Ureteric colic.pptx

Ureteric colic
Clinical features
Diagnostic modalities
Management
Urolithiasis in pregnancy

1. Ureteric colic Sukhdev, CMC Vellore

2. Most common urological case in emergency department Mandates urgent investigation Colic is a misnomer – pain is usually continuous

3. Phases of ureteric colic Acute or onset phase Constant phase Abatement or relief phase Usually continuous Sometimes in paroxysms Most patients arrive in ED in this phase Relieves spontaneously or by medications Lasts 1-2 hours Lasts 1-4 hours  

4. The pain Upper ureteral calculi – flanks Mid ureteral calculi – anteriorly and caudally Distal ureteral calculi – symptoms may mimic cystitis or detrusor overactivity Hematuria (micro/macro) is seen in 85% of patients with colic

5. Mechanism of ureteric colic Dilatation of UUT proximal to calculus causing stretching of renal capsule – increased PgE2 promotes afferent arteriolar vasodilatation and diuresis further increasing proximal tract pressure Spasm of ureteral smooth muscle surrounding the calculus

6. Renal function recovery post obstruction 100% after 1 week 30% after 4 weeks

7. Differential diagnoses Acute appendicitis Acute cholecystitis Acute pyelonephritis Torsion testis Torsion ovary Ovarian cyst rupture Diverticulitis Aneurysm rupture

8. Lab investigations Hematuria has a negative predictive value of 65% Can have leucocytosis and raised creatinine Urine crystals may predict the type of stone

9. Radiological investigations Plain abdominal radiograph USG IVU NCCT KUB

10. X RAY KUB 90% of urinary calculi are radio opaque Phlebolith vs distal ureteric calculi: Phlebolith are calcified veins and so will have a radiolucent centre

11. Renal ultrasound Can detect hydronephrosis X ray KUB + USG = alternative to NCCT KUB

12. IVU Not done in emergency setting However, provides a road map for subsequent endoscopic surgeries

13. NCCT KUB Adopted as investigation of choice for ureteric colic Sensitivity and specificity of 94-100% Ureteric calculi have peripheral ‘rim sign’ due to mucosal edema which can be used to differentiate them from phlebolith Merits Can detect radiolucent stones(exception of indinavir stones) Gives idea about HUN and calyceal anatomy Can diagnose other pathologies Demerits: If CT collimation is small, can miss small stones Ideally 5 mm cuts are preferred Lacks the orientation which the surgeons prefer. However, 3D reconstruction eliminates this

14. Rim sign

15. Do you need an X ray KUB when the patient has an NCCT KUB To tell whether the stone is radiolucent or radio opaque To tell the approximate size of stone comparing it to known bony landmarks like vertebrae Gives the surgical orientation of most endourological procedures

16. Management Ureteric colic patients can have vomiting and the ensuing hydration should be addressed Forced diuresis is contraindicated as it doesn’t facilitate stone passage(it worsens obstruction) Replacement of vomitus + maintenance fluids is more than enough

17. Analgesia Diclofenac 37.5 mg or ketorolac 30 mg IV or IM IV paracetamol 1 g Morphine 0.1 mg/kg IV lidocaine 120 mg/100 ml normal saline over 10 minutes

18. Spontaneous passage ≤4 mm will pass spontaneously 94% of the time >6 mm stones(larger than ureteral diameter) wont usually pass spontaneously

19. MET Medical expulsive therapy Facilitates stone passage Recommended for distal ureteric stones >5 mm but <10 mm(EAU) Alpha blockers better than calcium channel blockers Alpha receptors are more in distal ureter Duration of MET: ≤6 weeks(AUA)

20. Hospitalisation Most ureteric colic patients can be treated as OPD Patients who require admission are: Pain refractory to routine analgesia Refractory vomiting Infection AKI Solitary kidney Bilateral obstructing calculi

21. Cont’d These patients will require emergency JJ stenting or Percutaneous nephrostomy

22. Urolithiasis in pregnancy

23. Most common non obstetric cause of acute abdomen 1/1500 pregnancies Incidence not more than similar age group childbearing non pregnant population More common in multiparous women More common in 2 nd and 3 rd trimester

24. Why worrisome? Risk of premature labour Other complications like pre eclampsia, pregnancy loss are unaffected

25. Physiological changes in pregnancy Physiological HUN: starts at 6 months(24 weeks) and increases till 32 weeks(8 months) and stays stable thereafter 90% of RK and 67% of LK will have HUN Due to dextrorotation of gravid uterus and protection of left ureter by gas filled sigmoid colon Progesterone induced smooth muscle dilatation

26. Cont’d 2.Increased GFR and renal plasma flow 3.Creatinine clearance increases by 50%, with an average creatinine of 0.4-0.8 mg/dl

27. Lithogenicity in pregnancy Gestational hypercalciuria – due to ↑ GFR and thus, ↑ filtered load of calcium. Also due to placental 1 α hydroxylase which ↑vitamin D production Gestational hyperuricosuria Physiological HUN But still, the incidence of lithiasis in pregnant women is the same as in non pregnant women because of: Increase in anti lithogenic factors in urine like citrate, glycosaminoglycans Relative alkalinity of urine due to physiological respiratory alkalosis So, the most common stone in pregnancy is calcium phosphate

28. Investigations USG MRI Limited IVU

29. USG Less predictive value due to physiological HUN RI >0.7 can indirectly indicate obstruction Asymmetric Urine jet can indicate unilateral obstruction(sensitivity 100% and specificity 91%) Overall sensitivity is 76% and specificity is 67% in pregnancy Transvaginal USG for distal ureters if TAUS is inconclusive

30. MR urography Relatively insensitive for stones but signs of obstruction can be apparent

31. IVU Limited or 3 shot IVU Scout, 30 seconds and 20 minute films Demerits: Iodinated contrast media can cross placenta Fetal skeleton can obscure the calculi

32. CT Low dose and ultra low dose CT protocols have been devised But still better to avoid

33. Medications NSAIDS contraindicated Can cause premature closure of ductus arteriosus when used near term and can cause pulmonary hypertension Paracetamol safe to use(Category B) Morphine can be used but in a limited dose and over limited time Tamsulosin can be used(category B)

34. Surgery 70-80% of stones will pass spontaneously JJ stenting alone will need frequent stent changes(Q4-6 weeks to avoid encrustation) Stents can shift to bladder because of physiological HUN PCN if pregnancy ≤22 weeks

35. THANK YOU