Paediatric Renal Colic

[FionaS]

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A question for you general surgeons/paediatric surgeons...

I'm working in the ED at present and just saw this pt:

13 year old boy presents with sudden onset left loin pain, followed shortly thereafter by vomiting. No other symptoms whatsoever. No radiation/movement of pain. Urine dipstick showed trace protein and trace of blood, pH unknown because they forgot to write it down!

PMHx of Crohns (under specialist at local childrens hospital, on azathioprine). No features to suggest exac of Crohns.

Exam - obviously in pain, wriggling around on the couch. Left loin tenderness, abdo soft, no guarding, bowel sounds normal. Chest and cardiac exam NAD.

Pain has responded quite well to diclofenac.

I've sent him to the surgeons as renal colic.

Any other diagnoses spring to mind? Renal colic at his age is pretty rare.

 

[tussy]

Could totally be his crohn's disease - he could have fistulized and have a psoas abscess.

Did you consider testicular tortion.

Renal colic is more common in crohns disease so it is possible.

I would have definitley done more of a workup - did you do any diagnostic imaging???????

 

[gasnewby]

I've sent him to the surgeons as renal colic.

is surgical therapy really first line for renal colic? are you serious? how about a formal UA, CBC, and a flat plate, before you consult surgery. you don't even have a diagnosis.

 

[Blade28]

You mentioned groin pain...what about testicular pain, specifically? How was the rectal exam?

 

[FionaS]

ED works differently here - pts need to be out of the dept within 4 hours (government mandate), so it's rare we actually have a confirmed diagnosis before referring the pt. Makes you really rely on you hx and exam... Sucks because although the right people usually end up looking after the pt, it's pretty frequent that you get the diagnosis slightly or even completely wrong. And you don't even find out unless you chase your pts up. Drives me mad!


Testicular exam was NAD. No groin pain at all.

He was apyrexial (T 36.6), slightly tachy at 126, all the rest of his obs were will within normal limits. After his diclofenac his HR came down to 106.

FBC, U&Es and CRP were sent, but you don't get the results back for about 2 hours, and the pt had already been in dept for 2.5 hours (busy night).

The only imaging I have available at night is plain film - I did consider an AXR, wasn't sure about doing it considering his age. Discussed that with the surgeons, and they agreed to hold off and see how he responded to analgesia. If the film showed a stone, it wouldn't change the management at night. Given his soft abdo, afebrile and resolving tachycardia, it was unlikely to show anything else, so we held off until morning when everything is available (USS etc).

is surgical therapy really first line for renal colic? are you serious? how about a formal UA, CBC, and a flat plate, before you consult surgery. you don't even have a diagnosis.

Basically, yes. He was going to be admitted anyway, the question then becomes do I bleep the surgeons and sell the pt as renal colic, or bleep the medics and sell it as exac +/- complications of crohns?

Anyway, I'll look him up when I go in tonight and see what happened next, and what his blood results were. I'm interested to know. Also interested in that assoc btwn crohns and renal calculi someone mentioned - my quick google search last night didn't throw that up, have to see what I can find.

 

[gasnewby]

maybe i'm missing something. since when is lithotripsy or other surgical therapy first-line for renal colic? i don't understand your response.

sounds like you have your hands tied though.

 

[FionaS]

maybe i'm missing something. since when is lithotripsy or other surgical therapy first-line for renal colic? i don't understand your response.

sounds like you have your hands tied though.

He was being admitted for the pain relief side of things, not for any kind of acute intervention. Since we don't have an A&E obs ward either (apparently they're going to build one - construction should have started in October...) they have to be admitted to the speciality who'd look after them/sort them out in future ie surgery.

I do send renal colics home if I can - but not little 13 yos at 2am in lots of pain.

I understand what you're saying though!

 

[heartsurgeon]

renal colic though occuring at 13 yrs of age is not unusual given this pt has cronhs disease where oxalate stones do occur due terminal ileal dysfunction .

 

[DrDawg]

Where are you that there is a government mandate to pass a patient along within 4 hours, and routine labs take more than a couple hours?

Was he to be seen by Urologist or General surgeons?

I thought Imuran had an increase incidence in stones but wasn't able to find anything

 

[tussy]

I thought Imuran had an increase incidence in stones but wasn't able to find anything

Imuran doesn't increase the risk of kidney stones, but it can cause pancreatitis. Was a lipase done on this patient???

 

[gudog]

Where are you that there is a government mandate to pass a patient along within 4 hours, and routine labs take more than a couple hours?

Was he to be seen by Urologist or General surgeons?

I thought Imuran had an increase incidence in stones but wasn't able to find anything

Perhaps you are remembering the interaction between Imuran and Zyloprim (which stone patients are frequently prescribed) wherein Imuran toxicity can occur.

 

[FionaS]

Where are you that there is a government mandate to pass a patient along within 4 hours, and routine labs take more than a couple hours?

Was he to be seen by Urologist or General surgeons?

I thought Imuran had an increase incidence in stones but wasn't able to find anything

In the UK...

He was seen by urology, did have a renal stone, but didn't require any intervention.