Personal Practice

UROLITHIASIS: ACUTE RENAL COLIC-DIAGNOSIS

Rajesh Ahlawat and Rakesh Khera
From the Department of Urology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India.
Correspondence to: Dr. Rajesh Ahlawat, Sr. Consultant, Department of Urology,
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India.
E-mail: rahlawat@medscape.com

Keywords: Acute abdomen, abdominal pain, acute flank pain, Renal colic.

Acute renal colic is probably the most excruciatingly Clinical Presentation

painful event anyone can endure. Renal colic affects
approximately 1.2 million people each year and accounts for
about 1% of all hospital admissions. The overall lifetime
incidence of kidney stones in the general population is about
12% for men and tial 4% for women. Having a family member
with a history of stones doubles these rates [1]. Peak incidence
occurs in people aged 35-45 years, but the disease can affect
anyone at any age. Diagnosis of acute ureteric colic should be
considered. whenever acute back or flank pain is encountered
regardless of patient age. Most active emergency departments
treat on average at least one patient with acute renal colic
every day depending on the hospital’s patient population.
While proper diagnosis, prompt initial treatment, and
appropriate consultations are clearly the primary
responsibility of the emergency physician, substantial patient
education, including preventive therapy program options,
should also be started in the emergency department.
CLINICAL ASPECTS OF ACUTE RENAL COLIC
Predicting spontaneous stone passage
In general, smaller stones are more likely to pass
spontaneously, but stone passage 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 (UPJ) obstruction or a
ureteral stricture could make it difficult or impossible for even
very small stones to pass. If the stone is 4 mm or smaller, the
stone is eventually passed 90% of the time. Stones 5-7 mm
generally have a 50% chance of passing spontaneously.
Location of the calculus is equally important in predictive
spontaneous passage. A 5 mm stone at upper ureteric location
has a much lesser chance (50%) than a stone in lower ureteric
location (90%). Calculi larger than 7 mm are unlikely to pass
unassisted. However, nothing is more difficult in managing an
acute kidney stone attack than predicting what will happen
with the stone. Most experienced emergency department (ED)
physicians and urologists have observed very large stones
passing and some very small stones that do not move.
The colicky-type pain known as renal colic usually begins
in the upper lateral mid back over the costovertebral angle and
occasionally subcostally. It radiates inferiorly and anteriorly
toward the groin. The pain generated by renal colic is
primarily caused by the dilation, stretching, and spasm caused
by the acute ureteral obstruction. The term colic is a misnomer
because renal colic pain tends to remain constant, whereas
intestinal or biliary colic is usually somewhat intermittent and
often comes in waves. The pattern of the pain depends on the
individual's pain threshold and perception as well as on the
speed and degree of the changes in hydrostatic pressure within
the proximal ureter and renal pelvis. Ureteral peristalsis, stone
migration, and tilting or twisting of the stone with subsequent
intermittent obstructions may cause exacerbation or renewal
of the renal colic pain. The severity of the pain depends on the
degree and site of the obstruction, not on the size of the stone.
A patient can often point to the site of maximum tenderness,
which is likely to be at the site of the ureteral obstruction [2].
Upper ureter and renal pelvis: Pain from upper ureteral stones
tends to radiate to the flank and lumbar areas. On the right
side, this can be confused with cholecystitis or cholelithiasis;
on the left, the differential diagnoses include acute
pancreatitis, peptic ulcer disease, and gastritis.
Middle ureter: Midureteral calculi cause pain that radiates
anteriorly and caudally. This midureteral pain in particular
can easily mimic appendicitis on the right or acute
diverticulitis on the left.
Distal ureter: Distal ureteral stones cause pain that tends to
radiate into the groin or testicle in the male or labia majora in
the female because the pain is referred from the ilioinguinal
or genitofemoral nerves. If a stone is lodged in the intramural
ureter, symptoms may appear similar to cystitis or urethritis.
These symptoms include suprapubic pain, urinary frequency,
urgency, dysuria, stranguria, pain at the tip of the penis, and
sometimes various bowel symptoms, such as diarrhea and
tenesmus. These symptoms can be confused with pelvic

50 Apollo Medicine, Vol.1 September, 2004


inflammatory disease, ovarian cyst rupture, or torsion and
menstrual pain in women.
Most of the pain receptors of the upper urinary tract
responsible for the perception of renal colic are located
submucosally in the renal pelvis, calices, renal capsule and
upper ureter. Acute distention seems to be more important in
the development of the pain of acute renal colic than spasm,
local irritation, or ureteral hyperperistalsis. Stimulation of the
peripelvic renal capsule causes flank pain, while stimulation
of the renal pelvis and calices causes typical renal colic.
Mucosal irritation can be sensed in the renal pelvis to some
degree by chemoreceptors, but this irritation is thought to
play only a minor role in the perception of renal or ureteral
colic.
In the ureter, an increase in proximal peristalsis through
activation of intrinsic ureteral pacemakers may contribute to
the perception of pain. Muscle spasm, increased proximal
peristalsis, local inflammation, irritation, and edema at the
site of obstruction may contribute to the development of pain
through chemoreceptor activation and stretching of
submucosal free nerve endings.
Acute onset of severe flank pain radiating to the groin
with gross or microscopic hematuria, nausea, and vomiting
not associated with an acute abdomen are symptoms that
most likely indicate renal colic caused by an acute ureteral or
renal pelvic obstruction from a calculus. Renal colic pain
rarely, if ever, occurs without obstruction. Calyceal stones
may cause dull pain and occasionally produce colics, now
recognised as calyceal colics.
Pain from upper ureteral stones tends to radiate to the
flank and lumbar areas. On the right side, this can be
confused with cholecystitis or cholelithiasis; on the left, the
differential diagnoses include acute pancreatitis, peptic ulcer
disease, and gastritis. Midureteral calculi cause pain that
radiates anteriorly and caudally. This midureteral pain in
particular can easily mimic appendicitis on the right or acute
diverticulitis on the left. Distal ureteral stones cause pain that
tends to radiate into the groin or testicle in the male or labia
majora in the female because the pain is referred from the
ilioinguinal or genitofemoral nerves. If a stone is lodged in
the intramural ureter, symptoms may appear similar to
cystitis or urethritis. These symptoms include suprapubic
pain, urinary frequency, urgency, dysuria, stranguria, pain at
the tip of the penis, and sometimes various bowel symptoms,
such as diarrhea and tenesmus. These symptoms can be
confused with acute urinary tract infection pelvic
inflammatory disease, ovarian cyst rupture, or torsion and
menstrual pain in women. Acute distention seems to be more
important in the development of the pain of acute renal colic
than spasm, local irritation, or ureteral hyperperistalsis.
Stimulation of the peripelvic renal capsule causes flank pain,
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Personal Practice
while stimulation of the renal pelvis and calices causes
typical renal colic [3].
Phases of the acute renal colic attack
The actual pain attack tends to occur in somewhat
predictable phases, with the pain reaching its peak in most
patients within 2 hours of onset. The pain roughly follows the
dermatomes of T-10 to S-4. The entire process typically lasts
3-18 hours. Renal colic has been described as having three
clinical phases.
Acute phase: The typical attack starts early in the morning or
at night, waking the patient from sleep. When it begins during
the day, patients most commonly describe the attack as
starting slowly and insidiously. The pain is usually steady,
increasingly severe, and continuous; some patients
experience intermittent paroxysms of even more excruciating
pain. The pain level may increase to maximum intensity in as
little as 30 minutes after initial onset or more slowly, taking
up to 6 hours or longer to peak. The typical patient reaches
maximum pain 1-2 hours after the start of the renal colic
attack.
Constant phase: Once the pain reaches maximum intensity, it
tends to remain constant until it is either treated or allowed to
diminish spontaneously. This phase usually lasts 1-4 hours
but can persist longer than 12 hours in some cases.
Relief phase: During this final phase, the pain diminishes
fairly quickly, and patients finally feel relief. Relief can occur
spontaneously at any time after the initial onset of the colic.
Patients may fall asleep, especially if they have been
administered strong analgesic medication. Upon awakening,
the patient notices that the pain has disappeared. This final
phase of the attack most commonly lasts 1.5-3 hours.
Urinalysis
Microscopic examination of the urine is a critical part of
the evaluation of a patient thought to have renal colic. Gross
or microscopic hematuria is only present in about 85% of
cases. The lack of microscopic hematuria does not eliminate
renal colic as a potential diagnosis. Corecommittent
significant pyuria may indicate acute urinary tract infection.
Urinary crystals of calcium oxalate, uric acid, or cystine
may be found occasionally on urinalysis. When present,
these crystals are very good clues to the underlying type and
nature of any obstructing calculus.
While mild leukocytosis often accompanies a renal colic
attack, a high index of suspicion for a possible infection
should accompany any serum WBC count of 15,000/mm3 or
higher in a patient presenting with an apparent acute kidney
stone attack, even if afebrile. It is important to highlight that
obstruction accompanied with infection in an emergency and
may cause life threatening sepsis if not treated in time.
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Personal Practice
IMAGING STUDIES
Plain KUB abdominal film
The historical cornerstone of any evaluation of abdominal
pain that could be a stone is a radiograph of the abdomen for
kidneys, ureters, and bladder (KUB), which has been used for
this purpose since 1896 [5]. While all urinary calculi may not
always be visible on the KUB radiograph because of their
small size; overlying gas, stool, or bone; or stone
radiolucency, the stones that are observed can be correlated
with opacities found on other studies for identification and
tracking progress.
The plain KUB is inexpensive, quick, and usually helpful
even if no specific stone is observed. It is extremely useful in
following the progress of previously documented radiopaque
calculi. The KUB radiograph can suggest the fluoroscopic
appearance of a stone and its relationship to the bony age,
which determines whether it can be targeted with
extracorporeal shock-wave lithotripsy (ESWL). The KUB
radiograph is also more accurate in determining the exact size
and shape of a visible radiopaque stone, compared to CT scan
because the x-ray beam of the CT scan does not always cross
the stone at its widest point.
Differentiation between a phlebolith and an obstructing
calcific stone becomes easier when the KUB radiograph
demonstrates a lucent center, identifying the calcification as a
phlebolith. This central lucency is not observed as often on
CT scanning [6]. Many urologists recommend the plain KUB
in addition to CT scan for every evaluation.
Plain X-ray KUB has a relatively low sensitivity and
specificity for renal and ureteral calculi. Numerous pelvic
calcifications that make pinpointing specific stones difficult.
Any calcific density observed on KUB radiograph that
happens to overlie the course of the ureter is not guaranteed to
be a stone. Furthermore, obtaining a flat plate radiograph may
cause delays, may unnecessarily increase the cost of the
workup, and produces additional patient radiation exposure;
consequently, flat plate radiograph is no longer required in the
modern era when unenhanced CT scans are now the criterion
standard for diagnosis of acute renal colic.
Renal ultrasound
Ultrasound is fast, easy, safe, and relatively inexpensive to
perform. Ultrasound requires no intravenous contrast and can
easily detect any significant hydronephrosis, although this
must be differentiated from UPJ obstruction and an extrarenal
pelvis [7]. Ultrasound cannot be used to find small stones (ie,
<5 mm) and does not indicate kidney function.
Renal ultrasound works best in the setting of relatively
large stones within the renal pelvis or kidney and sometimes
at the UPJ. Whether the stones are radiolucent or opaque does
Apollo Medicine, Vol.1, September 2004
not matter because an ultrasound picture is based strictly on
density, not on calcium content. Ultrasound is a good way to
monitor known stones after medical or surgical therapy if the
stones are large enough to be detected by this modality and in
a suitable position. Ultrasound can also detect concomittent
abdominal aortic aneurysm or cholelithiasis, which can
sometimes be mistaken for acute renal colic. It is also useful in
differentiating filling defects observed on contrast studies
because stones are much more echogenic than tumors, clots,
or tissue [8]. Ultrasound is the initial imaging modality of
choice for patients with acute renal colic who are pregnant
because it avoids all potentially hazardous ionizing radiation.
Combining a renal ultrasound with an abdominal
radiograph has been proposed as a reasonable initial
evaluation protocol when a CT scan cannot be performed or is
unavailable.
Intravenous pyelogram
The main advantage of the IVP is the clear outline of the
entire urinary system that it provides, making it relatively easy
to visualize even mild hydronephrosis. This effect is enhanced
by the osmotic diuretic effect of the contrast medium. When
multiple pelvic calcifications exist, identifying the actual
stone is simple with the IVP. IVP can also show nonopaque
stones as filling defects. Disadvantages include the need for
intravenous contrast material, which may provoke an allergic
response or renal failure, and the need for multiple delayed
films, which can take hours. Conducting IVP test requires
presence of radiologist who may not be available at odd hours.
The delayed films take time because the contrast material
passes quite slowly into the blocked renal unit and ureter.
Filming continues until the entire distal ureter is visible,
which contributes to an increased radiation dose to the patient.
CT scans
Many institutions now have a renal colic study or protocol,
which consists of a noncontrast CT scan of the abdomen and
pelvis with a helical or spiral machine. Very narrow cuts are
taken through the kidneys and bladder areas where
symptomatic stones are most likely to be encountered.
CT scans are readily available in most hospitals and can be
performed and read in just a few minutes. Overall sensitivity
from multiple studies is reported at 94-100%, with accuracy
rated at 93-98% [9]. CT scans do not require contrast,
eliminating the risk of allergic reactions or renal failure.
Stones, including relatively radiolucent uric acid calculi,
cystine, matrix, and xanthine, show up as bright white spots,
making identification easy. While they do not contain
calcium, the stones are still much denser than the surrounding
soft tissue. The only exception is stones made of various
metabolites of medications, such as indinavir (Crixivan),
which is a protease inhibitor used in the treatment of HIV;
52

these stones are not visible on CT scans. These patients
require a contrast study, such as an IVP.
If the patient's true underlying pathology is something
other than a kidney stone, the CT scan is of more clinical
usefulness than an IVP in examining other possible problems
such as aneurysms, pancreatitis, appendicitis, ovarian
problems, and various bowel disorders.
Disadvantages of a CT scan include increased cost and
difficulties in identifying a stone if the patient exhibits limited
hydronephrosis and multiple pelvic calcifications [10]. A CT
scan cannot provide precise information about relative renal
function and usually cannot be used to diagnose MSK.
Curved planar reformatting using CT software can be
performed to convert the cross-sectional images of the CT
scan into an image that approximates a traditional abdominal
radiograph study. Because of the relatively high dose of
ionizing radiation it uses, CT scans should not be performed
on pregnant women.
Finally, the CT scan alone does not allow visual
differentiation between a radiolucent and a radiopaque
calculus. If a KUB or flat plate radiograph is performed at the
same time as the CT scan, then many of these objections and
problems disappear. However, obtaining the extra films
involves some additional delay, the patient is exposed to more
ionizing radiation, and the total cost for the workup increases.
Retrograde pyelograms
The most precise imaging method for determining the
anatomy of the ureter and renal pelvis, as well as making a
definitive diagnosis of any ureteral calculus, is neither the IVP
nor the renal colic CT scan. It is the retrograde pyelogram.
Urologists perform retrograde pyelograms when a precise
diagnosis cannot be made by other means or when a need
clearly exists for an endoscopic surgical procedure and the
exact anatomical characteristics of the ureter must be
clarified. Retrograde pyelograms are rarely performed merely
for diagnostic purposes because other less invasive studies
usually are sufficient. They are considered essential when
surgery is deemed necessary because of uncontrollable pain,
severe urinary infection or urosepsis with a blocked kidney, a
solitary obstructed kidney, a stone that is thought unlikely to
pass spontaneously because of its large size (generally >7
mm), or the presence of possible anatomical abnormalities,
such as ureteral strictures.
Retrograde pyelograms can be performed safely both in
patients highly allergic to intravenous contrast media and in
patients with renal failure because the contrast medium never
enters the bloodstream and therefore requires no renal
filtration or excretion and causes no anaphylaxis.
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Nuclear renal scans
A nuclear renal scan can be used to objectively measure
differential renal function, especially in a dilated system
where the degree of obstruction is in question. This is also a
reasonable study in pregnant patients where radiation
exposure must be limited.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) has virtually no role
in the current evaluation of acute renal colic in the typical
patient.
CONCLUSION
Acute renal colic is a common emergency requiring
evaluation. Non contract CT scan with or without a KUB x
ray is considered the best intial emergency evaluation for
proving the diagnosis, as well as finding out other pathologies
mimicking renal colic. In absence of spiral CT facilities,
ultrasound examination with plain x ray KUB has been
proposed as a reasonable initial evaluation protocol.
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