The pain can be anywhere in the urinary tract, which includes the area from the kidneys to the ureters, the urinary bladder and the urethra.
Nephritic Colic is a pain caused by a stone of the urinary tract ( urolithiasis ).
Stones can occur anywhere in these areas and can vary significantly in size. Most stones occur due to the accumulation of minerals or other substances, such as uric acid, which adhere to the urine and create a hard mass.
There are many treatment options for urinary stones. Many stones pass without surgery, so the management of Nephritic Colic is a major concern during treatment.
The symptoms of Nephritic Colic can vary depending on the size of the stone and its location in the urinary tract. Some small stones cause mild Nephritic Colic and a person can pass them in the urine without much discomfort.
Larger stones can cause unbearable pain, especially if they clog and block any small spot in the urinary tract, such as where the kidney or urinary bladder is located, or the ureter, the tube through which urine passes between the kidney and the bladder. .
The most common presentation of Nephritic Colic is pain that occurs on the affected side of the body between the lower ribs and the hip that radiates to the lower abdomen and groin.
The pain tends to come in waves that can last 20 to 60 minutes before decreasing until the next wave.
Nephric Colic is just one of the symptoms caused by urinary stones. Other symptoms that usually occur along with Nephritic Colic include:
- Pain or difficulty urinating.
- Blood in the urine that can give it a pink, red or brown color.
- Bad smelling urine
- Small particles in the urine.
- Feeling a constant and urgent need to urinate.
- Cloudy urine.
- Urinate more or less than normal.
Signs of a related urinary tract infection may appear in some cases. These include fever, chills and cold sweat. Anyone who experiences any of these symptoms should talk to a doctor.
Anyone with the following symptoms in addition to Nephritic Colic should contact the emergency medical services immediately:
- Complete inability to urinate.
- Uncontrollable vomiting.
- Fever over 101 ° F.
Nephritic Colic is caused by a stone that gets stuck in the urinary tract. This commonly occurs in an ureter, where the stone stretches the surrounding area of the tissue when trying to pass through it; Inflammation and pressure restricting the flow of urine can also occur.
The ureter can also suffer spasms. This situation is painful, since the ureter should not have stones inside it.
Urinary stones can be formed by numerous chemicals and minerals caused by some different risk factors. Risk factors for developing urinary stones include:
- Extra calcium in the urine.
- Diseases of the gastrointestinal (GI) tract, such as disease Crohn or colitis ulcerosa .
- Drop, which is caused by an excess of uric acid.
- Certain medications
- Surgeries in the GI tract, such as gastric bypass surgery.
- A family history of urolithiasis
Doctors often use blood tests to check for increased levels of stone-forming substances in a person’s body.
An imaging test such as a simple film x-ray, a computed tomography (CT) scan, or an ultrasound can help locate any important calculus in the urinary tract.
Medical treatment will often depend on the type of stone a person is experiencing. There are some different types of stones, which include:
- Calcium stones are the most common types of stones and are made up of calcium oxalate.
- Uric acid stones develop when uric acid is concentrated in the urine.
- Cystine stones are rare and are caused by the cystinuria disorder.
- Struvite stones are less common stones caused by certain bacteria in the urinary tract.
Most small stones are considered passable. In fact, up to 80 percent of the stones will pass from the body into the urine. Doctors recommend proper hydration and may prescribe pain relievers to help control pain while controlling the stone until it passes.
There are a variety of procedures to help eliminate larger stones and relieve Nephritic Colic. These include:
Extraction with stones guided by ureteroscopy : this is an invasive surgical procedure in which a doctor inserts a thin endoscope with a light and a camera into the urinary tract to locate the stone and remove it.
Extracorporeal shock wave lithotripsy (ESWL) : a non-invasive treatment, ESWL is the process of aiming small sound waves at the kidneys to divide the stones into small pieces. These fragments are passed in the urine.
Percutaneous nephrolithotomy: Percutaneous nephrolithotomy is usually performed under general anesthesia. It is the process of entering the kidney through a small cut in the back and the use of an illuminated scope and small instruments to remove the stone.
Stent placement : Sometimes doctors will place a thin tube in the person’s ureter to help relieve the blockage and promote the passage of stones.
Open surgery : some people who can not pass the stones may require open surgery, but have a longer recovery time. Doctors will often try to remove or break stones so that a person can pass them before considering open surgery.
Treatment may also include medications designed to help relieve symptoms or reduce stone buildup. These treatments may include:
- Alkalizing agents.
- Calcium channel blockers.
- Selective alpha-1 blockers.
Treatment and Management of Nephrolithiasis
The treatment of nephrolithiasis involves emergency management of Nephritic (ureteral) colic, including surgical interventions where indicated, and medical treatment for stone disease.
In emergency situations where there is concern about possible kidney failure, the approach to treatment should be to correct dehydration, treat urinary tract infections, prevent scarring, identify patients with a functional kidney and reduce the risk of acute kidney injury.
Adequate intravenous (IV) hydration is essential to minimize the nephrotoxic effects of IV contrast agents.
Most small stones in patients with relatively mild hydronephrosis can be treated with observation and acetaminophen. More severe cases with intractable pain may require stent drainage or percutaneous nephrostomy.
The internal ureteral stent is generally preferred in these situations due to the decrease in morbidity. Paracetamol can be used in pregnancy for mild to moderate pain.
Opioid medications, such as morphine and meperidine, are category C pregnancy medications, which means they can be used but cross the placental barrier.
Opioids can cause respiratory depression in the fetus; therefore, they should not be used near delivery or when other medications are appropriate.
An analysis of the chemical composition of the stone should be carried out whenever possible, and information should be provided to motivated patients about possible 24-hour urine tests for prophylaxis with long-term nephrolithiasis.
This is particularly important in patients with a single functional kidney, those with medical risk factors and children.
However, any highly motivated patient can benefit from a prevention and prophylactic treatment analysis if they are willing to follow long-term therapy.
The size of the stone is an important predictor of spontaneous passage. A stone less than 4 mm in diameter has an 80% chance of spontaneous passage; this drops to 20% for stones more than 8 mm in diameter.
However, the step of calculations also depends on the exact shape and location of the stone and the specific anatomy of the upper urinary tract in the particular individual.
For example, the presence of a ureteropelvic junction obstruction (UPJ) or ureteral stenosis may make it difficult or impossible to pass very small stones.
Most doctors and urologists in the emergency department have observed very large stones that pass by and some very small stones that do not move.
Aggressive medical therapy has shown promise in increasing the rate of passage of spontaneous calculus and relieving discomfort while minimizing the use of narcotics.
Aggressive treatment of any proximal urinary tract infection is important to prevent pyonephrosis and potentially dangerous urosepsis.
In these cases, consider percutaneous nephrostomy drainage instead of retrograde endoscopy, especially in very ill patients.
Medical therapy for stone disease takes both short and long-term forms. The first includes measures to dissolve the calculation (possible only with non-calcareous stones) or to facilitate the passage of stones, and the latter includes treatment to avoid the formation of additional stones.
The prevention of stones should be considered with greater force in patients who have risk factors to increase stone activity, including stone formation before the age of 30, family history of stones, multiple calculations in the presentation and residual stones after treatment surgical.
In 2016, the American Association of Urology / Endourological Society issued general guidelines for the various presentations of stones that can be managed conservatively.
The guidelines state that observation with or without medical expulsive therapy should be offered to patients with uncomplicated distal ureteral stones 10 mm or less in diameter.
The guidelines also state that active surveillance can be offered for non-obstructive and asymptomatic calyceal calculations.
In the case of pediatric patients with uncomplicated ureteral stones ≤10 mm or non-obstructive asymptomatic renal stones, active surveillance with periodic ultrasonography can be offered.
Pregnant patients with ureteral / renal stones with well-controlled symptoms can also be observed.
The treatment of pain is an essential step in the treatment, since it can increase the quality of life of a person until the stone passes.
While a person is still dealing with the symptoms, doctors can also recommend medications to calm the gastrointestinal tract and control nausea and vomiting.
Some people may also respond by placing a heat pack on their side or lower back, as it can relieve the muscle spasms associated with Nephritic Colic.
Indications for Hospitalization
The decision to hospitalize a patient with a stone is usually based on clinical reasons and not on a specific finding on an x-ray.
Generally, hospitalization for an acute attack of Nephritic Colic is now officially called an observation because most patients recover enough to go home within 24 hours.
The admission rate for patients with acute Nephritic Colic is approximately 20%. Hospitalization is clearly necessary when any of the following is present:
- Oral analgesics are insufficient to control pain.
- Ureteral obstruction of a stone occurs in a solitary or transplanted kidney.
- Ureteral obstruction of a stone occurs in the presence of a urinary tract infection (UTI), fever, sepsis, or pyonephrosis.
Infected hydronephrosis, defined as a urinary tract infection (UTI) proximal to an obstructing stone, requires hospital admission to receive antibiotics and rapid drainage.
Urine culture and midstream sensitivity were a poor predictor of infected hydronephrosis in one series, being positive only in 30% of cases.
The clinical presentation of infected hydronephrosis is variable. Pyuria (> 5 white blood cells [white blood cells] per high power field [HPF]) is almost always present, but it is not diagnostic of proximal infection.
In a small series of 23 patients with infected hydronephrosis, the temperature was higher than 38 ° C in 15 patients, the peripheral white blood cell count was more than 10 × 109 / L in 13 patients and the creatinine level was higher than 1, 3 mg / dL in 12 patients.
Renal ultrasound or CT can distinguish pionefrosis from simple hydronephrosis by demonstrating a level of fluid-fluid in the renal pelvis (urine over purulent debris).
In two small studies, the ultrasonographic sensitivity for pyonephrosis was 62-67%. The CT sensitivity for pyonephrosis has not been determined reliably. The emergency doctor must maintain a high index of suspicion.
Antibiotics should cover species of Escherichia coli and Staphylococcus, Enterobacter, Proteus and Klebsiella. In another small study of 38 patients with hydronephrosis, 16 had infected hydronephrosis and 22 had sterile hydronephrosis. Ultrasound alone detected 6 of 16 cases of pyonephrosis, a sensitivity of 38%.
Using a cut-off value of 3mg / dL for C-reactive protein and 100mm / h for erythrocyte sedimentation rate, the diagnostic accuracy for detecting infected hydronephrosis and pionefrosis increased to 97%.
Indications to consider for possible admission include comorbid conditions (eg, diabetes), dehydration requiring prolonged IV fluid therapy, renal failure or any immunocompromised state.
Patients with complete obstruction, perirenal urine extravasation, a solitary kidney or pregnancy, and those with a deficient social support system should also be considered for admission, especially if rapid urologic follow-up is not reliably available.
Larger stones (ie, ≥7 mm) that are unlikely to pass spontaneously require some type of surgical procedure. In some cases, it is reasonable to hospitalize a patient with a large stone to facilitate surgical intervention with stones.
However, most patients with acute Nephritic Colic can be treated on an outpatient basis.
Around 15-20% of patients require invasive intervention due to stone size, continuous obstruction, infection or intractable pain. The techniques available to the urologist when the stone can not pass spontaneously include the following:
- Stent placement.
- Percutaneous nephrostomy.
- Extracorporeal lithotripsy with shock waves.
- Ureteroscopia (URS).
- Percutaneous nephrostolitotomy.
- Open nephrostomy.
- Anatrophic nephrolithotomy.
Emergency Management of Nephritic Colic
The initial treatment of a patient with Nephritic Colic in the emergency room begins with obtaining IV access to allow the administration of liquid, analgesic and antiemetic medications.
Many of these patients are dehydrated from oral intake and poor vomiting. Although the role of supranormal hydration in the treatment of Nephritic (ureteral) colic is controversial (see below), patients who are dehydrated or diseased need adequate restoration of circulating volume.
After diagnosing a Nephritic (ureteral) Colic, determine the presence or absence of obstruction or infection. Obstruction in the absence of infection can be treated initially with analgesics and other medical measures to facilitate the passage of the stone.
Infection in the absence of obstruction can be treated initially with antimicrobial therapy. In any case, quickly refer the patient to a urologist.
If there is no obstruction or infection, analgesics and other medical measures can be started to facilitate the passage of the stone (see below) with the expectation that the stone will probably pass from the upper urinary tract if its diameter is less than 10mm (greater than calculations are more likely to require surgical measures).
If there is obstruction and infection, emergency decompression of the upper urinary collecting system is required. Also, immediately consult a urologist for patients whose pain does not respond to treatment.
Avoiding Nephritic Colic begins with the prevention of the stones that caused it. Doctors may recommend that a person increase their fluid intake and reduce their sodium intake.
A doctor may prescribe a thiazide diuretic if a person has calculi of the urinary tract of calcium oxalate. While drinking more fluid may or may not improve Nephritic Colic or help remove stones from the urinary tract, at least it will prevent dehydration.
Many people also benefit from eating a healthy diet rich in a variety of whole grains, vegetables, fruits and lean proteins. Doctors may also recommend increasing the intake of citrus fruits in the diet, such as oranges, lemons or grapefruit.
Many calculations will go by themselves, but they can still cause Nephritic Colic. Doctors will often explore the best combination of medical and surgical treatment options to help break down larger stones and let them go.
It is possible that the stones in the urinary tract reoccur after a successful treatment. Taking preventive measures can help prevent the development of stones in the future and reduce the symptoms of Nephritic Colic.