RENAL COLIC

RENAL COLIC

dr. I WAYAN SUARSANA , SpU

DIVISI UROLOGI SMF BEDAH RSUD UNDATA PALU
KIDNEY PAIN
Typical renal pain
Dull and constant ache
Felt in the costovertebral angle
just lateral to sacrospinalis muscle
just below the 12th rib
Often spread along sub costal area toward the
umbilicus
Expected in the renal disease that cause sudden
distention of the renal capsule
Acute pyelonephritis sudden edema
Acute ureteral obstruction Sudden renal
back pressure
HOWEVER
Many urologic renal disease are painless
Their progression is so slow sudden capsular
distention does not occur
Cancer
Chronic pyelonephritis
Staghorn calculus
Tuberculosis
Polycystic kidney
Hydronephrosis due to chronic ureteral
obstruction
URETERAL PAIN
Caused by the hyperperistalsis and spasm of the
renal pelvic and ureter
Attempt to rid itself of a foreign body
Attempt to overcome obstruction
THUS ..... This pain is
Stimulated by acute obstruction
Passage of a stone or blood clot
A combination of
A back pain (renal capsular distension)
Severe colicky pain ( Renal pelvic and ureteral
muscle spasm)
 MENGAPA SAMPAI
SEBESAR DAN SEBANYAK
INI ??
URETERAL PAIN
Radiate from the CVA down toward the lower
anterior abdominal quadrant (along the course
of the ureter
In men : also be felt in the bladder , scrotum or
testicle
In Women : Radiate into the vulva
URETERAL PAIN
The history of pain and the site of referral can be
used to judge the position of a ureteral stone
Upper ureteral stone
The pain radiates to the testicle
The nerve supplay of the testicle is similiar to that of
kidney and upper ureter (T11 12)
Mid ureter stone
Right mid ureter stone : The pain is referred to
McBurneys point (simulate appendicitis)
Left Mid ureter stone : The pain resemble diverticulitis
or other disease of the descending or sigmoid colon
(T 12- L1)
URETERAL PAIN
The history of pain and the site of referral can be
used to judge the position of a ureteral stone
Distal Ureteral stone
The stone approaches the bladder
oThere are inflammation and edema of the
ureteral orifice
oSymptoms of vesical irritability may occur
Urinary frequency
urgency
URETERAL PAIN
HOWEVER
In mild ureteral obstruction (as seen in
congenital stenosis) There is usually no
Pain, either renal or ureteral
Gastrointestinal Symptoms of Urologic
Disease

Gastrointestinal symptoms often present in painful

or painless renal or ureteral disease
Acute pyelonefritis :
Localized back pain
Vesical iritability, chills and fever
Generalized abdominal pain and distention
Ureteral stone
Renal or ureter colic and hematuria
May experience severe nausea and vomiting and
abdominal distention.
Gastrointestinal Symptoms of Urologic
Disease
Cause of the mimicry
Renointestinal reflexes
Organ relationships
Peritoneal Irritation

Renoistestinal reflexes
The common autonomic and sensory innervations of
the two systems
Afferent stimuli from renal capsule or musculature of
the pelvis refleks pylorospasm or changes of
enteric tract smooth muscle tone
 Gastrointestinal Symptoms of
Urologic Disease
Organ relationship
Inflammations or tumors in the retroperitoneum
may extend into or displace intraperitoneal
organ causing them to produce symptoms
Right kidney : closely related to hepatic fleksure of
the colon, duodenum, the head of the pancreas,
common bile duct, the liver and the gallbladder.
 Gastrointestinal Symptoms of
Urologic Disease
Peritoneal Irritation
The anterior surface of the kidneys are covered by
peritoneum
Renal inflammation peritoneal irritation
muscle rigidity
Symptoms arising from chronic renal disease
(staghorn calculus, cancer, PNC) may be entirely
gastrointestinal and simulate the syndromes of
peptic ulcer, gallbladder disease
Gastrointestinal Symptoms of
Urologic Disease

If survey of the gastrointestinal tract fails to

demonstrate suspected disease processes

GIVE EVERY CONSIDERATION TO STUDY OF

THE URINARY TRACT
Treatment Of Patients With
Renal Colic
Pain Relief
Treatment with NSAIDs
Prevention of recurrent episodes of renal colic
Effect of diclofenac on renal function
Spontaneous Passage of stones
Medical Expulsive treatment
 Pain relief

Is usually the most urgent therapeutic step in

patients with an acute stone episode
Pharmacological agent LE GR
Diclophenac sodium 1b A

Indomethacin 4 C
Ibuprophen

Metamizole 4 C
Tramadol
Level of evidence and grade of guideline
recommendations
LEVEL TYPE OF EVIDENCE
1a Meta analisis of randomized trials
1b At least one randomized trials
2a One well designed controlled study without randomization
2b One other type of well designed quasi experimental studies
3 Well design ed non experimental studies : comparative studies,
correlation studies and case report
4 Expert commite reports or opinion or clinical experience of respected
authorities

GRADE NATURE OF RECOMMENDATIONS

A Based on clinical studies of good quality , at least one randomized
trial
B Based on well conducted clinical studies but without randomized
clinical trial
C Made despite the absence of directly applicable clinical studies
 TREATMENT WITH NSAIDs
First shown with indomethacin in 1978

Diclofenac vs Spasmofen ( a narcotic analgesic)

A doble blind study
A better effect with diclofenac and fewer side effects

Diclofenac Vs ketoprofen and ketorolak

Randomized double blind , comparative studies
No difference were recorded between the two
substances
 Prevention of Recurrent Episodes of
Renal Colic

Recurrent pain episodes

Double blind placebo controlled trial
significantly fewer in patients treated with 50 mg
diclofenac three times daily during the first 7 days
The effect was most pronounced in the first 4 days
Prevention of Recurrent
Episodes of Renal Colic
Passage of the stone and normalization of
renal function should be confirmed
Drainage by stenting or PNS or by stone
removal should be carried out if pain relief
can not obtained by medical means
EFFECT OF DICLOFENAC ON RENAL
FUNCTION
The renal function can be affected in patients
with an already reduced function
This is not the case for normaly functioning
kidneys
Recommendatios and considerations regarding
treatment of the patient with renal colic

RECOMMENDATIONS LE G
R
Treatment should be started with an NSAIDs 1b A

Diclofenac sodium affects GFR in patients with

reduced renal function but not in patients with 2a 2a
normal renal function

Diclofenac sodium is recommended as a

method to counteract recurrent after an 1b A
episode of ureteral colic
INDICATIONS FOR ACTIVE STONE REMOVAL
INDICATIONS FOR CONSIDERING ACTIVE STONE LE GR
REMOVAL
Stone diameter 7 mm because of a low rate
spontaneous passage 2a B

Adequate pain relief can not be achieved 4 B

Stone obstruction is associated with infection 4 B

There is a risk of pyonephrosis or urosepsis 4 B

Single kidney with obstruction 4 B

Bilateral obstruction 4 B