I recently had a patient who came in complaining of severe
flank pain radiating to his groin with nausea and vomiting… it was determined
that he had nephrolithiasis (kidney stones). My attending asked me whether or
not we should admit the patient… Good question, I thought. I was able to rattle
off the text book treatments, but I wasn’t clear on the guidelines for
admission vs. out-patient treatment. Below is an overview of treatment
including some clear indications for admission.
General Treatment (for all types of stones):
1-PAIN CONTROL!
a-PO analgesic or IV morphine,
situation dependent
b-Parenteral NSAID (Ketorolac)
2-Hydration (vigorous)
3-Antibx, if UTI present
Additional treatment measures based on pain severity:
MILD-MOD pain = high fluid intake, oral
analgesics, wait for stones to pass (Give pt a urine strainer because you want
to know what “kind” of stone the patient has.)
SEVERE pain = IV fluids and pain control, KUB,
IVP to find site of obstruction, consult urology (surgery) if stones do not pass
in 3 days
ONGOING pain w/o relief from narcotics =
Surgery
Types of Surgery (10,000 foot view):
Shock wave lithotripsy: most common, it breaks
apart the larger stones so they can be passed spontaneously, typically used for
stone >5mm and < 2cm
Percutaneous nephrolithotomy: used if the
above fails, if stones are > 2cm, for struvite stones
Admission is indicated if:
1-Oral analgesics
are insufficient to manage the pain.
2-Ureteral
obstruction from a stone occurs in a solitary or transplanted kidney.
3-Ureteral
obstruction from a stone occurs in the presence of a urinary tract infection
(UTI), fever, sepsis, or pyonephrosis.
4-Large stones
(>1cm)
*The above
indications were found in a couple of sources, but more say that the ultimate
decision is made on a clinical basis, not solely on guidelines.
Parting suggestion: brush up on the different kinds of
kidney stones
Sources:
Medscape: Nephrolithiasis and Treatment, http://emedicine.medscape.com/article/437096-treatment
Step Up to Medicine 2nd Ed. by Agabegi and
Agabegi
Picture: http://knol.google.com/k/kidney-stones#
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