Hostname: page-component-78c5997874-s2hrs Total loading time: 0 Render date: 2024-11-14T03:24:28.831Z Has data issue: false hasContentIssue false

Predicting intervention in renal colic patients after emergency department evaluation

Published online by Cambridge University Press:  21 May 2015

Linda Papa*
Affiliation:
Department of Emergency Medicine, University Of Florida, Gainesville, Fla.
Ian G. Stiell
Affiliation:
Department of Emergency Medicine, University Of Ottawa, Ottawa, Ont.
George A. Wells
Affiliation:
Department of Epidemiology & Community Medicine, University Of Ottawa, Ottawa, Ont.
Ian Ball
Affiliation:
Department of Emergency Medicine, University Of Ottawa, Ottawa, Ont.
Erica Battram
Affiliation:
Department of Emergency Medicine, University Of Ottawa, Ottawa, Ont.
John E. Mahoney
Affiliation:
Division of Urology, University of Ottawa, University Of Ottawa, Ont.
*
Department of Emergency Medicine, University of Florida, 1329 SW 16th St., Ste. 2204, Gainesville FL 32608; 352 265-5911, fax 352 265-5606, [email protected]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objectives:

There is no set of prospectively validated criteria to identify the emergency department (ED) patients with renal colic who are most likely to eventually have to undergo an intervention. This study prospectively assessed predictors of intervention in this patient population.

Methods:

This prospective cohort study included adult patients with renal colic who presented to 2 tertiary care hospital EDs. Patients had an 18-variable data form completed by an emergency physician and a radiological study to confirm urolithiasis. After discharge, patients were followed at 1 and 4 weeks to assess for intervention. The outcome criteria included the patient having had at least 1 of the following procedures performed: extracorporeal shockwave lithotripsy (ESWL), ureteroscopy, percutaneous nephrostomy or open surgery. Data were analyzed using appropriate univariate techniques, and those variables associated with intervention were combined using logistic regression analysis.

Results:

Over an 8-month period, 245 patients with confirmed urolithiasis were followed; 20% (95% confidence interval [CI] 15%–25%) eventually had a procedure to remove their calculi. Three variables were significantly correlated with having a procedure: i) size of calculus ≥ 6 mm (odds ratio [OR] 10.7, 95% CI 4.6–24.8), ii) location of calculus above mid-ureter (OR 6.9, 95% CI 3.0–15.9), and iii) Visual Analogue Scale score for pain at discharge from the ED ≥ 2 cm (OR 2.6, 95% CI 1.0–6.8). The area under receiver operating characteristic curve was 0.77 (95% C I 0.70–0.84) (p < 0.001). If all variables were present there was a 90% probability of the patient having an intervention performed within 4 weeks of discharge from the ED. Conversely, if none of the variables were present there was only a 4% probability of an intervention. Overall, the model had a sensitivity of 92% (95% CI 89%–96%) and a specificity of 63% (95% CI 57%–69%).

Conclusions:

This study has identified variables that could potentially be used to identify those renal colic patients who require an intervention after ED evaluation. Future studies will prospectively validate this model.

Type
EM Advances • Innovations en MU
Copyright
Copyright © Canadian Association of Emergency Physicians 2005

References

1.Press, SM, Smith, AD. Incidence of negative hematuria in patients with acute urinary lithiasis presenting to the emergency room with flank pain. Urology 1995;45(5):753–7.CrossRefGoogle Scholar
2.Elton, TJ, Roth, CS, Berquist, TH, Silverstein, MD. A clinical prediction rule for the diagnosis of ureteral calculi in emergency departments. J Gen Intern Med 1993;8(2):5762.CrossRefGoogle ScholarPubMed
3.Stewart, C. Nephrolithiasis. Emerg Med Clin North Am 1988; 6(3):617–30.CrossRefGoogle ScholarPubMed
4.Pak, CY. Kidney stones. Lancet 1998;351:1797–801.CrossRefGoogle ScholarPubMed
5.Rhea, JT, DeLuca, SA, Toombs, BD. Evaluation of a sequence of diagnostic tests using the workup of ureteral stone as a model. Med Care 1982;20(8):843–8.CrossRefGoogle ScholarPubMed
6.Dalrymple, NC, Verga, M, Anderson, KR, Bove, P, Covey, AM, Rosenfield, AT, et al.The value of unenhanced helical computerized tomography in the management of acute flank pain. J Urol 1998;159(3):735–40.CrossRefGoogle ScholarPubMed
7.Chia, SJ, Lau, W, Tan, PK, Consigliere, D, Li, MK, Low, CH. Ureteric colic: value of initial investigations and the outcome. Ann Acad Med Singapore 1995;24(3):366–9.Google ScholarPubMed
8.Prina, LD, Rancatore, E, Secic, M, Weber, RE. Comparison of stone size and response to analgesic treatment in predicting outcome of patients with renal colic. Eur J Emerg Med 2002; 9(2):135–9.CrossRefGoogle ScholarPubMed
9.Kobayashi, T, Nishizawa, K, Watanabe, J, Ogura, K. Clinical characteristics of ureteral calculi detected by nonenhanced computerized tomography after unclear results of plain radiography and ultrasonography. J Urol 2003;170(3):799802.Google Scholar
10.Clark, JY, Thompson, IM, Optenberg, SA. Economic impact of urolithiasis in the United States. J Urology 1995;154:2020–4.Google Scholar
11.LeRoy, AJ. Diagnosis and treatment of nephrolithiasis: current perspectives. AJR Am J Roentgenol 1994;163(6):1309–13.CrossRefGoogle ScholarPubMed
12.Segura, JW, Preminger, GM, Assimos, DG, Dretler, SP, Kahn, RI, Lingeman, JE, Macaluso, JN Jr. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association. J Urol 1997; 158(5):1915–21.Google Scholar
13.Holman, CD, Wisniewski, ZS, Semmens, JB, Bass, AJ. Changing treatments for primary urolithiasis: impact on services and renal preservation in 16,679 patients in Western Australia. BJU Int 2002;90(1):715.Google Scholar
14.Tasso, SR, Shields, CP, Rosenberg, CR, Sixsmith, DM, Pang, DS. Effectiveness of selective use of intravenous pyelography in patients presenting to the emergency department with ureteral colic. Acad Emerg Med 1997;4(8):780–4.CrossRefGoogle Scholar
15.Hubner, WA, Irby, P, Stoller, ML. Natural history and current concepts for the treatment of small ureteral calculi. Eur Urol 1993;24(2):172–6.CrossRefGoogle ScholarPubMed
16.Irving, SO, Calleja, R, Lee, F, Bullock, KN, Wraight, P, Doble, A. Is the conservative management of ureteric calculi of > 4 mm safe? BJU Int 2000;85(6):637–40.Google Scholar
17.Laupacis, A, Sekar, N, Stiell, IG. Clinical prediction rules. A review and suggested modifications of methodological standards. JAMA 1997;277(6):488–94.CrossRefGoogle ScholarPubMed
18.Stiell, IG, Wells, GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33(4):437–47.Google Scholar
19.Jewett, MA, Bombardier, C, Menchions, CW. Comparative costs of the various strategies of urinary stone disease management. Urology 1995;46(3 Suppl A):1522.CrossRefGoogle ScholarPubMed
20.Ohkawa, M, Tokunaga, S, Nakashima, T, Yamaguchi, K, Orito, M, Hisazumi, H. Spontaneous passage of upper urinary tract calculi in relation to composition. Urol Int 1993;50(3):153–8.CrossRefGoogle ScholarPubMed
21.Ibrahim, AI, Shetty, SD, Awad, RM, Patel, KP. Prognostic factors in the conservative treatment of ureteric stones. Br J Urol 1991;67(4):358–61.Google Scholar
22.Ueno, A, Kawamura, T, Ogawa, A, Takayasu, H. Relation of spontaneous passage of ureteral calculi to size. Urology 1977;10(6):544–6.CrossRefGoogle ScholarPubMed
23.Fielding, JR, Silverman, SG, Samuel, S, Zou, KH, Loughlin, KR. Unenhanced helical CT of ureteral stones: a replacement for excretory urography in planning treatment. AJR Am J Roentgenol 1998;171(4):1051–3.CrossRefGoogle Scholar
24.Morris, SB, Hampson, SJ, Gordon, EM, Shearer, RJ, Woodhouse, CR. Should all patients with ureteric colic be admitted? Ann R Coll Surg Engl 1995;77(6):450–2.Google ScholarPubMed
25.German, I, Lantsberg, S, Crystal, P, Assali, M, Rachinsky, I, Kaneti, J, et al.Non contrast computerized tomography and dynamic renal scintigraphy in the evaluation of patients with renal colic: Are both necessary? Eur Urol 2002;42(2):188–91.Google Scholar
26.Wrenn, K. Emergency intravenous pyelography in the setting of possible renal colic: Is it indicated? Ann Emerg Med 1995;26(3):304–7.CrossRefGoogle ScholarPubMed
27.Haddad, MC, Sharif, HS, Shahed, MS, Mutaiery, MA, Samihan, AM, Sammak, BM, et al.Renal colic: diagnosis and outcome. Radiology 1992;184(1):83–8.Google Scholar
28.Walsh, PC, Retik, AB, Vaughn, ED, Wein, AJ, editors. Campbell's Urology, 7th ed. Philadelphia: Saunders; 1998.Google Scholar
29.Holm-Nielsen, A, Jorgensen, T, Mogensen, P, Fogh, J. The prognostic value of probe renography in ureteric stone obstruction. Br J Urol 1981;53(6):504–7.CrossRefGoogle ScholarPubMed
30.Chen, MYM, Zagoria, RJ, Dyer, RB. Radiologic findings in acute urinary tract obstruction. J Emerg Med 1997;15(3):339–43.Google Scholar
31.Katul, MJ, Wax, SH. Evaluation of renal function during experimental hydronephrosis by means of the radioisotope renogram. Surg Gynecol Obstet 1968;126(3):563–71.Google ScholarPubMed
32.Stiell, IG, Greenberg, GH, McKnight, RD, Nair, RC, McDowell, I, Worthington, JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21(4):384–90.Google Scholar
33.Stiell, IG, Wells, GA, Vandemheen, KL, Clement, CM, Lesiuk, H, DeMaio, V, et al.The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286(15):1841–8.Google Scholar
34.Stiell, IG, Wells, GA, Vandemheen, K, Clement, CM, Lesiuk, H, Laupacis, A, et al.The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6.Google Scholar
35.Stiell, IG, Clement, CM, McKnight, RD, Brison, R, Schull, MJ, Rowe, BH, et al.The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349(26):2510–8.CrossRefGoogle ScholarPubMed
36.Miller, OF, Rineer, SK, Reichard, SR, Buckley, RG, Donovan, MS, Graham, IR, et al.Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain. Urology 1998;52(6):982–7.CrossRefGoogle ScholarPubMed
37.Niall, O, Russell, J, MacGregor, R, Duncan, H, Mullins, J. A comparison of noncontrast computerized tomography with excretory urography in the assessment of acute flank pain. J Urol 1999;161(2):5347.CrossRefGoogle ScholarPubMed
38.Boulay, I, Holtz, P, Foley, WD, White, B, Begun, FP. Ureteral calculi: diagnostic efficacy of helical CT and implications for treatment of patients. AJR Am J Roentgenol 1999;172(6):1485–90.CrossRefGoogle ScholarPubMed
39.Collie, DA, Paul, AB, Wild, SR. The diagnostic yield of intravenous urography: a demographic study. Br J Urol 1994;73(6):603–6.CrossRefGoogle ScholarPubMed
40.Juul, N, Brons, J, Torp-Pedersen, S, Fredfeldt, KE. Ultrasound versus intravenous urography in the initial evaluation of patients with suspected obstructing urinary calculi. Scand J Urol Nephrol Suppl 1991;137:45–7.Google Scholar
41.Mendelson, RM, Arnold-Reed, DE, Kuan, M, Wedderburn, AW, Anderson, JE, Sweetman, G, et al.Renal colic: a prospective evaluation of non-enhanced spiral CT versus intravenous pyelography. Australas Radiol 2003;47(1):22–8.CrossRefGoogle ScholarPubMed