to exterior through urethra.
  • Percutaneous nephrolithotomy: The indications for this procedure include staghorn calculi, stones greater than 2.5cm in size, and failed extracorporeal shock wave lithotripsy. The stone is visualized and fragmented using ultrasonic, pneumatic or laser lithoclasts. 
  • Retrograde intrarenal surgery: This is an endoscopic modality of renal stone removal. 
  • Open surgery: The indications for open surgery include very large and complex stones occupying many calyces, morbidly obese patients and failure of previous procedures. Pyelithotomy is performed by placing the patient in lateral position via Morrison’s incision.

Prognosis

Most renal stones are small (less than 5 mm in diameter) and pass spontaneously in up to 80% of the people. A stone that has not passed within 1 to 2 months usually require intervention. The recurrence rate for urinary calculi is 50% within 5 years and 70% or higher within 10 years. The factors that predispose to recurrent stone formation include first attack before 25 years of age, single functioning kidney and abnormalities of the renal tract. Early recognition and immediate surgical drainage improves the prognosis.

Etiology

Renal colic is caused by a blockage in the urinary tract which is mainly due to stones in the kidney. When these stones interfere with the flow of urine, they cause the kidneys to swell, producing waves of colicky pain. Kidney stones that can lead to renal colic can be made up of a variety of chemicals. Calcium oxalate stones occur due to hypercalciuria and hypercalcemia which mostly occurs in primary hyperparathyroidism [1] [2] [3]. Uric acid stones occur due to gout and myeloproliferative disorders. Struvite stones are formed by infection caused by urease producing bacteria e.g. Proteus and Staphylococci [4] [5]. Various enzyme disorders can lead to the formation of cysteine and xanthine stones [6] [7].

A number of factors increase the risk of developing renal stones. These include dehydration, hot climate, low fluid intake, high protein and salt intake, diet high in vitamin A, diuretic overuse, intestinal obstruction, family history of kidney stones, use of calcium based antacids, pregnancy, recent surgery and urinary tract infection. The congenital and inherited causes of kidney stones include familial hypercalciuria, hyperoxaluria, medullary sponge kidney, cystinuria and renal tubular acidosis type 1.

Epidemiology

Renal stone disease is common, affecting individuals of all countries and ethnic groups. In the United States, the prevalence is about 1.2%, with a lifetime risk of developing a renal stone at age 60-70 of about 7% in men. In some regions, the risk is higher, most notably in countries like Saudi Arabia, where the lifetime risk of developing a renal stone in men aged 60 to 70 is over 20%. The risk of recurrence of stone formation within 1 year is 10% and within 10 years might be as high as 50%. Black people have a lower incidence of stone development compared to white people. The male to female ratio is 3:1; however, females have a higher incidence of infected hydronephrosis. Nephrolithiasis is rare in children. Approximately 5 to 10 children aged 10 months to 16 years develop kidney stones each year.

Sex distribution
Age distribution

Pathophysiology

Urinary calculi consist of aggregates of crystals, usually containing calcium or phosphate in combination with small amounts of proteins and glycoproteins. Renal stones vary greatly in size. There might be sand-like particles anywhere in the urinary tract, or large round stones in the bladder. These stones are formed by the phenomenon of supersaturation of the urine by stone-forming constituents, including calcium, oxalate and uric acid [8] [9]. The resulting calculi may lead to muscle spasm, increased proximal peristalsis, local inflammation, irritation and edema at the site of obstruction. They can contribute to the development of pain through chemoreceptor activation and stretching of submucosal free nerve endings. The severity of pain depends on the degree and site of the obstruction, not on the size of stone. Staghorn calculi fill the whole renal pelvis and branch into the calyces. They are usually associated with infection and composed largely of struvite. Deposits of calcium may be present throughout the renal parenchyma, giving rise to fine calcification within it, especially in patients with renal tubular acidosis, hyperparathyroidism, vitamin D intoxication and healed renal tuberculosis. Cortical nephrocalcinosis may occur in areas of cortical necrosis, typically after acute renal injury in pregnancy or other severe acute kidney injury. Another factor that leads to stone development is the formation of Randall’s plaques. Calcium oxalate precipitates on the basement membrane of the thin loops of Henle, resulting in Randall’s plaque and eventually a calculus.

Prevention

Renal colic can be prevented by making a few lifestyle modifications. These include:

  • Excess fluid intake: The patient is encouraged to drink plenty of fluids to help decrease pain and flush blockages from the urinary tract. An intake of more than 2.5 liters of liquids per day is usually advised. 
  • Dietary modifications: Eating foods like okra, oysters and raw broccoli that contain rich doses of magnesium can help strengthen the immune system and reduce the incidence of urinary tract infections that lead to stone formation. Foods rich in oxalate, vitamin C, cereal fiber, high salts and fats should be avoided. Sulfur containing protein (egg, meat, fish) should be restricted in cystinuria.
  • Medications: Drugs (such as thiazide diuretics, allopurinol and calcium citrate) are given to reduce the risk of stone formation according to the type of the stone. Idiopathic hypercalciuria is treated with bendroflumethiazide.
  • Frequent urination: This keeps the level of toxins down and prevents the formation of kidney stones.

Summary

Renal colic is a severe type of abdominal pain caused by kidney stones. It typically begins in the abdomen and radiates to the hypochondrium or the groin. The pain is often constant and colicky in character due to ureteral peristalsis. It may be associated with fever, rigors, chills, nausea, vomiting and blood in urine. The pain is usually located on one side, but might be on both sides of lower back. Nephrolithiasis is more common at 20 to 50 years of age. These stones consist of crystals, usually containing calcium or phosphate in combination with small amounts of proteins. Successful management includes removal of the stone and prevention of recurrence.

Patient Information

Renal colic is a type of pain caused by kidney stones. The pain begins in abdomen and radiates to the groin. It is most common in men between 20 to 30 years of age. The patients usually present with severe pain, fever, nausea, vomiting and blood in the urine. With proper treatment and preventive measures, the disease has a very good prognosis.

References

Article

  1. Sedlack JD, Kenkel J, Czarapata BJ, Paul MG, Pahira JJ, Lee TC. Primary hyperparathyroidism in patients with renal stones. Surgery, gynecology & obstetrics. Sep 1990;171(3):206-208.
  2. Rao DS, Frame B, Block MA, Parfitt AM. Primary hyperparathyroidism. A cause of hypercalciuria and renal stones in patients with medullary sponge kidney. Jama. Mar 28 1977;237(13):1353-1355.
  3. Kamhi D. [Hyperparathyroidism and calcareous stones of the urinary system]. Turk Tip Cemiyeti mecmuasi. Apr 1956;22(4):235-242.
  4. Flannigan R, Choy WH, Chew B, Lange D. Renal struvite stones--pathogenesis, microbiology, and management strategies. Nature reviews. Urology. Jun 2014;11(6):333-341.
  5. Griffith DP. Struvite stones. Kidney international. May 1978;13(5):372-382.
  6. Ahmed K, Dasgupta P, Khan MS. Cystine calculi: challenging group of stones. Postgraduate medical journal. Dec 2006;82(974):799-801.
  7. Knoll T, Janitzky V, Michel MS, Alken P, Kohrmann KU. [Cystinuria - Cystine Stones: Recommendations for Diagnosis, Therapy and Follow-up]. Aktuelle Urologie. Mar 2003;34(2):97-101.
  8. Gambaro G, Fabris A, Abaterusso C, et al. Pathogenesis of nephrolithiasis: recent insight from cell biology and renal pathology. Clinical cases in mineral and bone metabolism : the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases. May 2008;5(2):107-109.
  9. Reynolds TM. ACP Best Practice No 181: Chemical pathology clinical investigation and management of nephrolithiasis. Journal of clinical pathology. Feb 2005;58(2):134-140.
  10. Nadeem M, Ather MH, Jamshaid A, Zaigham S, Mirza R, Salam B. Rationale use of unenhanced multi-detector CT (CT KUB) in evaluation of suspected renal colic. International journal of surgery. 2012;10(10):634-637.
  11. Grenier N, Taourel P. [Imaging of acute urinary obstruction: non-enhanced CT or KUB and US]. Journal de radiologie. Feb 2004;85(2 Pt 2):186-194.

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Last updated: 2017-08-09 17:35