Acute renal colic and ureterolithiasis - kidney stones (1 - 65 years)

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Acute renal colic and ureterolithiasis - kidney stones (1 - 65 years)

Other potential reasons to consult urology

  • Uncontrolled pain from urolithiasis
  • Recent recurrence or repeat visit

Consider appropriate workup (+/- CT) then urology consult if needed

Severe pain?

Meets discharge criteria?

< 10 years or history of stent?

Discharge with:

  • Strainer
  • Tamsulosin (if stone present), discontinue after successful expulsion
    • < 4 years old: 0.2 mg once a day at bedtime
    • > 4 years old: 0.4 mg once a day at bedtime
  • Short term oral opioid analgesia
  • NSAIDs if creatine normal

Oupatient urology referral if any of the following:

  • Less than 18 years old
  • Obstructing stones >6 mm
  • All ureteral stones > 1 cm
  • Other complex finding on labs or radiology exams

Risk factors

  • Previous ureterolithiasis
  • Family history of ureterolithiasis
  • Enhanced enteric oxalate absorption (gastric bypass procedures, bariatric surgery, short bowel syndrome)
  • Frequent upper urinary tract infections (especially with a urease-producing organism, such as Proteus or Klebsiella)
  • Medications: indinavir, acyclovir, sulfadiazine, and triamterene
  • Prolonged ceftriaxone therapy
  • Persistently acidic urine
  • Hypercalciuria, hyperoxaluria, or hypocitraturia
  • Diet: low calcium intake, high oxalate intake, high animal protein intake, high sodium intake, or low fluid intake

Off pathway. Consider other diagnosis, CT or urology consult. 

Consult Urology
XR Abdomen 1 View - Indication: Abdominal Pain

Normal creatinine?

Inclusion Criteria
  • Clinical concern for urethrolithiasis
Exclusion Criteria
  • Complex urological surgical history (simple stents ok in adults)
  • History of complex urethrolithiasis

Treat appropriately

Discharge criteria

  • Reassuring vital signs
  • Pain under control
  • Able to urinate
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Patient/caregivers comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Treat appropriately

Urine test Interpretation

Presumed UTI (UA Pyuria)

  • Positive nitrite or leukocyte esterase and microscopy showing bacteria or > 10 WBC / hpf

Definitive UTI (Urine culture)

  • Urinalysis that suggests infection (pyuria and/or bacteriuria) AND one of the following:
  • Suprapubic aspiration: > 1,000 cfus
  • Catheter sample: > 50,000 cfus (often reported as 10-50,000 cfus depending on lab)
  • Clean catch sample: > 100,000 cfus

Any one of the following present?

  • Fever or signs of sepsis
  • Elevated Creatinine (> 1.8)
  • Elevated WBC (> 16)
  • Physician believes CT is more appropriate for the specific patient (e.g. working up other potential diagnosis requiring CT)
Consult Urology

Lab findings of renal insufficiency?

Presumed UTI on UA?

< 18 years or pregnant?

Abdominal plain films are NOT the imaging modality of choice for initial diagnosis of ureterolithiasis

Clinical findings associated with ureterolithiasis

  • Flank pain
  • Abdominal pain
  • Gross hematuria
  • Dysuria
  • Urgency
  • Nausea and vomiting
US Renal

Note: Ureterolithiasis due to HIV protease inhibitors may not be visualized on non-contrast CT

Morphine 0.1 mg/kg IV
Cephalexin suspension
Ibuprofen (advil, Motrin) 100 mg/5 ml Liquid 10 mg/kg
Ketorolac (Toradol) Injection 15 mg
Complete Blood Count With Auto Differential
Urinalysis With Microscopic & Reflex To Culture
Urine Culture
Basic Metabolic panel
Urine Pregnancy, Urine
Sodium Chloride 0.9 % Bolus - 20 ml/kg
Ibuprofen (advil, Motrin) 100 mg/5 ml Liquid 10 mg/kg
Ketorolac (Toradol) Injection 15 mg
Consult Urology
CT Abdomen Pelvis W WO Contrast - Indication: Flank Pain, Stone Disease Suspected

Urolithiasis vs. Nephrolithiasis

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