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loin pain

‫المرحله الخامسه‬
Loin Pain (Renal Colic)
‫وليد خالد العبيدي‬.‫د‬
 Renal colic is a very severe pain that can present suddenly and
without warning.
 It is usually caused by stones in the kidney, renal pelvis or ureter.
The pain is caused by dilatation, stretching and spasm of the ureter.
In contrast, the slow stretching associated with chronic obstruction
with some types of cancer is painless.
 In many cases no cause is found (stone pass).
 The
lifetime risk for stones is said to be about 10% for men with a
male-to-female ratio of 2:1
 A family history of stones doubles the risk but most patients with
renal colic do not have a family history.
 The peak age of onset is 20 to 40 and if stones present significantly
outside this age group there is a greater chance of an underlying
metabolic abnormality.
 The risk of stones is higher in higher socio-economic groups.
Risk factors:
1. Excessive calcium in the urine(milk, red meat )
2. Excessive oxalate in the urine(tea, red meat, cola, chocolates ,nuts)
3. Excessive excretion of uric acid, with or without clinical gout(red
4. Deficiency of citrate in the urine(red meat cause acidosis)
5. Cystinuria (an autosomal recessive)
6. Drugs, especially thiazide diuretics
7. People with urinary stasis due to anatomical abnormalities of the
pelvi-calyceal system, e.g. medullary sponge kidney, PUJ
obstruction, ureteric stricture, vesico-ureteric reflux, horseshoe
 The classical features of renal colic are sudden severe pain:
 Pain starts in the loin about the level of the costo-vertebral angle
(but sometimes lower) and moves to the groin, with tenderness of
the loin or renal angle, sometimes with haematuria.
 If the stone is high and distends the renal capsule then pain will be
in the flank but as it moves down pain will move anteriorly and
down towards the groin.
 A stone that is moving is often more painful than a stone that is
 The pain radiates down to the testis, scrotum, labia.
 Whereas the pain of biliary or intestinal colic is intermittent, the
pain of renal colic is more constant but there are often periods of
relief or just a dull ache before it returns. The pain may change as
the stone moves. The patient is often able to point to the place of
maximal pain and this has a good correlation with the current site
of the stone.
 There is usually associated nausea and often vomiting.
 There are often urinary symptoms that may be dysuria, frequency,
oliguria and haematuria.
 There may be a previous history of renal colic.
 There may have been recent dehydration, including strenuous
physical exercise or starting a drug that increases the risk.
 The
patient with colic of any type writhes around in suffering. This
is in contrast to the patient with peritoneal irritation who lies still.
 The patient is apyrexial in uncomplicated renal colic (pyrexia
suggests infection and the body temperature is usually very high
with pyelonephritis).
 Examination of the abdomen will usually reveal tenderness over
the affected loin. Bowel sounds may be reduced. This is common
with any severe pain.
 There may be severe pain in testis but the testis should not be
 Blood pressure may be high.
 Full
and thorough abdominal examination is essential to check for
other possible diagnoses, e.g. acute appendicitis, ectopic
pregnancy, aortic aneurysm.
Differential diagnosis:
 This depends upon the position of the pain and the presence or
absence or pyrexia.
1. Biliary colic: usually from gall stones. Pain may radiate to the
shoulder. There may be some jaundice and dark urine.
2. Dissection of an aortic aneurysm: beware the patient who
presents with features of renal colic for the first time over the age
of 60. This may be dissection of aortic aneurysm leading to
ruptured aortic aneurysm.
3. Pyelonephritis: very high temperature. Pain unlikely to radiate to
groin. Infection may co-exist.
4. Acute pancreatitis: pain radiates to back. There tends to be
epigastric or left upper quadrant pain and tenderness. Paralytic
ileus may set in. Vomiting occurs early in the condition.
5. Acute appendicitis: tender and guarding over McBurney's point.
Possibly absent if posterior appendix. Any peritonism will cause
lying still, not writhing.
6. Perforated peptic ulcer: rigid abdomen; patient lies still.
7. Epididymo-orchitis or torsion of testis: very tender testis.
8. Back pain: usually tender over vertebrae.
9. Renal tumour
10. Drug addiction: There are reports of people with fictitious stories
of renal colic, designed to obtain an injection of pethidine. These
patients tend to be abusive when offered anything other than
11. Munchausen syndrome
1. Urinalysis:
 The stone often causes some bleeding into the renal tract and this
may produce a positive result for blood on stick testing (a negative
test does not exclude the diagnosis).
 If microscopy shows pyuria, this suggests infection.
 Check urine Ph: pH above 7 suggests urea splitting organisms such
as Proteus whilst a pH below 5 suggests uric acid stones.
2. MSU for microscopy, culture and sensitivities (if patient febrile
or +ve urinalysis for bacteria).
3. Blood for renal function, electrolytes, calcium, phosphate
and urate
4. Encourage the patient to try to catch the stone for analysis.
This may mean urinating through a tea strainer, filter paper such as
a coffee filter or a gauze.
5. Imaging of the urinary tract :
A. Traditionally starts with a KUB x-ray. This is larger than the
plain abdominal x-ray as it takes in both kidneys, ureters and
bladder. Around 75% of stones are of calcium and so will be
B. Abd. USS
C. Helical CT is now regarded as the gold standard for the
investigation of urinary stones. Current guidance is that the best
technique is unenhanced helical CT and CT is now the first line
investigation in some hospitals, in order to avoid accumulation
of radiation which occurs if CT is performed only after an initial
A. Medical assessment is advisable (Exclude other Dx.)
B. Initial treatment
 Relief of pain must be an early priority.
1. Intramuscular NSAID :
 MOA (Mechanism Of Action):
a. Less likely to cause nausea and vomiting.
b. Anti-inflammatory and Analgesia.
c. Decrease GFR &intrarenal pelvic pressure.
 Example :
a. IM ketorolac(60mg/2ml)
b. IM diclofenac(75mg/ 3 ml)
2. Opioid morphine OR pethidine or tramadol if
inadequate or contraindicated
3. Antiemetic may be required if there is severe nausea and vomiting,
dehydration or an opioid is given. Avoid metoclopramide in young
people in view of the risk of extrapyramidal side effects.
4. Steroid:
 MOA: Decrease ureteric oedema around stone lead to: pain
relieve and facilities' stone passage.
 Dexamethasone amp(8 mg/ 2ml).
5. If Intramuscular NSAID or Opioid inadequate:
a. IV acetaminophen: paracetamol vial 1g.
b. IV Nefopam amp infusion (20mg/2ml).
6. IV fluid: G5%.
C.Indications for hospital admission:
1. People who fail to respond to analgesia after 1 hour should be
admitted to hospital.
2. An abrupt recurrence of severe pain
3. Retractable Pain (persisting for more than 24 hours not respone to
oral medication)
4. Symptoms of systemic illness or infection; fever may suggest an
infected obstructed kidney, which is a surgical emergency
5. Inability to take adequate fluids due to nausea and vomiting
6. Anuria
7. Known non-functioning kidney , Known solitary kidney ,
8. Renal impairment.
9. Pregnancy
10. Poor social support
11. Inability to arrange early referral
12. Person's preference for admission
13. Need for assessment.
D. Conservative management: medical expulsive therapy
 Patients
managed at home :
1. Good hydration: Patients Should drink a lot of fluids.
2. Void urine into a container or through a tea strainer or gauze to
catch any identifiable calculus.
3. Analgesia:
a) Paracetamol is safe and effective for mild to moderate pain;
codeine can be added if more pain relief is required.
b) Oral NSAID: diclofenac potassium 50mg BID, or
Aceclofenac acid 100mg BID
4. α-blocker like Tamsulosin cap 0.4mg at night (relax ureter
enhance ureteric stone expulsion).
5. Patients should ideally receive an appointment for radiology
within 2 weeks of the onset of symptoms.
6. An urgent urology outpatient appointment should be arranged
for if renal imaging shows a problem requiring intervention.
E. Intervention options:
Emergency drainage :
 Achieved by placement of a nephrostomy catheter or ureteric
 A JJ stent (called JJ stents because the top and bottom have a
curled end to prevent migration of the stent) is sometimes used
to relieve any urinary tract obstruction caused by the stone and
to aid removal of the stone.
 Urgent intervention is required for:
1. Obstructed and infected upper urinary tract
2. Impending renal deterioration
3. Intractable pain or vomiting
4. Anuria
5. Obstruction of a solitary or transplanted kidney.
Elective :
1. ESWL (Extracorporeal shock wave lithotripsy).
2. Ureteroscopy and ureterolithotripsy for ureteric stone.
3. Percutaneous nephrolithotomy (PCNL) is used for stones not
suitable for ESWL (includes cystine stones, stones greater than
2 cm, and staghorn calculi).
Deterioration of renal function: Complete blockage of the
urinary flow from a kidney decreases GFR and, if it persists, may
cause irreversible renal damage (after 2 weeks).
2. Sepsis: life threatening(Infection + obstruction).
3. Ureteric stricture.
 Most symptomatic renal stones are small (less than 5 mm in
diameter) and pass spontaneously.
 Stones larger than 1 cm in diameter usually require intervention
(urgent intervention is required if complete obstruction or infection
is present).
 A stone that has not passed within 1–2 months is unlikely to pass
Paracetamol 10 mg/ml Solution for Infusion
a. Mild
(from headaches,
periods, toothaches, backaches, osteoarthritis, or cold/flu aches
and pains).
b. Fever.
Dose per administration
Maximum Daily Dose
≤10 kg
7.5 mg/kg
30 mg/kg
> 10 kg
15 mg/kg
60mg/kg not exceeding 3g
Side Effects: drug usually has no side effects.
Pregnancy: Clinical experience of intravenous administration
of paracetamol is limited. However, epidemiological data
from the use of oral therapeutic doses of paracetamol
indicate no undesirable effects in pregnancy or on the health
of the fetus / newborn infant.
Effects on ability to drive and use machines: Not relevant.
1. Very rare cases of hypersensitivity reactions. may contain inactive
ingredients, which can cause allergic reactions.
2. Liver disease, regular use/abuse of alcohol.
3. Renal insufficiency: In cases of severe renal impairment (creatinine
clearance 10-30 mL/min), the elimination of paracetamol is slightly
delayed, elimination rate is 3 times slower Therefore when giving
paracetamol to patients with severe renal impairment (creatinine
clearance ≤30 mL/min), the minimum interval between each
administration should be increased to 6 hours.
4. Elderly Patient: No dose adjustment is required in this
 Acetaminophen does
the stomach and
intestinal ulcers that NSAIDs such as aspirin, ibuprofen,
and naproxen may cause. However, acetaminophen
does not reduce swelling (inflammation) like the NSAIDs
 Do not take this medication for fever for more than 3
days unless directed by your doctor. For adults, do not
take this product for pain for more than 10 days (5 days
in children) unless directed by your doctor.
 The minimum interval between each administration must be
at least 4 hours.
 Missed Dose: If you are taking this medication on a
regular schedule and miss a dose, take it as soon as
you remember. If it is near the time of the next dose,
skip the missed dose. Take your next dose at the
regular time. Do not double the dose to catch up.
100ml vial contains 1000mg paracetamol.
Tramadol hydrochloride 50 mg/ml
(100 mg /2ml ampoule)
 MOA: Tramadol is a centrally acting analgesic which
possesses opioid agonist properties.
 Therapeutic indications: Treatment of moderate to severe
pain, also has an antitussive action
 Method of administration: intramuscularly, by slow
intravenous injection compatible for up to 24 hours with the
following infusion solutions: 5% Glucose.
 Adults: A dose of 50 or 100 mg 4-6 hourly is usually
required. Intravenous injections must be given slowly
over 2-3 minutes. Up to a total daily dose of 600 mg.
 Children :Over 12 years: Dosage as for adults.
Under 12 years Tramadol Injection has not been studied
in children. Therefore, safety and efficacy have not been
established and the product should not be used in
 Renal insufficiency/dialysis and hepatic impairment:
 In patients with renal and/or hepatic insufficiency the
elimination of tramadol is delayed.
 For creatinine clearance <30 ml/min the dosing should be
increased to 12 hourly intervals.
 Contraindications
1. Patients who have previously shown hypersensitivity to the
active substance tramadol.
2. acute intoxication with hypnotics, centrally acting analgesics,
opioids, psychotropic drugs or alcohol.
3. uncontrolled epilepsy.
4. narcotic withdrawal treatment.
5. patients who are receiving monoamine oxidase inhibitors or
within 2 weeks for their withdrawal.
 Warnings
 Tramadol has a low dependence potential. On long-term use
tolerance, psychic and physical dependence may develop.
 Convulsions have been reported at therapeutic doses.
 Effects on ability to drive and use machines: may cause
drowsiness and this effect may be potentiated by alcohol and
other CNS depressants. If patients are affected they should be
warned not to drive or operate machinery.
 Undesirable effects:
The most commonly reported adverse drug reactions are nausea
and dizziness, both occurring in more than 10% of patients .
Diclofenac Sodium Ampule
Mechanism of action:
Diclofenac is an acetic acid nonsteroidal anti-inflammatory drug
(NSAID) with analgesic and antipyretic properties.
The anti-inflammatory effects of diclofenac are believed to be
due to inhibition of both leukocyte migration and the enzyme
cyclooxygenase (COX-1 and COX-2), leading to the peripheral
inhibition of prostaglandin synthesis. As prostaglandins
sensitize pain receptors, inhibition of their synthesis is
responsible for the analgesic effects of diclofenac. Antipyretic
effects may be due to action on the hypothalamus, resulting in
peripheral dilation, increased cutaneous blood flow, and
subsequent heat dissipation.
It is primarily available as the sodium salt.
Metabolism: Hepatic
Route of elimination:
65% of the dose is excreted in the urine
and approximately 35% in the bile
Diclofenac is
(inflammation), and joint stiffness caused by arthritis.
Side Effects
Upset stomach, nausea, heartburn, diarrhea, constipation, gas, headache,
drowsiness, and dizziness may occur, may raise your blood pressure.
1. Allergies.
2. asthma
3. Bleeding or clotting problems.
4. High blood pressure, liver disease.
5. Kidney problems
6. During pregnancy, this medication should be used only when
clearly needed. It is not recommended for use during the first and
last trimesters of pregnancy due to possible harm to the unborn
baby and interference with normal labor/delivery.
 Non-opioid painkiller.
 It is not fully understood how nefopam works, but it
interrupts the pain messages being sent to the brain and also
acts in the brain to stop pain messages being felt.
Relieving acute moderate pain, such as pain after an operation,
dental pain or pain following accidents or injuries.
Nefopam has fewer side effects than strong opioid painkillers
such as codeine and morphine. It can be useful for the
management of persistant pain that is not relieved by other nonopioid painkillers such as paracetamol or ibuprofen.
Use with caution in:
Elderly people.
People with decreased kidney function.
People with decreased liver function.
People who have difficulty passing urine, for example men with
Not to be used in
Children under 12 years old.
People with a history of convulsions, epilepsy.
People taking medicines called monoamine oxidase inhibitors
(MAOIs). These include the antidepressants phenelzine ;
rasagiline and selegiline used in the treatment of Parkinson's
disease; and the antibiotic linezolid.
allergic to any of its ingredients.
Pregnancy and breastfeeding
The safety of this medicine for use during pregnancy has not
been established. The manufacturer advises that it should be
avoided during pregnancy unless there are no safer treatment
Side effects
Difficulty passing urine (urinary retention).
Low blood pressure.
Dizziness and fainting.
Tachycardia, palpitations.
Blurred vision.