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RENAL CALCULI

Acute passage of a kidney stone from the renal pelvis through the ureter gives rise to pain at times so excruciating that it has been likened to the discomfort of childbirth. The often sudden, extremely painful episode of renal colic prompts more than 450,000 visits to EDs annually and places emergency physicians on the front line of management of acute nephrolithiasis. ED management is focused on excluding other serious diagnoses and providing adequate pain relief.

Pathophysiology:Most calculi arise in the kidney when urine becomes supersaturated with a salt that is capable of forming solid crystals. Symptoms arise as these calculi become impacted within the ureter as they pass toward the urinary bladder.

 

Acute passage of a kidney stone from the renal pelvis through the ureter gives rise to pain at times so excruciating that it has been likened to the discomfort of childbirth. The often sudden, extremely painful episode of renal colic prompts more than 450,000 visits to EDs annually and places emergency physicians on the front line of management of acute nephrolithiasis. ED management is focused on excluding other serious diagnoses and providing adequate pain relief.

Pathophysiology:Most calculi arise in the kidney when urine becomes supersaturated with a salt that is capable of forming solid crystals. Symptoms arise as these calculi become impacted within the ureter as they pass toward the urinary bladder.

Emergency Department Care:

  • Intravenous access should be obtained to facilitate delivery of analgesic and antiemetic medications.
  • Intravenous hydration is controversial.
    • Some authorities believe that intravenous fluids hasten passage of the stone through the urogenital system. Others express concern that additional hydrostatic pressure exacerbates the pain of renal colic.
    • No data exist to support either theory. Intravenous hydration should be given to patients with clinical signs of dehydration or to those with a borderline serum creatinine level who must undergo IVP.
  • Analgesia should be provided promptly.
    • The pain of renal colic is mediated by prostaglandin E2. Nonsteroidal anti-inflammatory drugs inhibit formation of this mediator, and ketorolac (the only parenteral NSAID approved by the FDA) has been proven in multiple studies to be as effective as opioid analgesics, with fewer adverse effects.
    • Opioid analgesics can be added in cases of incomplete pain control.
  • Antiemetics should be administered as needed.
  • Medical expulsive therapy
    • Multiple prospective randomized controlled studies (Dellabella, 2003; Dellabella, 2005; Porpiglia, 2004) have demonstrated that patients treated with oral alpha-blockers have an increased rate of spontaneous stone passage and a decreased time to stone passage. The best studied of these is tamsulosin, 0.4 mg administered daily.
    • Calcium channel blockers in combination with oral steroids have also proven efficacious in multiple studies. The most common regimen is 30-mg slow-release nifedipine daily plus oral corticosteroid such as prednisolone.
  • Strain urine for stone collection.

Consultations:



  • Consult a urologist immediately in cases of ureterolithiasis with proximal UTI. Infected hydronephrosis is a true urologic emergency and requires hospital admission, intravenous antibiotics, and immediate drainage of the infected hydronephrosis via percutaneous nephrostomy or ureteral stent placement.
  • Urologic consultation is also appropriate in patients who are unable to tolerate oral fluids and medications and in those with unrelenting pain, renal failure, renal transplant, a solitary functioning kidney, and history of prior stones that required invasive intervention.

Renal failure or kidney failure is the condition in which the kidneys fail to function adequately.

Biochemically, it is typically detected by an elevated serum creatinine. In the science of physiology, renal failure is described as a decrease in the glomerular filtration rate


Date: 2015-01-12; view: 775


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Lesson 7. GASTROENTEROLOGY | ACUTE RINAL FAILURE
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