History

Fact Explanation
Loin and abdominal pain Ureterolithiasis is a common cause of emergency admission to surgical wards. It is mostly seen in middle aged patients.[1] Obstruction of the ureter leads to intermittent spasms of ureteric wall proximal to the obstruction. This results in severe intermittent pain which starts in the loin region and radiates to the groin. Ureteric colic is most often due to ureteric stones and rarely may be due to blood clots, tumor fragments or renal papillae.
Radiation of pain from the loin to groin The pain of ureteric colic is distributed along the nervous innervation of the ureter. The pain appears to originate in the loin and radiates around the flank to the groin, external genitalia and the anterior surface of the thigh. The radiation is more prominent as the stone descends along the ureter.
Haematuria Microscopic haematuria may be present due to traumatization of the ureteric wall by the stone. Suspect clot colic if gross haematuria is present.
Patient appears agitated and restless The pain is severe and the patients are restless, moves about during bouts of pain.
Pain during micturition/ Strangury These symptoms are prominent when the stone is migrating through the intramural part of the ureter.
Presentation with complications Ureteric obstruction may lead to hydronephrosis which present with abdominal discomfort. Stasis if urine predisposes to infection, pyelonephritis presents with high fever, rigors, loin pain & tenderness. Perforation of the ureter is a rare complication. Extravasation of urine into the peritoneum may present with acute onset severe abdominal pain, features of peritonitis and inability to pass urine.
Risk factors/ Associations Ureteric stones usually form within the kidney. Urinary stasis, infection and changes in the solute concentration of the urine predispose to stone formation. The commonly encountered stone varieties are oxalate and tri-phosphate stones. Uric acid stones, Xanthine stones and cystine stones are rare. Urinary tract infection with proteus spp result in acidic urine and increase the risk of tri-phosphate stones. Gout and cystinuria predispose to uric acid stones and cystine stones respectively.[2] Patients with gross haematuria are at risk of clot colic. Renal papillary necrosis is associated with diabetes mellitus, analgesic abuse, pyelonephritis, sickle cell disease and obstruction of the urinary tract.[3]
References
  1. ROMERO V, AKPINAR H, ASSIMOS DG. Kidney Stones: A Global Picture of Prevalence, Incidence, and Associated Risk Factors Rev Urol [online] 2010, 12(2-3):e86-e96 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2931286
  2. TEICHMAN JOEL M.H.. Acute Renal Colic from Ureteral Calculus. N Engl J Med [online] 2004 February, 350(7):684-693 [viewed 26 August 2014] Available from: doi:10.1056/NEJMcp030813
  3. JUNG DC, KIM SH, JUNG SI, HWANG SI, KIM SH. Renal papillary necrosis: review and comparison of findings at multi-detector row CT and intravenous urography. Radiographics [online] 2006 Nov-Dec, 26(6):1827-36 [viewed 26 August 2014] Available from: doi:10.1148/rg.266065039

Examination

Fact Explanation
General examination : Anxious and distressed patient Due to severe pain.
General examination : Features of dehydration Due to reduced intake of fluids.
Abdominal examination : Abdominal tenderness The loin and flank region may be tender. Rest of the abdominal examination is usually normal.
References

Differential Diagnoses

Fact Explanation
Biliary colic Gallstone formation is the commonest disease of the gallbladder. Gallstones are of three types – Cholesterol, pigment and mixed stones. Cholesterol stones formation is precipitated in bile super-saturated with cholesterol. Black pigment stones are formed in patients with chronic haemolytic conditions. Infected bile and cirrhosis are risk factors for brown pigment stone formation. Majority of gallstones are asymptomatic. Obstruction of the neck of the gallbladder by the stone results in biliary colic. The pain is acute in onset and is located in the right hypochondrium. The pain characteristically radiates along the flank to the infra-scapular region. Biliary colic is not a true colic in that there are no pain free periods between exacerbations. It lasts for 2-4h before gradually subsiding. The patient may be nauseated and anorexic. The initial inflammatory process is induced by chemicals within the bile. This may secondarily get infected and progress to acute cholecystitis which presents with fever, constant hypochondrial pain and jaundice. Physical examination findings are tenderness in the right hypochondrium. The diagnosis is by clinical information and imaging modalities – USS, abdominal X-ray.[1]
Acute appendicitis Acute appendicitis is a common surgical casualty admission. It is more common among teenagers and young adults. Acute inflammation of the appendix is often linked with obstruction of its lumen by faecoliths, food particles and rarely by tumors. The patient presents with a migratory type abdominal pain, nausea/ vomiting & anorexia. The abdominal pain is initially a diffuse dull pain located in the peri-umbilical area which localizes to the right iliac fossa (RIF) as the inflammation spread to the parietal peritoneum. A mild temperature (<38) may be present. Abdominal examination will reveal rebound tenderness and guarding in the RIF. Diagnosis is by the clinical information supported by abdominal ultrasound scan. Suspect malignancy of the caecum when acute appendicitis develops in an elderly patient.[2]
Renal Cell Carcinoma (RCC) Renal cell carcinoma may cause obstruction of the ureters from clot formation (clot colic) and dislodged tumor particles. Renal cell carcinoma is the commonest tumor of the kidney and is more common among males.[3] Adenocarcinoma is the commonest histological variety. The patient presents with gross haematuria, abdominal mass or abdominal discomfort. RCC is well known to present with atypical features – anemia/constitutional symptoms, polycythemia, lower limb edema, left sided varicocele, pyrexia of unknown origin and ectopic hormone production (Renin, androgens, Calcitonin). The tumor frequently metastasizes to the lung, liver and bone. Growth along the renal vein may lead to obstruction of the gonadal vein and the vena cava. On physical examination an abdominal mass situated in the lumbar region may be palpable. The diagnosis is by imaging of the abdomen, Ultrasound scan, CT scan and MRI can be used for diagnosis.
References
  1. TERJUNG B, NEUBRAND M, SAUERBRUCH T. [Acute biliary colic. Etiology, diagnosis and therapy]. Internist (Berl) [online] 2003 May, 44(5):570-6, 578-84 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12966786
  2. HUMES DJ, SIMPSON J. Acute appendicitis. BMJ [online] 2006 Sep 9, 333(7567):530-4 [viewed 26 August 2014] Available from: doi:10.1136/bmj.38940.664363.AE
  3. LIPWORTH L, TARONE RE, MCLAUGHLIN JK. The epidemiology of renal cell carcinoma. J Urol [online] 2006 Dec, 176(6 Pt 1):2353-8 [viewed 26 August 2014] Available from: doi:10.1016/j.juro.2006.07.130

Investigations - for Diagnosis

Fact Explanation
Abdominal X-ray Majority of ureteric stones are radio-opaque. Pure uric acid stones and xanthine stones are radio-lucent. Trace the pathway of the ureter in the X-ray from the renal hilum along the tips of the transverse processes of the lumbar vertebra. Gallstones, calcified lymph nodes, faecoliths, phleboliths and intestinal foreign bodies may be mistaken for ureteric stones.
CT scan CT scan is being increasingly used to diagnose patients presenting with ureteric colic. Spiral CT is considered a diagnostic investigation with high sensitivity and specificity.[1] The presence of a stone and the morphology of the kidney and ureter can be assessed by CT scan.
Intravenous urogram (IVU) Radiolucent stones can be diagnosed by IVU as a filling defect in the contrast-filled urinary tract. Extravasation of contrast may suggest ureteric perforation. Combination of IVU with ultrasound scan can increase the diagnostic accuracy.[2]
Ultrasound scan The presence of hydronephrosis and hydroureter can be excluded by USS. Presence of an obstructed urinary system requires prompt intervention.
Urinalysis Red blood cells can be found in urine.
References
  1. YILMAZ S, SINDEL T, ARSLAN G, OZKAYNAK C, KARAALI K, KABAALIOğLU A, LüLECI E. Renal colic: comparison of spiral CT, US and IVU in the detection of ureteral calculi. Eur Radiol [online] 1998, 8(2):212-7 [viewed 26 August 2014] Available from: doi:10.1007/s003300050364
  2. SAITA H, MATSUKAWA M, FUKUSHIMA H, OHYAMA C, NAGATA Y. Ultrasound diagnosis of ureteral stones: its usefulness with subsequent excretory urography. J Urol [online] 1988 Jul, 140(1):28-31 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3288773

Investigations - Fitness for Management

Fact Explanation
Renal function tests : Serum electrolytes, blood urea and serum creatinine To assess renal function. If open surgery is considered prior to surgery renal function tests should be carried out.
Full blood count If open surgery is considered.
References

Management - General Measures

Fact Explanation
Reassurance and patient education Provide information about the diagnosis. The aetiology, complications, investigations and treatment options should be discussed with the patient. The patient may be distressed and worried due to the severe pain. Reassurance should be provided.
Pain relief Pain relief can be achieved with non-steroidal anti-inflammatory agents such as diclofenac sodium. Tramadol or opioids such as pethidine and morphine may be occasionally required in severe pain.[1]
Use of smooth muscle relaxants Smooth muscle relaxants such as propantheline have being tried in certain centers. Further evaluation is required to recommend routine use.[2]
References
  1. OSORIO L, LIMA E, AUTORINO R, MARCELO F. Emergency management of ureteral stones: Recent advances Indian J Urol [online] 2008, 24(4):461-466 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.44248
  2. NUSS GR, RACKLEY JD, ASSIMOS DG. Adjunctive Therapy to Promote Stone Passage Rev Urol [online] 2005, 7(2):67-74 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477562

Management - Specific Treatments

Fact Explanation
Expectant management - Spontaneous Expulsion Ureteric stones smaller than 0.5cm can be observed with regular X-ray as 80% of such stones pass spontaneously with urine.
Medical Expulsion Therapy Despite the possibility of spontaneous expulsion, patient factors such as poor pain tolerance and development of infection necessitate active expulsion of the stone which are less than 10mm in diameter in means of reducing contraction and basal tone of the ureteric musculature and reducing the peristalsis. Alpha blockers such as Tamsulosin and Nifedipine are used in this purpose and corticosteroids are also reported to facilitate the expulsion as well. However, studies have demonstrated the effect of MET to be most useful in combination with shockwave lithotripsy[5]
Indications for surgical intervention Consider surgical removal of the stone when the stone is large, is not moving down the ureter, complicated with urinary infection, repeated attacks of severe colics occur and when there is complete obstruction of the kidney. Removal can be by endoscopic techniques or by open surgery. Obstruction of the urinary tract causing hydronephrosis and hydroureter requires surgical intervention to prevent infection and kidney damage. Stone removal should be expedited in pre-existing renal dysfunction and in single functioning kidney.
Endoscopic removal Endoscope/ ureteroscope can be used as a minimally invasive procedure. The ureter is entered into via the bladder and the stone is directly visualized. It may be removed by Dormia basket or by grasping forceps. The stone that can’t be removed as a whole fragmented by laser, percussive force or electrohydraulic force. Endoscopic ureteric meatotomy can be used if the stone is lodged within the intramural part of the ureter. An incision is made at the meatus to widen the ureteric meatus.[1] [2]
Lithotripsy in situ Ureteric stones can be fragmented within the ureter by a lithotripter.[3] Avoid this technique when large stones are encountered and if the stone is deeply embedded within the wall of the ureter.
Open surgery : Ureterolithotomy Open surgery is rarely used for longstanding large ureteric stones. The abdominal X-ray is used identify the position of the stone within the ureter. An appropriately cited surgical incision is made to the expose the ureter. Slings are applied proximally and distally to the stone to prevent movement of the stone during surgery. Ureterotomy is performed directly over the stone. The stone is freed by blunt dissection and removed. The ureter is closed with absorbable sutures and a drain is left in situ. Laparoscopic approach has being introduced sussessfully in the recent past with good results.[4]
References
  1. MUGIYA S, NAGATA M, UN-NO T, TAKAYAMA T, SUZUKI K, FUJITA K. Endoscopic management of impacted ureteral stones using a small caliber ureteroscope and a laser lithotriptor. J Urol [online] 2000 Aug, 164(2):329-31 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10893577
  2. PUPPO P, RICCIOTTI G, BOZZO W, INTROINI C. Primary endoscopic treatment of ureteric calculi. A review of 378 cases. Eur Urol [online] 1999, 36(1):48-52 [viewed 26 August 2014] Available from: doi:19926
  3. CASS AS. In situ extracorporeal shock wave lithotripsy for obstructing ureteral stones with acute renal colic. J Urol [online] 1992 Dec, 148(6):1786-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1433608
  4. MANDHANI A, KAPOOR R. Laparoscopic ureterolithotomy for lower ureteric stones: Steps to make it a simple procedure Indian J Urol [online] 2009, 25(1):140-142 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.45556
  5. SEITZ CHRISTIAN. Medical Expulsive Therapy of Ureteral Calculi and Supportive Therapy After Extracorporeal Shock Wave Lithotripsy. European Urology Supplements [online] 2010 December, 9(12):807-813 [viewed 26 August 2014] Available from: doi:10.1016/j.eursup.2010.11.008