Renal colic is an acute and violent pain in the region of the back which is a urinary tract obstruction and dilatation of these pathways upstream of the obstacle.
Renal colic is a painful kidney damage caused by an obstruction in the normal flow of urine, usually stones (calculus) or (once four) compression.
It requires analgesics and anti-inflammatory emergency.
After an episode relapse is common.
There are about 2 million people with urinary calculi in France and each year it is estimated that 5 to 10% cause colic.
It is estimated that nearly 10% of men and 5% of women have suffered or suffer from colic at least once in their lives.
The diagnosis of renal colic may be particularly difficult to do during pregnancy.
Back pain (in the region of the kidneys, especially in the back corner of the spine and last ribs) is due to the sudden increase in pressure in the renal cavities that collects urine produced by kidney (renal pelvis caliceal cavities).
This is due to an obstruction (usually a calculation) of the ureter, the tube that carries urine from the kidneys normally to the bladder.
The increase in pressure in the kidneys causes a release of prostaglandin E2 and prostacyclin, substances that will cause vasodilation (dilation of blood vessels) and an increase in local blood flow.
Unfortunately, this mechanism will increase urine formation (GFR) in the kidney and increase the pressure. Treatment with anti-inflammatory drugs aims to break this vicious circle. Vasoconstriction (narrowing of blood vessels) occurs in a second time.
Substances are released by the body to increase the contractions of the muscle cells of the urinary ducts to try to eliminate the obstacle (in vain if the stone is too large), but it also increases the pain.
Back pain is in the foreground.
Back pain is intense, appears abruptly on one side and may radiate to the abdomen, the iliac fossa (above the groin) and genitals.
The pain can vary, with paroxysms and periods of remission but can not find any position that relieves pain.
Among the symptoms, but there may be gastrointestinal symptoms (nausea, vomiting …) or urinary symptoms (feeling sharp and / or frequent urination, bladder pain …) but, in general, no signs (alteration of state general apathy …), including no fever, unlike what we see in back pain of pyelonephritis, urinary tract infections.
Renal colic “simple” can sometimes worsen or be outright.
In 75% of cases, renal colic due to nephrolithiasis (calculation) urinary.
Apart from nutritional factors, personal and family factors favor the formation of calculations:
- A history nephrology:
• Urinary tract infections or pyelonephritis;
• Family history of lithiasis;
• Personal history of kidney stones.
- Anatomical malformations:
• A horseshoe kidney;
• Malformation of uretero-pelvic junction;
• A single kidney;
• History of intervention in the kidney or ureter;
• A ureterocele.
• Primary hyperparathyroidism;
• Tubular acidosis;
• Primary hyperoxaluria;
• Jejuno-ileal shunt, intestinal resection;
• Renal failure;
• Cacchi-Ricci disease
- Taking certain medications:
• Calcium and vitamin D;
• Ascorbic acid in high doses (> 4 g / d).
- In 25% of cases, the obstruction is due to another cause:
• Radiation urethritis, tuberculosis, etc.. ;
• Syndrome ureteropelvic junction;
• Tumor of the upper urinary tract;
• Pelvic tumor;
• Retroperitoneal fibrosis and lymphadenopathy;
Triggers are also identified bine
Dehydration (lack of water) is often a precipitating factor found. We must be wary of situations where water losses are increased, for example in case of fever, hot and dry climate, with heavy physical exertion or diarrhea.
Among dietary factors may promote stone formation include:
- A diet rich in animal protein (increases urinary oxalate and calcium)
- Inadequate calcium intake (<600 mg / day) or excessive (> 1200 mg / d)
- Consumption of salt, oxalate-rich foods (chocolate, spinach, rhubarb, tea), grapefruit juice
All causes of sudden abdominal pain can give symptoms suggestive of renal colic
Other causes of pain:
- Peptic ulcer;
- Cracking of an aneurysm of the aorta;
- Ectopic pregnancy;
Of simple radiographs and ultrasound can usually confirm the diagnosis
The diagnosis is usually made on symptoms and examination by the physician (clinical examination). However, the management of urinary calculi requires diagnostic imaging, evaluation and monitoring.
In simple colic, the plain radiograph (abdomen without preparation) coupled ultrasound (or helical CT without injection) may be sufficient. For pregnant women, the Doppler is the examination of choice.
Nephritic colic in complicated or if diagnostic doubt, the scanner is very efficient ( spiral CT without injection ). The injection of contrast material is recommended in cases of diagnostic doubt, in the case of urinary tract infection in the urological assessment and medical computing.Ultrasonography is useful for pregnant women and children, or in case of cons-indication to the injection of contrast material. The nuclear magnetic resonance imaging (NMRI) is also possible in pregnancy or renal insufficiency, but the signs are indirect calculation because it is not visible in MRI.
The results of a first episode generally comprise a scanner with injection (or, alternatively, intravenous urography), cystography, and sometimes scintigraphy. BMD bone is indicated (desirable) in postmenopausal women if hypercalciuria (elimination of calcium in the urine).
In a series of renal colic in pregnant women, the dipstick possible to find microscopic hematuria in half the cases and leukocyturia 1 out of 3 times. However, ultrasound showed a dilated cavities pyélocalicielles in 88% of cases.
Renal colic is in most cases benign.
Renal colic sometimes (less than 6% of cases) considered severe (complicated renal colic) or because they occur in a fragile person (renal insufficiency, solitary kidney, pregnancy, kidney transplant, kidney disease …), or because there are signs of severity (infection, weak flow of urine, persistent severe pain despite a good analgesic treatment.
In these cases, urinary diversion is usually required urgently.
Emergencies, the advice of a gynecologist and obstetrician is useful in cases of renal colic in pregnant women because of the risk of preterm delivery and premature rupture of membranes. This is the 2 e and 3 e trimesters that occur 99% of cases of renal colic.
Recurrences are common after an episode of colic. It is about 15% in the following year, 35% within 5 years, 50% within ten years and reach 75% within 20 years.
Recurrence of urolithiasis is common, it is important to follow the dietary recommendations that will be made. It will change the eating habits and the type of water you drink depending on the type of calculation responsible for urinary obstruction (in France, it is the majority of calculations in calcium oxalate in 70% of cases) .
In general, care should be taken to have proper hydration (drink at least 1.5 liters of water per day, check the color of urine: a shade too dark may indicate a lack of hydration) because urine volume is most important factor inhibiting the formation of stones while power is only responsible for 10-20% of calcium oxalate stones. It is also advisable to regularly eat fruits and vegetables because they prevent the crystallization of salts in the urinary tract.
Treatment is primarily analgesic.
Treatment aims to relieve pain and treat the obstacle. It should be implemented quickly because the pain is due to increased pressure in the kidney is growing.
The anti-inflammatory drugs (NSAIDs) will block the production of prostaglandins by the kidney, decrease the tone of the muscle fibers of the urinary tract and reduce the swelling that has formed at the obstruction. The ideal is to use an NSAID, ketoprofen infusion types. Intramuscular administration is less reliable. The intrarectally may possibly be used. Must also meet the cons-indications conventional NSAIDs (bleeding evolving gastric or intestinal ulcer evolving severe hepatic impairment, severe renal insufficiency, severe heart failure, uncontrolled). Note that pregnant women, NSAIDs are cons-indicated (forbidden) to 3 e quarter and discouraged before. Treatment is usually based on a combination paracetamol and antispasmodic (eg, phloroglucinol). Morphine can be used outside of work.
Is no longer recommended to drink large quantities to try to eliminate the possible calculation because it may also increase the pressure in the kidney blocked until the obstacle is not levied on the urinary tract. We advise now drink according to her thirst.
Also used analgesics Level I even morphine if the NSAID and analgesic level I is not enough.Some offer immediately involve NSAIDs and opioids.
To relax the smooth muscle fibers, we propose sometimes in the absence of cons-indications, alpha-blockers (tamsulosin at a dose of 0.4 mg / day for one month) or calcium channel blockers (nifedipine dose 30 mg / day for one month). They facilitate the expulsion of stones less than 10 mm, located in the lower ureter, with rare and mild side effects.
The expulsion of the calculation is spontaneous in 68% of cases for calculations and less than 5 mm in 47% of cases when the size is between 5 and 10 mm.
The return home is usually possible, if it is a simple colic when the patient is completely relieved, urinated and manages to eat with a period of 4 hours after the last injection of morphine, appropriate.
If you are not hospitalized , care must be taken to make the treatment until the end, to drink normally (make sure the urine is clear), sift the urine (through a coffee filter) to collect potential stone fragments and bring in consultation so that we can make the chemical analysis (see question # 10), take her temperature every morning and seek emergency in case of fever (> 38 ° C), chills , vomiting, or alteration of recurrence of pain, discomfort, urine red urine and if it not for 24 hours.
In severe cases, a urine diversion is necessary. It is performed by the urologist.
Processing calculation is done away from the emergency (generally expected a month) it has not been eliminated by the initial medical treatment. There are several techniques:
- By endoscopy using a ureteroscope introduced by natural ways to go enter the calculation or split on site. The operator can go back to the kidney;
- By extracorporeal lithotripsy: a small fragment is calculated using an apparatus located outside of the body;
- By surgery: in case of failure or inability of previous techniques. It is made by endoscopy or conventional first.
Specific treatment causes non lithiasic be made if necessary.
Nephrology is the medical specialty that supports the diagnosis and treatment of all kidney disease (nephropathy called), which affect blood filtration, the primary function of the kidneys.
This support ranges from the most basic symptoms and early (blood or protein in the urine, for example) to the most serious complication is chronic renal failure. This complication can lead to the need to supplement renal function by dialysis treatment provided by nephrologists, or kidney transplant performed by urologists.
Close collaboration with other specialties is essential. With urologists, nephrologists involved in assessment of patients with kidney stones (nephrolithiasis) or renal insufficiency.
With intensivists, nephrologists involved in the diagnosis and treatment of acute renal failure. In collaboration with cardiologists, the nephrologist may be associated with therapeutic decision in cases of hypertension associated with renal disease or renal arteries. With the diabetologist, nephrologist will intervene to ensure the monitoring and treatment of diabetic patients suffering from kidney complications.
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Balssa L., F. Kleinclauss Management of acute renal colic, Advances in Urology (2010) 20, 802-805.
Carpentier X. et al. Pathophysiology of renal colic, Advances in Urology (2008) 18, 844-848.
Lechevallier E. et al. Imaging and calculation of the upper urinary tract, Progress in Urology (2008) 18, 863-867.
Caulin C. (Ed.) Vidal recos (3 e edition), Vidal 2009.
Mark Beers (ed.) The Merck Manual (4 th French edition), 2006.