Renal colic

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Steven C. Campbell, M.D., Ph.D.Soumya Sachdeva Luke Rusowicz-Orazem, B.S.

Overview

Renal colic is a type of pain commonly caused by kidney stones or accumulation of crystals. These kidney stones cause interference with the flow of urine and the kidney may swell up causing pain (colic).

The pain typically begins in the kidney area or below it and radiates through the flank until it reaches the bladder. The pain is colicky in nature, meaning that it comes on in spasmodic waves as opposed to being a steady continuous pain. It may come in two varieties: dull and acute; the acute variation is particularly unpleasant and has been described as one of the strongest pain sensations felt by humans.[2]

Depending on the type and sizes of the kidney stones moving through the urinal tract the pain may be stronger in the renal or bladder area or equally strong in both.

Differential diagnosis

Classification of acute abdomen based on etiology Presentation Clinical findings Diagnosis Comments Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Common causes of Peritonitis Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Perforated gastric and duodenal ulcer + Diffuse − + + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Acute suppurative cholangitis + + RUQ + + + + ± Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + RUQ + − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Gall stone disease/Cholelithiasis ± − Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic symptoms Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding Functional Irritable Bowel Syndrome - Diffuse - - - - N Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria - High dietary fiber Osmotic laxatives Antispasmodicdrugs Causes Common Causes Chronic interstitial nephritis Cystinuria Endometriosis Nephrocalcinosis Nephrolithiasis Oxalosis Probenecid Urinary blockage Causes by Organ System Cardiovascular Renal artery embolism Chemical/Poisoning No underlying causes Dental No underlying causes Dermatologic No underlying causes Drug Side Effect Probenecid Ear Nose Throat No underlying causes Endocrine No underlying causes Environmental No underlying causes Gastroenterologic Chilaiditi syndrome, Wilson's disease Genetic No underlying causes Hematologic Papillary necrosis Iatrogenic No underlying causes Infectious Disease No underlying causes Musculoskeletal/Orthopedic No underlying causes Neurologic No underlying causes Nutritional/Metabolic No underlying causes Obstetric/Gynecologic Endometriosis, Müllerianosis Oncologic No underlying causes Ophthalmologic No underlying causes Overdose/Toxicity No underlying causes Psychiatric No underlying causes Pulmonary No underlying causes Renal/Electrolyte Analgesic nephropathy syndrome, Chronic interstitial nephritis, Cystinuria, Danubian endemic familial nephropathy, Hydatiduria, Medullary sponge kidney, Nephrocalcinosis, Nephrolithiasis, Oxalosis, Papillary necrosis, Pyelocalyceal diverticulum, Renal artery embolism, The primary hyperoxalurias, Urinary blockage Rheumatology/Immunology/Allergy No underlying causes Sexual No underlying causes Trauma No underlying causes Urologic No underlying causes Miscellaneous No underlying causes Causes in Alphabetical Order Analgesic nephropathy syndrome Chilaiditi syndrome Chronic interstitial nephritis Cystinuria Danubian endemic familial nephropathy Endometriosis Hydatiduria Medullary sponge kidney Müllerianosis Nephrocalcinosis Nephrolithiasis Oxalosis Papillary necrosis Probenecid Pyelocalyceal diverticulum Renal artery embolism The primary hyperoxalurias Urinary blockage Wilson's disease Treatment and Prognosis Most small stones are passed spontaneously and only pain management is required. For this type of pain, strong Non-steroidal anti-inflammatory drugs (NSAID) such as Diclofenac provide better pain relief than opiates. Lying down on the non-aching side and applying a hot bottle or towel to the area affected may help. If the pain is not too intense, a more speedy release of the stones may be achieved by walking. Larger stones may require intervention for their removal. See Also Kidney stones