Acute Ureteral Colic Research Articles

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic.

In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.

Clinical and Radiological Predictors of Early Intervention in Acute Ureteral Colic.

PurposeAcute ureteric colic (AUC) is generally one of the most common reasons for emergency department attendance. Expectant management is recommended in non-complicated ureteral calculi. However, data regarding the optimal duration of observation or indications of early intervention (EI) are not well understood. This article describes the clinical and radiological factors that promote EI in AUC.Patients and MethodsThis was an observational and retrospective cohort study. Patients with AUC diagnosed based on non-contrast computerized tomography (NCCT) between 2019 and 2020 were enrolled in the study. These patients were classified into two main categories: spontaneous passage of stone (SSP) and EI. In addition, a comparative analysis was performed to identify clinical and radiological variables that promote EI.ResultsOne-hundred and sixty-one patients were included. High WBCs are associated with a significant increase in EI. Forty-three percent (n=37) of patients with serum WBCs higher than 10 had an EI, while 23% had SSP (n=17;p<0.001). High CRP level is also significantly associated with EI (n=36; 86%; p<0.001). Upper and middle ureteral calculi are statistically associated with EI (n=54; 62%) in comparison to the SSP cohort (n=22; 30%;p<0.001). EI is also linked to the maximal length of ureteric calculi (MCL) of 9 mm (6–13mm), and HU density of stone of 700 (430–990) H.U (p<0.001). Ureteric stone volume of 0.2 (0.06–0.3) cm3 is significantly associated with EI (p<0.001). Ureteral wall thickness of 3 (2–3 mm), the presence of extrarenal pelvis (n=20; 23%), and AP diameter of renal pelvis 18 (13–28 mm) are all significantly associated with a higher rate of EI (p<0.001). Multiple binary logistic regression analysis showed that MCL is the strongest predictor of EI.ConclusionMCL is an independent and robust predictor of EI in AUC. Biochemical variables and radiological characteristics can also act as an adjunct to promote EI.

Predicting emergency interventions in patients with acute ureteral colic using acute renal colic scoring system in a Pakistani cohort.

To evaluate the acute renal colic score (ARC) in predicting the need of emergency intervention (EI) in patients with ureteric colic secondary to a ureteral stone. In an emergency room (ER) of a university hospital, we conducted a prospective cohort study over a period of 6months. ARC score was calculated using four parameters, i.e., serum creatinine, total white cell count (TLC), stone length and level. Primary outcome measure was EI, which was defined as the need of endourological intervention within 48h of presentation. ARC was calculated for each patient against the two possible outcomes, i.e., EI vs. no EI. The need of intervention was based on patient-related clinical factors and the decision of the attending urologist. The study included 132 patients. EI was performed in 85 patients (64.4%). URS was the most common intervention performed in 81 (95.3%) patients, followed by the a insertion of a double J stent in two (2.4%) patients for forniceal rupture and high TLC count and percutaneous nephrostomy in two (2.4%) patients for raised creatinine and TLC. All four variables in ARC score including serum creatinine (p < 0.001), TLC (p < 0.001), stone size (p < 0.001) and stone level (p < 0.001) were found to be significantly associated with need for EI. Using ROC the sensitivity and specificity of the score was 92.9% and 87.5%, respectively, with AUC of 0.93. ARC score is highly sensitive and specific in determining the need of EI in patients with uncomplicated ureteric colic within 48h of initial presentation.

Variability of renal colic management and outcomes in two Canadian cities

Some centres favour early intervention for ureteral colic while others prefer trial of spontaneous passage, and relative outcomes are poorly described. Calgary and Vancouver have similar populations and physician expertise, but differing approaches to ureteral colic. We studied 60-day hospitalization and intervention rates for patients having a first emergency department (ED) visit for ureteral colic in these diverse systems. We used administrative data and structured chart review to study all Vancouver and Calgary patients with an index visit for ureteral colic during 2014. Patient demographics, arrival characteristics and triage category were captured from ED information systems, while ED visits and admissions were captured from linked regional hospital databases. Laboratory results were obtained from electronic health records and stone characteristics were abstracted from diagnostic imaging reports. Our primary outcome was hospitalization or urological intervention from 0 to 60 days. Secondary outcomes included ED revisits, readmissions and rescue interventions. Time to event analysis was conducted and Cox Proportional Hazards modelling was performed to adjust for covariate imbalance. We studied 3283 patients with CT-defined stones. Patient and stone characteristics were similar for the cities. Hospitalization or intervention occurred in 60.9% of Calgary patients and 31.3% of Vancouver patients (p<0.001). Calgary patients had higher index intervention rates (52.1% v. 7.5%), and experienced more ED revisits and hospital readmissions during follow-up. The data suggest that outcome events were associated with overtreatment of small stones in one city and undertreatment of large stones in the other. An early interventional approach was associated with higher ED revisit, hospitalization and intervention rates. If these events are markers of patient disability, then a less interventional approach to small stones and earlier definitive management of large stones may reduce system utilization and improve outcomes for patients with acute ureteral colic.

Diclofenac Treatment Prolongs Renal Transit Time in Acute Ureteral Obstruction: A Renographic Study

Objective: Prostaglandin inhibitors, mostly diclofenac, are currently first–choice therapy for ureteral colic, their main action being reduction of intrapelvic pressure and diuresis. We hypothesized that diclofenac, by increasing tubular reabsorption, can delay excretion of contrast medium and give a false impression of severe obstruction. Methods: Gamma camera renography was performed with 50 MBq ⁹⁹Tc^m–MAG3 before and with 150 MBq 30 min after intramuscular injection of 75 mg diclofenac in 10 patients with acute ureteral colic. The time to maximum isotope activity in each kidney, T_max, was compared with T_max in 10 control patients, who did not receive diclofenac but underwent two identical renographies. Results: T_max was significantly delayed after diclofenac, from 353 s at baseline to >1,200 s on the stone side, and from 225 to 465 s on the healthy side. Without diclofenac there was no T_max retardation between the two renographies. Conclusion: Diclofenac treatment can lead to overestimation in ureteral stone disease, by delaying renal excretion bilaterally, but predominantly on the side of calculus.

Indomethacin Suppositories Versus Intravenously Titrated Morphine for the Treatment of Ureteral Colic

Study objectives: To develop a protocol for the blinded IV titration of morphine and to compare the analgesic efficacy and side effect profile of indomethacin suppositories versus IV morphine in the treatment of acute ureteral colic. Design: Randomized, double-blind, double-dummy, two-period crossover study. Setting: Emergency department of a central-city, teaching hospital. Participants: Patients 18 to 75 years of age with pain suggestive of ureteral colic. Exclusions included pregnancy, adverse reactions to the study drugs, chronic nonsteroidal anti-inflammatory drug (NSAID) therapy, or any pain medicine taken within four hours of ED admission. Interventions: Patients were randomized to one of two groups: indomethacin 100-mg rectal suppository or morphine by IV titration (5-mg loading dose and up to two additional 2.5-mg doses if needed). At the end of 30 minutes, if adequate pain relief had not been obtained, treatment was crossed over. Measurements: Verbal analog scale (initial pain) and visual analog pain relief scale. Main results: Seventy-five patients were entered into the study. Only data from those patients with stone presence confirmed by IV pyelogram or stone passage were analyzed. Twenty-four could not be evaluated (23 who did not meet criteria for stone presence and one whose pain resolved spontaneously before study medications could be administered). Of the remaining 51 patients, 31 received indomethacin first and 20 received morphine first. Morphine recipients reported more pain relief at ten minutes ( P = .02), but at 20 and 30 minutes, no significant difference ( P = .17 and .74, respectively) existed between the two groups. Conclusion: IV morphine produced more rapid analgesia than rectally administered indomethacin. There were no significant differences in vital sign changes or number of side effects between the two treatment groups. This study is the first to compare an NSAID with morphine administered by IV titration, considered by many to be the "gold standard" for relief of acute, severe pain. Future studies could evaluate the simultaneous administration of an opioid combined with an NSAID or compare an IV titrated opioid with an IV NSAID. [Cordell WH, Larson TA, Lingeman JE, Nelson DR, Woods JR, Burns LB, Klee LW: Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic. Ann Emerg Med February 1994;23:262-269.]

Treatment of Ureteral Colic with Intravenous Indomethacin

AbstractA randomized prospective double-blind study of the analgesic effect of 50mg. intravenous indomethacin, a prostaglandin synthesis inhibitor, was done on 47 consecutive patients with acute ureteral colic. The placebo used was 5mg. intravenous riboflavin because of the same color as indomethacin. Indomethacin provided complete relief in 78 per cent of the cases, while riboflavin provided relief in 30 per cent. The difference is statistically significant. No side effects were observed with indomethacin.