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eMedicine Specialties > Emergency Medicine > Genitourinary
Renal Calculi
Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill,
Carolinas Medical Center
Updated: Oct 29, 2009
Introduction
Background
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.
急診醫師的責任在於排除其他嚴重的診斷以及給予足夠的疼痛控制
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.
Frequency
United States
The lifetime prevalence of nephrolithiasis is approximately 12% for men and 7% for women in the United States, and it is
rising. Recurrence rates after the first stone episode are 14%, 35%, and 52% at 1, 5, and 10 years, respectively. An
increased incidence has been noted in the southeastern United States, prompting the term "stone belt" for this region of
美國東南方地區結石病人眾多，有"結石帶"之暱稱。
the country.1
International
Nephrolithiasis occurs in all parts of the world, with a lower lifetime risk of 2-5% in Asia, 8-15% in the West, and 20% in
Saudi Arabia.
Mortality/Morbidity
Approximately 80-85% of stones pass spontaneously.
大約80~85%的病人可以自行排出石頭，但是有20%左右的病人可能會因為以下
幾種原因需要住院治療：持續疼痛、無法經口進食、感染、石頭無法排出。
Approximately 20% of patients require hospital admission because of unrelenting pain, inability to retain enteral
fluids, proximal urinary tract infection (UTI), or inability to pass the stone.
A ureteral stone associated with obstruction and upper UTI is a true urologic emergency. Complications include
perinephric abscess, urosepsis, and death. Immediate involvement of the urologist is essential.
輸尿管結石造成阻塞是與上泌尿道感染是泌尿科急症，因為可能會造成腎周膿
瘍、尿路敗血與死亡。
Race
White males are affected 3-4 times more often than African American males.
African Americans have a higher incidence of infected ureteral calculi than whites.
Sex
The male-to-female ratio is approximately 3:1.
Female patients have a higher incidence of infected hydronephrosis.
Age
Peak onset of symptomatic nephrolithiasis is in the third and fourth decades of life.
Beware of the patient older than 60 years with an apparent first kidney stone. Consider the possibility of
symptomatic abdominal aortic aneurysm (AAA) in the older patient, and rule out this possibility before pursuing the
diagnosis of nephrolithiasis. Use bedside ultrasonography if the patient's condition is potentially unstable. CT scan
is a reasonable alternative in the stable patient. >60歲以上的病患一定要先排除AAA的可能性，必要時排CT以確定診斷。
Nephrolithiasis in children is rare; approximately 5-10 children aged 10 months to 16 years are seen annually for
the condition at a typical US pediatric referral center.
Clinical
History
Most calculi originate within the kidney and proceed distally, creating various degrees of urinary obstruction as they
become lodged in narrow areas, including the ureteropelvic junction, pelvic brim, and ureterovesical junction. Location and
quality of pain are related to position of the stone within the urinary tract. Severity of pain is related to the degree of
obstruction, presence of ureteral spasm, and presence of any associated infection.
UPJ的症狀
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to
the groin, due to distension of the renal capsule.
Stones impacted within the ureter cause abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen with
radiation to the testicles or the vulvar area. Intense nausea, with or without vomiting, usually is present.
UVJ的症狀
Stones lodged at the ureterovesical junction also may cause irritative voiding symptoms, such as urinary frequency
and dysuria.
Calculi that have entered the bladder are usually asymptomatic and are passed relatively easily during urination.
Rarely, a patient reports positional urinary retention (obstruction precipitated by standing, relieved by recumbency),
which is due to the ball-valve effect of a large stone located at the bladder outlet.
Physical
The classic patient with renal colic is writhing in pain, pacing about, and unable to lie still, in contrast to a patient with
peritoneal irritation, who remains motionless to minimize discomfort.
Fever is not part of the presentation of uncomplicated nephrolithiasis. If present, suspect infected hydronephrosis,
pyonephrosis, or perinephric abscess.
The most common finding in ureterolithiasis is flank tenderness due to the dilation and spasm of the ureter from
transient obstruction as the stone passes from the kidney to the bladder.
Abdominal examination usually is unremarkable. Bowel sounds may be hypoactive, a reflection of mild ileus, which
is not uncommon in patients with severe, acute pain.
In patients older than 60 years with no prior history of renal stones, the emergency physician should look carefully
for physical signs of AAA (see Aneurysm, Abdominal).
Testicles may be painful but should not be very tender and should appear normal.
Causes
The formation of the 4 basic chemical types of renal calculi is associated with more than 20 underlying etiologies. Stone
analysis, together with serum and 24-hour urine metabolic evaluation, can identify an etiology in more than 95% of patients.
Specific therapy can result in a remission rate of more than 80% and can decrease the individual recurrence rate by 90%.
Therefore, emergency physicians should stress the importance of urologic follow-up, especially in patients with recurrent
stones, solitary kidneys, or previous kidney or stone surgery and in all children.2
含鈣結石
最近的研究指出：低蛋白低鹽飲食比低鈣飲食能有效預防含鈣結石的產生。
雖然第一次的結石症狀跟飲食中含鈣的多寡有關，但是目前的趨勢認為，
預防結石的復發不用限制飲食中含鈣的成分。
Calcium stones (75%): Recent data suggest that a low-protein, low-salt diet may be preferable to a low-calcium diet
in hypercalciuric stone formers for preventing stone recurrences.3 Epidemiological studies have shown that the
incidence of stone disease is inversely related to the magnitude of dietary calcium intake in first-time stone
formers. There is a trend in the urology community not to restrict dietary intake of calcium in recurrent stone
formers. This is especially important for postmenopausal women in whom there is an increased concern for the
development of osteoporosis. Calcium oxalate, calcium phosphate, and calcium urate are associated with the
following disorders:
Hyperparathyroidism - Treated surgically or with orthophosphates if the patient is not a surgical candidate
Increased gut absorption of calcium - The most common identifiable cause of hypercalciuria, treated with
calcium binders or thiazides plus potassium citrate
Renal calcium leak - Treated with thiazide diuretics
Renal phosphate leak - Treated with oral phosphate supplements
Hyperuricosuria - Treated with allopurinol, low purine diet, or alkalinizing agents such as potassium citrate
Hyperoxaluria - Treated with dietary oxalate restriction, oxalate binders, vitamin B-6, or orthophosphates
Hypocitraturia - Treated with potassium citrate
Hypomagnesuria - Treated with magnesium supplements
感染性結石
鳥糞石
Struvite (magnesium ammonium phosphate) stones (15%)
Struvite stones are associated with chronic UTI with gram-negative rods capable of splitting urea into
ammonium, which combines with phosphate and magnesium. Underlying anatomical abnormalities that
predispose patients to recurrent kidney infections should be sought and corrected.
Usual organisms include Proteus, Pseudomonas, and Klebsiella species. Escherichia coli is not capable
of splitting urea and, therefore, is not associated with struvite stones.
UTI does not resolve until stone is removed entirely.
感染性結石是因為細菌的慢性感染，持續分解尿素成為胺而形成的；
E. coli 不會分解尿素，所以不會產生感染性結石。
Urine pH is typically greater than 7.
Uric acid stones (6%): These are associated with urine pH less than 5.5, high purine intake (eg, organ meats,
legumes, fish, meat extracts, gravies), or malignancy (ie, rapid cell turnover). Approximately 25% of patients with
uric acid stone have gout. Serum and 24-hour urine sample should be sent for creatinine and uric acid
determination. If serum or urinary uric acid is elevated, the patient may be treated with allopurinol 300 mg daily.
Patients with normal serum or urinary uric acid are best managed by alkali therapy alone.
Cystine stones (2%)
Cystine stones arise because of an intrinsic metabolic defect resulting in failure of renal tubular reabsorption
of cystine, ornithine, lysine, and arginine.
Urine becomes supersaturated with cystine with resultant crystal deposition.
These are treated with low-methionine diet (unpleasant), binders such as penicillamine or
a-mercaptopropionylglycine, large urinary volumes, or alkalinizing agents. A 24-hour quantitative urinary
cystine determination helps to titrate the dose of drug therapy to achieve a urinary cystine concentration of
less than 300 mg/L.
Drug-induced stone disease: A number of medications or their metabolites can precipitate in urine causing stone
formation. These include indinavir; atazanavir; guaifenesin; triamterene; silicate (overuse of antacids containing
magnesium silicate); and sulfa drugs including sulfasalazine, sulfadiazine, acetylsulfamethoxazole,
acetylsulfasoxazole, and acetylsulfaguanidine.4,5,6
Differential Diagnoses
Aneurysm, Abdominal
Obstruction, Small Bowel
Aneurysm, Thoracic
Pancreatitis
Appendicitis, Acute
Papillary Necrosis
Back Pain, Mechanical
Pediatrics, Urinary Tract Infections and Pyelonephritis
Cholecystitis and Biliary Colic
Pelvic Inflammatory Disease
Cholelithiasis
Pneumonia, Bacterial
Constipation
Pneumothorax, Tension and Traumatic
Dissection, Aortic
Pregnancy, Ectopic
Diverticular Disease
Pregnancy, Urinary Tract Infections
Epididymitis
Renal Cell Carcinoma
Foreign Bodies, Gastrointestinal
Renal Vein Thrombosis
Foreign Bodies, Rectum
Testicular Torsion
Gastritis and Peptic Ulcer Disease
Torsion of the Appendices and Epididymis
Glomerulonephritis, Acute
Transplants, Renal
Herpes Zoster
Urinary Obstruction
Inflammatory Bowel Disease
Urinary Tract Infection, Female
Lumbar (Intervertebral) Disk Disorders
Urinary Tract Infection, Male
Obstruction, Large Bowel
Wilms Tumor
Other Problems to Be Considered
Pyonephrosis
Renal artery embolus
Workup
Laboratory Studies
Urinalysis
One retrospective study found that 67% of patients with ureterolithiasis had more than 5 RBC per high
power field (hpf) and 89% of patients had more than 0 RBC/hpf on urine microscopic examination.7 In
addition, 94.5% have hematuria if screened with microscopy plus urine dipstick testing.8
Degree of hematuria is not predictive of stone size or likelihood of passage. 血尿跟石頭的大小無關。
No literature exists to support the theory that ureterolithiasis without hematuria is indicative of complete
ureteral obstruction. 結時卻沒有血尿不代表完全輸尿管阻塞
Pyuria (>5 WBC/hpf on a centrifuged specimen) in a patient with ureterolithiasis should prompt a careful
search for signs of infected hydronephrosis. Obtain a complete blood count (CBC), creatinine, and urine
culture. Treatment with antibiotics is indicated in patients with ureterolithiasis and pyuria. Admission to the
hospital is mandatory if the patient has any signs of infected hydronephrosis (fever, elevated WBC count,
elevated creatinine), or if follow-up within 24 hours is not reliably available. 有結石與膿尿必須排除infected hydronephrosis
A urine pH greater than 7 suggests presence of urea-splitting organisms, such as Proteus, Pseudomonas,
or Klebsiella species, and struvite stones. PH>7可能存在有可以分解尿素的細菌。
A urine pH less than 5 suggests uric acid stones.
PH<5可能有尿酸結石。
Electrolytes
Serum creatinine level is the major predictor of contrast-induced nephrotoxicity.
If creatinine level is greater than 2 mg/dL, use diagnostic techniques that do not require an infusion of
contrast, such as ultrasonography or helical CT scan.
Hypokalemia and decreased serum bicarbonate level suggest underlying distal (type 1) renal tubular
acidosis, which is associated with formation of calcium phosphate stones. 低血鉀+低碳酸氫+stone-->type 1 RTA
Imaging Studies
Most authors recommend diagnostic imaging to confirm the diagnosis in first-time episodes of ureterolithiasis,
when the diagnosis is unclear, or if associated proximal UTI is suspected. Lindqvist et al found that patients who
are pain-free after receiving analgesics could be discharged from the ED and undergo radiologic imaging after 2-3
weeks without increasing morbidity.9
Kidney, ureter, and bladder (KUB) radiography
Multiple studies show that the KUB radiography has low (40-50%) sensitivity and specificity for the presence
of ureterolithiasis and adds nothing to the emergent clinical impression. At follow-up, the urologist may find
the KUB radiograph to be helpful in determining the exact size and shape of the stone, in establishing a
baseline for follow-up studies, and for visualization of the surgical orientation.
KUB radiographs can be used to monitor passage of a previously documented opaque stone. Note that
most stones will appear larger on KUB radiograph than on CT, with CT-based measurement of maximum
stone dimension approximately 12% smaller compared with a KUB-based measurement.10
CT上的石頭比KUB上看到的小12%
Computed tomography (CT): Noncontrast helical CT has become the criterion standard imaging study in the ED
diagnosis of ureterolithiasis (see Media file 1).
Noncontrast helical CT scan of the abdomen demonstrating a stone at the right ureterovesical
junction.
CT診斷率比IVP好!
Numerous studies have demonstrated that CT has a sensitivity of 95-100% and superior specificity and
accuracy compared with the historic criterion standard, intravenous pyelogram (IVP).11
Other advantages of helical CT include rapid (<5 min) acquisition time, avoidance of intravenous (IV)
contrast, and potential for diagnosis of other pathology including AAA, pancreatitis, appendicitis, ovarian
disorders, diverticular disease, renal carcinoma, and biliary tract disorders.12
Principal disadvantages are that helical CT gives no information on renal function or degree of urinary
obstruction. A recent study also demonstrated that stone size as measured on CT KUB correlates poorly
with actual size of the stone measured after spontaneous passage.13 For this reason, caution should be
used in counseling patients on the likelihood of spontaneous stone passage when stone size is determined
using CT-based measurement.
Pure indinavir stones are radiolucent and may not be visualized well by helical CT scan. However, indinavir
stones often serve as a nidus for deposition of calcium oxalate or calcium phosphate deposition and thus
become radioopaque. CT KUB remains the test of choice for patients on indinavir who present with
apparent renal colic.
Sulfadiazine stones, most often seen in AIDS patients taking sulfadiazine for treatment of toxoplasmosis,
are also difficult to visualize on CT because of relatively low attenuation.14
Intravenous pyelogram: Prior to the advent of helical CT, IVP was the test of choice in diagnosing ureterolithiasis.
IVP is widely available and fairly inexpensive but less sensitive than noncontrast helical CT.
Contrast is administered intravenously at a dose of 1 mL/kg, and KUB films are taken immediately and at 1,
5, 10, and 15 minutes until contrast fills both distal ureters (see Media file 2). Look for direct visualization of
stone within the ureter, unilateral ureteral dilation, delayed appearance of the nephrogram phase, lack of
normal peristalsis pattern of the ureter, or perirenal contrast extravasation. Degree of obstruction is graded
based on delay in appearance of the nephrogram.
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Intravenous pyelogram (IVP) demonstrating dilation of the right renal collecting system and right
ureter consistent with right ureterovesical stone.
同時使用H1、H2、steroid可以降低過敏發生機率。
Anaphylaxis to ionic contrast agents (eg, Renografin, Conray) occurs in 1-2 patients per 1000 IVP studies.
Risk of recurrence is approximately 15% if reexposed to ionic agents but falls to 5% when nonionic agents
are used. Risk of anaphylaxis can be reduced further by pretreatment with a combination of H1- and
H2-blockers and steroids, but studies showing the benefit of pretreatment began pretreatment more than 12
hours prior to study. Risk of nephrotoxicity is not clearly reduced with use of nonionic agents. Indications for
use of nonionic contrast agents vary among institutions but consistently include history of prior mild to
moderately severe reaction to ionic contrast, asthma, multiple allergies, or severe cardiac disease.
Disadvantages of IVP include radiation exposure and risk of nephrotoxicity or anaphylactoid reaction to
contrast agent. IVP is relatively contraindicated in pregnant or dehydrated patients or if serum creatinine
level exceeds 2 mg/dL. IVP is absolutely contraindicated in patients with a history of severe contrastinduced anaphylaxis. False-negative results usually occur with stones located at the ureterovesical junction.
如果石頭卡在UVJ可能會使IVP產生偽陰性。
Ultrasonography: This is a good imaging modality in patients who are pregnant or to rule out the presence of an
AAA in patients older than 60 years with a first or atypical presentation of nephrolithiasis.15
A handful of small studies have found sensitivities of 65-100% (see Media files 3-4). Ultrasonography has
been found to be less accurate in diagnosis of ureteral stones when compared with IVP or helical CT.
Diagnostic criteria include direct visualization of the stone, hydroureter more than 6 mm in diameter, and
perirenal urinoma suggesting calyceal rupture.11
Renal sonogram showing a dilated renal collecting system consistent with ureteral obstruction.
Transabdominal sonogram revealing a ureteral stone at the ureterovesical junction.
Advantages include lack of radiation exposure and ability to complete the study at the bedside in patients
who are potentially in unstable condition.
Disadvantages include inferior sensitivity, lack of universal availability, dependence on operator expertise,
and inability to accurately estimate the degree of urinary obstruction.
A urine-filled bladder provides an excellent acoustic window for ultrasound imaging; sonograms
occasionally may demonstrate a stone at the ureterovesical junction that is not seen on helical CT or IVP.
Future studies may utilize 2-dimensional ultrasonography in combination with color Doppler analysis of the
ureteral jets to enhance sensitivity of ultrasonography in patients with ureteral colic.16
Magnetic resonance imaging: MRI can be used to detect ureteral stones. One study of 40 consecutive patients
with acute flank pain found sensitivity of 54-58% and specificity of 100% using breath-hold heavily T2-weighted
sequences.17 Sensitivity and specificity increased to 96.2-100% and 100%, respectively, using gadoliniumenhanced 3-D FLASH MR urography. Although MRI does not play a major role in the diagnosis of ureteral stones,
lack of radiation makes MRI a good choice in pregnant women who have nondiagnostic findings from a sonogram.
Procedures
Occasionally, a patient may require urinary catheterization to relieve retention due to extreme pain or an obstructing
bladder neck stone.
Treatment
Emergency Department Care
Intravenous access should be obtained to facilitate delivery of analgesic and antiemetic medications.
Intravenous hydration is controversial. IVF補充未有定論
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. One small
study of 43 ED patients found no difference in pain score or rate of stone passage in patients who received
2 liters of saline over 2 hours versus those who received 20 mL of saline per hour.18
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.
腎絞痛是由PGE2所引起，給NSAID-ketorolac是有效的。
Analgesia should be provided promptly. 止痛是必要的
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 US FDA) has been
proven in multiple studies to be as effective as opioid analgesics, with fewer adverse effects.19,20
Opioid analgesics can be added in cases of incomplete pain control.
Antiemetics should be administered as needed. 必要時給予止吐劑
Medical expulsive therapy 石頭排出藥物
口服tamsulosin 0.4mg QD可以加速石頭排出~。
21,22,23
Multiple prospective randomized controlled studies
in the urology literature 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. CCB (nifedipine 30mg QD) + steroid (25mg QD) 也有同樣的效果。
A systematic review by Singh et al in November 2007 found that medical expulsive therapy using either
alpha antagonists or calcium channel blockers augmented the stone expulsion rate for moderately sized
distal ureteral stones. Adverse effects were noted in 4% of those taking alpha antagonists and in 15.2% of
those taking calcium channel blockers.24
A systematic review by Beach et al in August 2006 found that medical expulsive therapy with alpha
antagonists for 28 days increased the rate of stone passage, decreased the time to stone passage, and
decreased the rates of hospitalization and ureteroscopy, with minimal adverse effects.25
A 2009 randomized study of 77 emergency department patients with ureterolithiasis found no benefit to a
14-day course of tamsulosin, though the study group was small and the average stone size was 3.6 mm,
making spontaneous passage without expulsive therapy highly likely.26
Future studies may identify a subgroup of patients such as those with larger stones or history of inability to
pass stones that would benefit from medical expulsive therapy.
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.
Medication
Pain of renal colic is mediated locally primarily by prostaglandin E2. Ureteral obstruction stimulates synthesis of
prostaglandin E2 in the renal medulla, which increases ureteral contractility and renal blood flow, leading to increased
ureteral pressures and painful renal colic.
Narcotic analgesics
These agents act at the CNS mu receptors and are the standard of care for treatment of renal colic. They are inexpensive
and proven effective. Disadvantages include sedation, respiratory depression, smooth muscle spasm, and potential for
abuse and addiction.
Butorphanol (Stadol)
Mixed agonist-antagonist narcotic with central analgesic effects for moderately severe to severe pain. Causes less
smooth muscle spasm and respiratory depression than morphine or meperidine. Weigh these advantages against
increased cost of butorphanol.
Dosing
Adult
0.5-2.9 mg IV q3-4h prn
1-4 mg IM q3-4h prn
Pediatric
Not established
Interactions
Guanabenz, MAOIs, CNS depressants, phenothiazines, barbiturates, and skeletal muscle relaxants increase toxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic or renal insufficiency, respiratory limitations (bronchial asthma, obstructive respiratory conditions,
cyanosis); may increase CSF pressure and cardiac overload; causes respiratory depression
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents inhibit synthesis of prostaglandin E2 and are at least as effective as narcotic analgesics in numerous
randomized controlled trials. NSAIDs cause less nausea and less sedation than narcotic analgesics, do not cause
respiratory depression, and have no abuse potential. Principal disadvantage is cost. Potential adverse effects on renal
function, GI mucosa, and platelet aggregation do not appear clinically important when used for short-term pain relief.
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases formation of
prostaglandin precursors. Only NSAID approved for IV or IM use in adults in United States. Single IM dose of 30 mg
provides pain relief comparable to meperidine 100 mg IM with fewer adverse effects. Also can be administered IV. Onset
of analgesic action is evident within 10 min of IM administration. Efficacy of PO formulation for outpatient treatment of renal
colic has not yet been studied.
Dosing
Adult
30-60 mg IM initial, followed by 15-30 mg q6h prn; not to exceed 5 d of treatment
Pediatric
Not established
Interactions
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and,
possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of
furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to
watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of
bleeding
Do not administer into CNS
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur;
increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC
counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia,
granulocytopenia, or thrombocytopenia occur
Antiemetics
Patients with acute renal colic frequently experience intense nausea and/or vomiting. Effective pain control often is
accompanied by resolution of nausea and vomiting, but some patients may require antiemetics in addition to analgesics.
Various antiemetic medications are used, including phenothiazines and butyrophenones.
Metoclopramide (Reglan)
Only antiemetic that has been studied specifically in treatment of renal colic. In 2 small double-blinded studies, provided
relief of nausea and pain relief equal to that of narcotic analgesics.
Antiemetic effect due to blockade of dopaminergic receptors in chemoreceptor trigger zone in CNS. Does not possess
antipsychotic or tranquilizing activity and is less sedating than other central dopamine antagonists. Onset of action is 1-3
min after IV injection and 10-15 min after IM injection.
Dosing
Adult
10 mg IV/IM; repeat q4-6h prn
Pediatric
0.1-0.2 mg IV; repeat q6-8h prn
Interactions
Accelerated gastric emptying may increase rate or extent of absorption of drugs such as acetaminophen, aspirin,
diazepam, lithium, and tetracycline; as a central dopamine antagonist, may diminish effectiveness of dopamine agonists
such as amantadine, bromocriptine, levodopa, or pergolide
Contraindications
Documented hypersensitivity; pheochromocytoma; GI hemorrhage, obstruction, or perforation; history of seizure disorders
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in history of mental illness or Parkinson disease; children and adolescents more likely to experience
extrapyramidal side effects; elderly persons more likely to experience drowsiness
Antibiotics
Infected hydronephrosis mandates IV antibiotic therapy in addition to urgent drainage via percutaneous nephrostomy or
urethral stent placement. Aerobic gram-negative enteric organisms, including E coli and Klebsiella, Proteus,
Enterobacter, and Citrobacter species, are typical pathogens. Enterococcal infection occasionally is seen in patients
recently on antibiotics. Candida albicans sometimes is responsible in diabetic or immunosuppressed patients. Initial
empiric antibiotic therapy should cover common bacterial pathogens.
Ampicillin (Omnipen) plus gentamicin (Garamycin)
Ampicillin is beta-lactam aminopenicillin antibiotic. Non–penicillinase-producing staphylococci and most streptococci are
susceptible. Ampicillin is effective against E coli and Proteus and Enterococcus species, but most Klebsiella, Serratia,
Acinetobacter, indole-positive Proteus, and Pseudomonas species and Bacteroides fragilis are resistant.
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Gentamicin is aminoglycoside antibiotic, which is active against Staphylococcus aureus and Enterobacteriaceae
organisms including E coli and Proteus, Klebsiella, Serratia, Enterobacter, and Citrobacter species. Pseudomonas
aeruginosa is usually sensitive, although its sensitivity varies somewhat. When used in combination with ampicillin,
gentamicin also effective against Enterococcus faecalis.
Dosing
Adult
Ampicillin: 150-200 mg/kg/d IV in equally divided doses q3-4h; dosages can be increased, but not to exceed 14 g/d
Gentamicin (patients with normal renal function): 3-6 mg/kg/d IV administered in 2-3 divided doses; monitor at least a
trough level drawn on third or fourth dose (0.5 h before dosing); may draw peak level 0.5 h after 30-min infusion
Pediatric
Ampicillin: 100-200 mg/kg/d IV in equally divided doses q4-6h; not to exceed 12 g/d
Gentamicin: 2.5 mg/kg IV q8h
Interactions
Ampicillin - Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive
effects on ampicillin rash; may decrease effects of oral contraceptives
Gentamicin - Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity;
enhances effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may
increase auditory toxicity of aminoglycosides—irreversible hearing loss of varying degrees may occur (monitor regularly)
Contraindications
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk
to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis,
hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; evaluate rash
and differentiate from hypersensitivity reaction; patients who develop diarrhea during or after therapy should be evaluated
for pseudomembranous colitis; ampicillin excreted via kidneys, and dosing interval should be adjusted as follows:
CrCl <50 mL/min: Adjust dosing interval
CrCl 10-50 mL/min: Extend dosing interval to q6-12h
CrCl <10 mL/min: Extend dosing interval to q12-16h
Gentamicin also excreted via kidneys, and following reduction in dose and dosing frequency necessary in patients with
renal insufficiency:
CrCl >70 mL/min: Multiply maintenance dose by 0.85 and administer IV q8-12h
CrCl 50-69 mL/min: Multiply maintenance dose by 0.85 and administer IV q12h
CrCl 25-49 mL/min: Multiply maintenance dose by 0.85 and administer IV q24h
CrCl <25 mL/min: Multiply maintenance dose by 0.85 and administer IV
Ticarcillin and clavulanic acid (Timentin)
Ticarcillin is extended-spectrum penicillin, beta-lactam antibiotic. Clavulanic acid is beta-lactamase inhibitor that, in
combination with ticarcillin, extends spectrum of ticarcillin to include many beta-lactamase–producing bacteria.
Timentin active against most staphylococci and streptococci and gram-negative organisms including E coli, Morganella
morganii, Proteus mirabilis, Proteus vulgaris, Neisseria gonorrhoeae, and Pseudomonas and Providencia species.
Anaerobic spectrum includes Peptococcus and Peptostreptococcus species, Clostridium perfringens, Clostridium
tetani, and Bacteroides species, including many strains of B fragilis. Timentin not effective against Enterococcus species
or methicillin-resistant staphylococci.
Timentin excreted via urinary tract.
Dosing
Adult
<60 kg: 200-300 mg/kg/d (based on ticarcillin content) IV divided q4-6h
>60 kg: 3.1g IV infused over 30 min q4-6h
Hemodialysis: 2 g IV q12h supplemented with 3.1 g after each dialysis session
Pediatric
200-300 mg/kg/d (based on ticarcillin content) IV in divided doses q6h; not to exceed 18-24 g/d
Interactions
Tetracyclines may decrease effects; high concentrations may physically inactivate aminoglycosides if administered in
same IV line; synergistic effects with aminoglycosides; probenecid may increase levels; can inhibit renal tubular excretion
of methotrexate—do not coadminister
Contraindications
Documented hypersensitivity; severe pneumonia; bacteremia; pericarditis; emphysema; meningitis
Purulent or septic arthritis should not be treated with oral penicillin during acute stage
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by
measuring AST and ALT during therapy; caution in patients with hepatic insufficiencies; perform urinalysis and BUN and
creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid
possible neurotoxic reactions; may cause pseudomembranous colitis; after loading dose of 3.1 g, administer maintenance
dose using renal function kinetics as follows:
CrCl >60 mL/min: No dosage adjustment needed
CrCl 30-60 mL/min: 2 g IV q4h
CrCl 10-30 mL/min: 2 g IV q8h
CrCl <10 mL/min: 2 g IV q12h
CrCl <10 mL/min with hepatic failure: 2 g IV q24h
Ciprofloxacin (Cipro)
Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones active against
aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some
resistance has been noted in S aureus and Streptococcus pneumoniae. Not effective against anaerobes. Variably
effective against E faecalis, though ampicillin and gentamicin likely to be more effective.
Dosing
Adult
400 mg IV q8-12h
Pediatric
<18 years: Not recommended; if quinolone therapy clearly indicated, may be used in dose of 15-20 mg/kg/d IV divided
q12h
>18 years: Administer as in adults
Interactions
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after; cimetidine may
interfere with metabolism; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may
increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of
anticoagulants (monitor PT)
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk
to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust
dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; associated
with tendon rupture and should be discontinued in any patient who develops tendonitis; may lower seizure threshold and
should be used cautiously in patients with seizures or cerebral atherosclerotic disease
Levofloxacin (Levaquin)
Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones active against
aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some
resistance has been noted in S aureus and S pneumoniae. Not effective against anaerobes. Variably effective against E
faecalis, though ampicillin and gentamicin likely to be more effective.
Dosing
Adult
250 mg IV over 60 min qd for 10 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Interactions
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after; cimetidine may
interfere with metabolism; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may
increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of
anticoagulants (monitor PT)
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk
to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust
dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; associated
with tendon rupture and should be discontinued in any patient who develops tendonitis; may lower seizure threshold and
should be used cautiously in patients with seizures or cerebral atherosclerotic disease
Ofloxacin (Floxin)
Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Active against aerobic
gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has
been noted in S aureus and S pneumoniae.
Not effective against anaerobes. Variably effective against E faecalis, though ampicillin and gentamicin likely to be more
effective.
Dosing
Adult
200 mg IV over 60 min q12h
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Interactions
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking; cimetidine
may interfere with metabolism; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations;
may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of
anticoagulants (monitor PT)
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk
to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust
dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; associated
with tendon rupture and should be discontinued in any patient who develops tendonitis; may lower seizure threshold and
should be used cautiously in patients with seizures or cerebral atherosclerotic disease
Corticosteroids
These agents are strong anti-inflammatory drugs that reduce ureteral inflammation. They also have profound metabolic
and immunosuppressive effects.
Prednisolone (Econopred, Pediapred, Delta-Cortef, Articulose-50, AK-Pred)
In combination with nifedipine or tamsulosin, proven to facilitate spontaneous passage of a ureteral stone in several small
prospective studies. Only a short course of therapy (5-10 d) should be administered.
Dosing
Adult
25 mg PO qd
Pediatric
0.1-2 mg/kg/d PO qd
Interactions
Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin
decrease effects of corticosteroids
Contraindications
Documented hypersensitivity; viral, fungal, tubercular skin, and connective tissue infections; peptic ulcer disease; hepatic
dysfunction; GI disease
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk
to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia
gravis
Calcium channel blockers
These agents are smooth muscle relaxants that, in combination with prednisolone, facilitate ureteral stone passage in
several small prospective studies.
Nifedipine (Procardia)
Sustained-release (SR) formulation simplifies treatment and encourages compliance. Only short-term therapy (5-10 d)
should be considered for this indication.
Dosing
Adult
30 mg SR PO qd
Pediatric
Not established
Interactions
Caution with coadministration of any agent that can lower BP, including beta-blockers and opioids; H2 blockers
(cimetidine) may increase toxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk
to fetus
Precautions
May cause lower extremity edema; allergic hepatitis has occurred (rare)
Alpha-adrenergic blockers
These agents promote smooth muscle relaxation and, in combination with prednisolone, facilitate spontaneous passage
of a ureteral stone.
Tamsulosin (Flomax)
Alpha-adrenergic blocker specifically targeted to alpha1-receptors. Has advantage of relatively less orthostatic
hypotension and requires no gradual up-titration from initial introductory dosage. Inhibits postsynaptic alpha-adrenergic
receptors, resulting in vasodilation of veins and arterioles and decrease in total peripheral resistance and blood pressure.
Improves irritative and obstructive voiding symptoms. Only short-term therapy (5-10 d) should be considered for this
indication.
Dosing
Adult
0.4 mg PO qd
Pediatric
Not established
Interactions
Cimetidine may significantly increase plasma concentrations; may increase toxicity of warfarin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
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B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for use as antihypertensive drug; may cause orthostasis; avoid situations that may result in injuries if syncope occurs;
exclude presence of carcinoma or cancer before initiating treatment; adverse effects include increased rate of retrograde
ejaculation and rhinitis
Follow-up
Further Inpatient Care
Admission rate for patients with acute renal colic is approximately 20%. Three absolute indications for admission
are (1) infected hydronephrosis, (2) unrelenting pain or vomiting despite analgesics and antiemetics, and (3)
泌尿道結石的住院適應症
dehydration.
Infected hydronephrosis is defined as UTI proximal to an obstructing stone. Infected hydronephrosis
mandates admission for antibiotics and prompt drainage.
Midstream urine culture and sensitivity was a poor predictor of infected hydronephrosis in one series,
being positive in only 30% of cases.27 中段尿只有30%的感染陽性率。
The clinical presentation of infected hydronephrosis is variable. Pyuria (>5 WBC/hpf) is almost
always present but not diagnostic of proximal infection. In one small series of 23 patients with
infected hydronephrosis, the temperature was higher than 38°C in 15 patients, the peripheral WBC
count was more than 10 X 109/L in 13 patients, and the creatinine level was greater than 1.3 mg/dL in
12 patients.28 結石引起的感染性腎盂腎炎不一定會有膿尿，但可能會有發燒、白血球上昇、Cr>1.3mg/dl
Renal ultrasonography or helical CT may distinguish pyonephrosis from simple hydronephrosis by
demonstrating a fluid-fluid level in the renal pelvis (urine on top of purulent debris). In 2 small studies,
the ultrasonographic sensitivity for pyonephrosis was found to be 62-67%. CT sensitivity for
pyonephrosis has not been reliably determined.29,30 The emergency physician must maintain a high
index of suspicion.31 Antibiotics should cover E coli and Staphylococcus, Enterobacter, Proteus,
and Klebsiella species.
In another small study of 38 patients with hydronephrosis, 16 had infected hydronephrosis and 22
had sterile hydronephrosis. Ultrasonography alone detected 6 of 16 cases of pyonephrosis, a
sensitivity of 38%. Using a cutoff value of 3 mg/dL for C-reactive protein and 100 mm/h for
erythrocyte sedimentation rate, the diagnostic accuracy of detecting infected hydronephrosis and
pyonephrosis increased to 97%.32
這些人也需要住院治療
<4mm 80%自行排出
>8mm 20%自行排出
>6mm住院治療
Patients with complete obstruction, perinephric urine extravasation, a solitary kidney, renal transplant, renal
failure, or pregnancy, and those with a poor social support system, also should be considered for
admission, especially if rapid urologic follow-up is not reliably available.
A stone less than 4 mm in diameter has an 80% chance of spontaneous passage; this falls to 20% for
stones larger than 8 mm in diameter. The urologist may choose to admit a patient with a ureteral stone larger
than 6 mm because of low likelihood of spontaneous passage.
About 15-20% of patients require invasive intervention due to stone size, continued obstruction, infection, or
intractable pain. Several techniques are available to the urologist when the stone fails to pass spontaneously.33
Extracorporeal shock wave lithotripsy (ESWL) utilizes an underwater energy wave focused on the stone to
shatter it into passable fragments. Approximately 70% of stones can be treated with ESWL alone. This
technique is especially suitable for stones that are smaller than 2 cm and lodged in the upper or middle
calyx. Anesthesia or sedation is required. ESWL is contraindicated in pregnancy, untreatable bleeding
disorders, patients weighing more than 300 lb, tightly impacted or cystine stones, or in cases of ureteral
obstruction distal to the stone.
Ureteroscopy is especially suitable for removal of stones that are 1-2 cm, lodged in the lower calyx or
below, cystine stones, and high attenuation ("hard") stones. Stones smaller than 5 mm in diameter generally
are retrieved using a stone basket, whereas tightly impacted stones or those larger than 5 mm are
manipulated proximally for ESWL or are fragmented using an endoscopic direct-contact fragmentation
device.
Percutaneous nephrolithotomy involves entering the renal pelvis percutaneously using the Seldinger
technique after ultrasonography or fluoroscopic localization. Renal calyces, pelvis, and proximal ureter can
be examined and stones extracted with or without prior fragmentation. This technique is especially useful for
stones larger than 2 cm in diameter. A percutaneous nephrostomy can be used as an emergency
procedure to relieve obstruction in a high-risk patient in whom other treatments are not feasible.34
Open nephrostomy rarely is used since the development of ESWL and endoscopic and percutaneous
techniques. Open nephrostomy now constitutes only 1-2% of all interventions. Disadvantages include longer
hospitalization, longer convalescence, and increased requirements for blood transfusion.
Further Outpatient Care
Patients who do not meet admission criteria may be discharged from the ED in anticipation that the stone will pass
spontaneously at home.
Arrange for follow-up with a urologist in 2-3 days. Patients should be told to return immediately for fever,
uncontrolled pain, or vomiting.
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a
urologist for chemical analysis.
Follow-up for patients with first-time incidence of stones should consist of stone analysis and abbreviated
metabolic evaluation to rule out hyperparathyroidism, renal tubular acidosis, and chronic infection with
urea-splitting bacteria. 第一次結石的病人要分析結石的成分
Patients with recurrent ureterolithiasis should undergo a more thorough metabolic evaluation. Patients with
recurrent stones who undergo thorough metabolic evaluation and specific therapy enjoy a remission rate in
excess of 80% and can decrease the rate of stone formation by 90%. A stone chemical analysis together
with serum and appropriate 24-hour urine metabolic tests can identify the etiology in more than 95% of
patients. A typical 24-hour urine determination should include urinary volume, pH, specific gravity, calcium,
citrate, magnesium, oxalate, phosphate, and uric acid. Most common findings are hypercalciuria,
hyperuricosuria, hyperoxaluria, hypocitraturia, and low urinary volume. Therefore, the emergency physician
should encourage urologic follow-up.
Inpatient & Outpatient Medications
Discharge on an oral analgesic and an antiemetic if needed. No studies exist that demonstrate superiority of one
oral analgesic over another. Typical choices include agents such as hydrocodone, oxycodone, meperidine, or oral
anti-inflammatory agents.
Medical therapies to aid in passage of a stone have been studied. Multiple randomized controlled prospective
studies show that outpatient treatment with sustained-release nifedipine 30 mg/d plus prednisolone 25 mg/d or
tamsulosin 0.4 mg/d decreases the time to spontaneous passage of the stone; increases the overall spontaneous
expulsion rate; and decreases the need for analgesics, hospitalization, and endoscopic intervention.21,22,23
Deterrence/Prevention
Patients with recurrent nephrolithiasis traditionally have been instructed to drink 8 glasses of fluid daily to maintain
adequate hydration and decrease chance of urinary supersaturation with stone-forming salts.
Prospective studies suggest that daily consumption of coffee, tea, beer, or wine decreases risk of stone formation,
while daily consumption of apple or grapefruit juice increases risk of stone formation.35
Complications
茶、啤酒、咖啡、白酒可以降低石頭形成
蘋果、葡萄柚會促進石頭生成。
Infected hydronephrosis is the most deadly complication because the presence of infection adjacent to the highly
vascular renal parenchyma places the patient at risk for rapidly progressive sepsis and death.
Calyceal rupture with perinephric urine extravasation due to high intracaliceal pressures occasionally is seen and
usually is treated conservatively.
Complete ureteral obstruction may occur in patients with tightly impacted stones. This is best diagnosed via IVP
and is not discernible on noncontrast CT scan. Patients with 2 healthy kidneys can tolerate several days of
complete unilateral ureteral obstruction without long-term effects on the obstructed kidney. If a patient with
complete obstruction is well hydrated and pain and vomiting are well controlled, the patient can be discharged from
the ED with urologic follow-up within 1-2 days.
Prognosis
Approximately 80% of ureteral stones pass spontaneously without hospitalization or invasive intervention.
Approximately 20% of patients require hospitalization due to dehydration, continued pain or vomiting, or inability to
pass the stone spontaneously.
Recurrence rates after an initial episode of ureterolithiasis are 14%, 35%, and 52% at 1, 5, and 10 years,
respectively. Risk of recurrence can be reduced drastically by specific medical therapy based on analysis of the
stone and serum and urine metabolic profiles.
Patient Education
For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see
eMedicine's patient education articles Blood in the Urine and Kidney Stones.
Miscellaneous
Medicolegal Pitfalls
Failure to diagnose or delay in diagnosing symptomatic AAA: Pain of a leaking abdominal aortic aneurysm often is
misdiagnosed initially as renal colic.
In one series of 134 patients with symptomatic AAA presenting to the ED, the following statistics were reported:36
Eighteen percent had an initial misdiagnosis of nephrolithiasis.
All were older than 60 years of age and none had a prior history of renal calculi.
Eighty percent had a pulsatile mass noted by at least one examiner.
Forty-three percent had microhematuria on urinalysis.
Delay of diagnosis of AAA in the ED was associated with higher mortality and morbidity rates than in the
group who received the correct diagnosis promptly.
Failure to diagnose UTI proximal to a ureteral stone and to seek urgent urologic intervention in these patients
Multimedia
Media file 1: Noncontrast helical CT scan of the abdomen demonstrating a stone at the right
ureterovesical junction.
Media file 2: Intravenous pyelogram (IVP) demonstrating dilation of the right renal collecting
system and right ureter consistent with right ureterovesical stone.
Media file 3: Renal sonogram showing a dilated renal collecting system consistent with ureteral
obstruction.
Media file 4: Transabdominal sonogram revealing a ureteral stone at the ureterovesical junction.
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Keywords
kidney stone symptoms, kidney stone causes, kidney stone treatment, renal calculi, kidney stone, renal stone, ureteral
calculi, nephrolithiasis, ureterolithiasis, kidney calculi, acute nephrolithiasis
Contributor Information and Disclosures
Author
Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at
Chapel Hill, Carolinas Medical Center
Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic
Emergency Medicine
Disclosure: Nothing to disclose.
Medical Editor
David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of
Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians,
American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Managing Editor
Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research
Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings
County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for
Academic Emergency Medicine
Disclosure: Nothing to disclose.
CME Editor
John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical
Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician,
Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians,
American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health
System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart
Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians,
Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.
Further Reading
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