Nephrolithiasis the ED: Rolling Stones

-Case-
A 45-year-old man arrives in the ED pacing, clutching his right side, and is visibly miserable. He says the pain started suddenly a few hours ago and “comes in waves”; it radiates from his flank to his groin. He’s nauseated, has vomited once, and can’t sit still. Vitals are normal, but the story still seems suspicious…

-Evaluation-
Nephrolithiasis, or kidney stones, are a common cause of acute flank pain and can be incredibly painful. Most stones are composed of calcium oxalate, but uric acid, struvite, and cystine stones are also possible.

  • Classic Presentation:
    • Sudden, severe, colicky flank pain
    • Radiation to groin or testicle/labia
    • Nausea and vomiting
    • Hematuria (microscopic or gross)
  • Risk Factors:
    • Dehydration
    • Male sex, age 30-50
    • High sodium/protein diets
    • Family or personal history of stone

Workup:

  • UA: hematuria is common but not required
  • Serum Cr: helps to risk stratify and for disposition planning with evaluation of renal function
  • Imaging:
    • CT abd/pelvis (non-contrast) = gold standard; this may be a tough call; not all cases of kidney stones are slam dunks, so many times a contrasted scan is ordered to evaluate for more than just nephrolithiasis!
    • Ultrasound: good for pregnant patients or repeat stone formers; may show hydronephrosis

-Management-

  1. Pain Control: NSAIDs (e.g., IV ketorolac) are first-line unless contraindicated
  2. Antiemetics: ondansetron or metoclopramide for nausea/vomiting
  3. Hydration: IV fluids for comfort, though not proven to speed stone passage
  4. Tamsulosin (Flomax): alpha blocker that may aid passage of distal stones <10 mm
  5. Disposition:
    • Discharge if pain is controlled, no AKI, and stone is likely to pass
    • Admit for intractable pain, infection, obstruction with AK, large stone size (think >10mm) or if the patient only has a single kidney or transplant

-Fast Facts-

  • Hematuria helps but isn’t necessary for diagnosis
  • CT is gold standard, but ultrasound is a good initial tool in many cases
  • NSAIDs are ideal due to renal and ureteral spasm relief
  • Don’t forget to check for signs of infection – fever + obstructing stone = urologic emergency

Flank pain, restlessness, and nausea fit the stone story perfectly. A quick plan with analgesia, fluids, and imaging can make all the difference for these patients. Know who to scan, who to discharge, and who needs a urologic lifeline. When it comes to kidney stones, timing, comfort, and caution are your guiding lights!

Want to learn more? Read our in-depth study guide on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Interventional Treatment for Urolithiasis. Eur Urol. 2016;69(3):475-482. doi:10.1016/j.eururo.2015.07.041
  2. Moore CL, Daniels B, Singh D, et al. Ultrasound First for Kidney Stones: A Prospective Pilot Study of Emergency Department Patients. J Ultrasound Med. 2013;32(3):473-480. doi:10.7863/jum.2013.32.3.473
  3. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med. 2014;371(12):1100-1110. doi:10.1056/NEJMoa1404446
  4. Scales CD, Smith AC, Hanley JM, Saigal CS. Prevalence of Kidney Stones in the United States. Eur Urol. 2012;62(1):160-165. doi:10.1016/j.eururo.2012.03.052
  5. Lipkin M, Shah O. The use of alpha-blockers for the treatment of nephrolithiasis. Rev Urol. 2006;8(Suppl 4):S35-S42.
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