1. Management of Renal Colic in A&E department Protocol presented during A&E medical meeting 20/06/2012 Dr David / Dr Tien

2. Typical presentation The pain lasts minutes to hours, and occurs in spasms with intervals of no pain or dull ache. The person is restless and cannot lie still (which helps to differentiate from inflammatory causes, such as peritonitis). The pain lasts minutes to hours, and occurs in spasms with intervals of no pain or dull ache. The person is restless and cannot lie still (which helps to differentiate from inflammatory causes, such as peritonitis). The pain may radiate to the groin, scrotum, testis, labia, and anterior thigh. The pain may radiate to the groin, scrotum, testis, labia, and anterior thigh. The pain is often accompanied by nausea, vomiting, hypotension, frequent urination, dysuria, oliguria, and haematuria. The pain is often accompanied by nausea, vomiting, hypotension, frequent urination, dysuria, oliguria, and haematuria. There may be a history of previous episodes. There may be a history of previous episodes. There is often a history of precipitating factors, which include dehydration with reduced urine output, increased protein intake, heavy physical exercise, and use of drugs associated with stone formation There is often a history of precipitating factors, which include dehydration with reduced urine output, increased protein intake, heavy physical exercise, and use of drugs associated with stone formation

3. Physical examination Examination may reveal loin tenderness or tenderness of the lower quadrant Examination may reveal loin tenderness or tenderness of the lower quadrant Peritoneal signs are absent. Peritoneal signs are absent. Fever suggests either a separate diagnosis of urinary tract infection or coexisting urinary tract infection. Fever suggests either a separate diagnosis of urinary tract infection or coexisting urinary tract infection.

4. Interest of urine test (BU) Urine test: look for blood (to confirm the diagnosis) and leucocytes (to look for infectious complication) Urine test: look for blood (to confirm the diagnosis) and leucocytes (to look for infectious complication) Absence of haematuria makes the diagnosis of renal colic less likely (but does not exclude the diagnosis). Absence of haematuria makes the diagnosis of renal colic less likely (but does not exclude the diagnosis). Presence of haematuria supports the diagnosis, but specificity and positive predictive value are poor. Presence of haematuria supports the diagnosis, but specificity and positive predictive value are poor. Presence of nitrite and leucocytes indicates possible urinary tract infection (may be the primary diagnosis or coexistent with renal colic). Presence of nitrite and leucocytes indicates possible urinary tract infection (may be the primary diagnosis or coexistent with renal colic).

5. Differential diagnosis Pyelonephritis (can also be associated with kidney stone) Pyelonephritis (can also be associated with kidney stone) Ectopic pregnancy: Woman of reproductive age and recent delayed menstrual period (Beta HCG) Ectopic pregnancy: Woman of reproductive age and recent delayed menstrual period (Beta HCG) Endometriosis, Ovarian cyst Endometriosis, Ovarian cyst Leaking abdominal aortic aneurysm: People older than 60 years of age, especially men with left-sided pain Leaking abdominal aortic aneurysm: People older than 60 years of age, especially men with left-sided pain Biliary colic, Pancreatitis, Bowel ischemia Biliary colic, Pancreatitis, Bowel ischemia Pneumonia, pleuretic pain Pneumonia, pleuretic pain

6. Confirmation by imaging o Uroscanner (Unenhance CT scanner): Unenhanced helical CT is fast and accurate in determining the cause of colic and is highly accurate for emergency situations. o Most often, CT confirmed a ureteral stone and allowed appropriate discharge or urologic intervention. In a smaller subset of patients, CT established a significant alternative diagnosis that allowed the prompt initiation of appropriate treatment (aortic aneuvrism). o Ultrasound (US): US is inferior to spiral CT in the demonstration of ureteral calculi in patients with renal colic. US should be limited to the situation where CT scan is not available or contra-indicated.

7. Uroscanner / Ultrasound ? o Uroscanner CT allows a rapid, contrast-medium- free, anatomically accurate diagnosis of urinary tract calculi and has a sensitivity of 98% and a specificity of 97%. CT provides an alternative diagnosis in 6% of patients. Helical CT should be the first choice in imaging a patient with renal colic. o If this technique is not available or contra- indicated (eg: pregnant women), ultrasonography should be considered.

8. Initial treatment in A&E Voltaren (Diclofenac) 75 mg intravenous (unless contraindication of non-steroidal anti-inflammatory drug NSAID like pregnant women 3 rd trimestre or renal failure) Voltaren (Diclofenac) 75 mg intravenous (unless contraindication of non-steroidal anti-inflammatory drug NSAID like pregnant women 3 rd trimestre or renal failure) Consider an opioid (for example morphine) if diclofenac is not suitable or is insufficient to control the pain: Consider an opioid (for example morphine) if diclofenac is not suitable or is insufficient to control the pain: Morphine 2 to 3 mg intravenous injection (IV) bolus following Morphin titration protocole (up to a cumulative dose 10 mg if pain is not relieved after the first bolus). Morphine 2 to 3 mg intravenous injection (IV) bolus following Morphin titration protocole (up to a cumulative dose 10 mg if pain is not relieved after the first bolus). Paracetamol IV or an antispasmodic drug like Spasfon can also be prescribed in association with Voltaren Paracetamol IV or an antispasmodic drug like Spasfon can also be prescribed in association with Voltaren

9. If complications > Hospitalization o They are in shock or have fever or signs of systemic infection (which can lead to life-threatening sepsis). They are at increased risk from loss of renal function (and require emergency imaging and drainage to prevent irreversible loss of renal function): Solitary or transplanted kidney, Pre-existing renal impairment, Bilateral obstructing stones are suspected. They are at increased risk from loss of renal function (and require emergency imaging and drainage to prevent irreversible loss of renal function): Solitary or transplanted kidney, Pre-existing renal impairment, Bilateral obstructing stones are suspected. They do not respond to appropriate analgesic and anti-emetic treatment within 1 hour They do not respond to appropriate analgesic and anti-emetic treatment within 1 hour They have abrupt recurrence of severe pain despite initial analgesia (Consider admission if pain is persisting beyond 24 hours) They have abrupt recurrence of severe pain despite initial analgesia (Consider admission if pain is persisting beyond 24 hours) They are dehydrated and cannot take oral fluids due to vomiting — they require intravenous fluids. They are dehydrated and cannot take oral fluids due to vomiting — they require intravenous fluids. There is uncertainty regarding the diagnosis (for example if a leaking abdominal aortic aneurysm cannot be excluded). There is uncertainty regarding the diagnosis (for example if a leaking abdominal aortic aneurysm cannot be excluded). Pregnant women. Pregnant women. Patient more than 60 years with chronic diseases / Patient preference for admission. Patient more than 60 years with chronic diseases / Patient preference for admission. Contact by telephone is not possible or no reliable social support. Contact by telephone is not possible or no reliable social support.

10. No complication > Discharge o Give patient the prescription with Non-Steroidal Anti-inflammatory drugs and painkillers by mouth: Voltaren 75mg x 2 + Efferalgan Codein 2 tab x 3 Advise the person to contact A&E on-duty doctor if there is an abrupt recurrence of severe pain or sign of seriousness like fever, shiver, vomiting++ (food of drink intolerance) > come back in emergency to A&E. Advise the person to contact A&E on-duty doctor if there is an abrupt recurrence of severe pain or sign of seriousness like fever, shiver, vomiting++ (food of drink intolerance) > come back in emergency to A&E. Offer referral to urologist in OPD so that investigations can be carried out within 3 days. Offer referral to urologist in OPD so that investigations can be carried out within 3 days.

11. Prognostic Most symptomatic renal stones are small (less than 5 mm in diameter ) and pass spontaneously. Spontaneous passage is less likely for larger stones: Most symptomatic renal stones are small (less than 5 mm in diameter ) and pass spontaneously. Spontaneous passage is less likely for larger stones: Stones less than 5 mm in diameter pass spontaneously in up to 80% of people. Stones less than 5 mm in diameter pass spontaneously in up to 80% of people. Stones between 5 mm and 10 mm in diameter pass spontaneously in about 50% of people. Stones between 5 mm and 10 mm in diameter pass spontaneously in about 50% of people. Stones larger than 1 cm in diameter usually require intervention (urgent intervention is required if complete obstruction or infection is present). Stones larger than 1 cm in diameter usually require intervention (urgent intervention is required if complete obstruction or infection is present).

12. Urological expertise if complication: Renal colic with fever Renal colic with fever Rupture of urinary tract (CT scanner) Rupture of urinary tract (CT scanner) Obstructive renal insufficiency (unique kidney or bilateral migration of calculi) Obstructive renal insufficiency (unique kidney or bilateral migration of calculi) Hyperalgic renal colic (not responding to initial treatment NIAS + Morphin) Hyperalgic renal colic (not responding to initial treatment NIAS + Morphin)

13. Urological expertise if particular context: Chronic Renal failure or pre-existing uropathy Chronic Renal failure or pre-existing uropathy Single kidney (anatomical or fonctionnal) Single kidney (anatomical or fonctionnal) Pregnancy Pregnancy Bilateral stone migration Bilateral stone migration Calculi > 6mm Calculi > 6mm

14. Probability of spontaneous elimination of the stone

15. Look for complications / risk factors > admission in hospital o Fever or sign of sepsis (CRP, WBC, BU) > start antibiotics after ECBU o Severe pain despite initial treatment (after 1 hour) o Recurrence of severe pain within 24hours o Risk of loss of renal function* / anuria o Risk of dehydration due to drink and food intolerance (vomiting++) o Stone more than 6mm o Pregnant women o Patient lives far from an hospital, social isolation o Patient > 60 years with chronic diseases / Patient preference for admission Admission in hospital 1Surgical ward if stable (inform urologist on call) 2ICU if unstable (severe sepsis / shock) Discharge the patient 1Medical treatment by mouth (NSAI + Efferalgan Codein) 2Follow up J3 by urologist 3Give advices (discharge form with advices) Suspicion of renal colic: o Loin pain / Back pain o On & Off evolution o Past history of kidney stone Confirmation by Imaging: 1.Uroscanner (without contrast) 2Ultrasound (if CT contra-indicated) YES NO

16. Management of renal colic (ASP + Echography)

17. Management of renal colic in A&E (Uro-scanner)