skipping the ct for renal colic in the young patient?

[Painter1]

in a young patient (e.g. age in their 20s) with textbook story of renal colic and blood in UA, would u ever skip a ct to spare the patient all that radiation?

you would rx them pain meds, given them strict instructions to return if fever/chills/nausea/vomiting or if their symptoms do not resolve/improve within a couple days? most stones pass on thier own with the excetion of the large proximal stones so to me it seems reasonable to postpone the ct pending if symptoms don't improve.

what you guys think? standard of care?

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[12R34Y]

I do this frequently. I often do bedside ultrasound myself and look for hydronephrosis and oftentime will get formal as they can frequently see stones that I can't.

pain control and able to take PO is the name of the game in kidney stone management. If they fail outpatient therapy and return I get scan, looking for infected stone, if UA shows infection I get scan to confirm, also if over 50y/o and worried about alternative path like AAA I'll get scan (but also if older I don't care nearly as much about radiation).

this was discussed recently on here.

later

 

[Jeff698]

Yes.

Take care,
Jeff

 

[southerndoc]

I always do this for younger individuals. I document that their pain is relieved (not expecting them to be completely pain free), that they have no sign of infection (if they do, they get a CT), and that I've discussed with them the risks of radiation and a CT was offered but deferred. I always offer the CT if they want it, but usually most will skip it after discussion of radiation risk.

I always tell patients that the majority of kidney stones will pass on their own, and that the CT will rarely change management. If their pain persists for >48 hours, worsens, or I'm unable to get some relief of pain in the ED, then I order the CT without question.

 

[TysonCook]

I do it as well. Clinical questions that may change what I do:
1) Past Hx of stones that did/didn't need stenting/removal
2) duration of symptoms (4+ days, prob getting a CT)
3) Objective fever
4) Tolerance of "not needing to know"

PO fluids, po anitemetics, po pain meds and DC w/ f/u in 48h prn.

 

[edgesofsanity]

I do this frequently. I often do bedside ultrasound myself and look for hydronephrosis and oftentime will get formal as they can frequently see stones that I can't.

pain control and able to take PO is the name of the game in kidney stone management. If they fail outpatient therapy and return I get scan, looking for infected stone, if UA shows infection I get scan to confirm, also if over 50y/o and worried about alternative path like AAA I'll get scan (but also if older I don't care nearly as much about radiation).

this was discussed recently on here.

later

Let me 2nd the use of a bedside ultrasound looking for hydronephrosis - additionally, you can make sure they actually have 2 kidneys. You'd have a harder time defending in court if it turned up they had only one kidney that ended up with an impacted stone that you sent home...

 

[brianmartin]

What about an abdominal film?

 

[Rendar5]

What about an abdominal film?

Relatively poor sensitivity and additionally it doesn't do what you might necessarily want.

It doesn't look for mimickers such as AAA's, it doesn't localize the stone well, it doesn't measure stone size and/or show the degree of hydronephrosis. In terms of localization, it doesn't tell you whether the stone is obstructive or not (and not a cause of renal colic).

 

[NinerNiner999]

Actually, I CT just about every patient with "stones" regardless of age. I do so for a few reasons:
1) The size and location of the stone are important. >5mm gets a call to urology at the minimum.
2) >5mm with fever/UTI, renal failure and Hydro usually gets admitted.
3) I don't want to give toradol for someone with Flank pain who actually has a renal hemorrhage (which I've seen).

 

[Rendar5]

Actually, I CT just about every patient with "stones" regardless of age. I do so for a few reasons:

3) I don't want to give toradol for someone with Flank pain who actually has a renal hemorrhage (which I've seen).

Anything in the H&P on that case that was different from the usual colic?

 

[deleted65604]

I'm with Niner on this one. ERs are almost universally overwhelmed and ER capacity is dependent on quick dispositions to maximize utilization of rooms. I don't feel comfortable sending someone out the door who continues to be experiencing pain without some degree of observation when I don't have a firm diagnosis. If they have a known 3 mm stone however, I simply up the pain medicine and send them out the door.

You are going to get tons of patient complaints if you miss diagnoses, or even don't give people EXACT diagnoses and predict when they'll get better. Tons of patient complaints equals no more job for you.

I saw a patient a few months ago with post-procedure pain from lithotripsy. The vast majority of posters here it seems would have been petrified to have scanned him believing they would cause a fatal cancer. They would have missed the retro-peritoneal hematoma and subsequent Page kidney.

What if it isn't a stone? What if it is a perforated gastric ulcer into the lesser sack and their abdomen isn't tender yet? What if it is a ruptured retroperitoneal tumor? What if it is a retrocecal appendicitis that is presenting atypically?

Even small stones around 3 mm frequently cause mild hydronephrosis. You are talking about a tiny fraction of patients that you could avoid a CT on.

In America, we have a 1 in 5 chance of getting cancer in our lifetime. Say for every CT scan you do, you increase their chance of getting cancer by 1/3000, that would increase their chance of getting cancer to 1/5+1/3000 or 0.2003.

YOUR risk of missing something fatal is probably greater than 0.0003.

 

[southerndoc]

I saw a patient a few months ago with post-procedure pain from lithotripsy. The vast majority of posters here it seems would have been petrified to have scanned him believing they would cause a fatal cancer. They would have missed the retro-peritoneal hematoma and subsequent Page kidney.

I'm not disagreeing with you, but some would state that unless the patient required a blood transfusion, became severely hypotensive, required a surgical procedure, or other invasive therapy, then your findings were clinically insignificant.

At least that's what the NEXUS/CCR, head injury rules, etc. want to rule out. There are some things that were missed during these studies, but they were clinically insignificant (I'm sure the patients would argue otherwise).

 

[NinerNiner999]

Anything in the H&P on that case that was different from the usual colic?

Absolutely nothing. It was so typical that I almost had to pry the Toradol out of my nurse's hands.

 

[med2UCC]

Fairly recently I had a guy who presented with classic kidney stone symptoms, 19 years old. We CT'd him ( we CT everyone who comes in with symptoms of kidney stones unless they are extremely young ) and found... a severely inflamed appendix. He had surgery 2 hours later. We CT for kidney stones in my shop. Cheers,
M
Oh, we do use bedside ultrasound but not everyone in the department is trained - I'm doing the course Easter day. This may change things slightly.

 

[Apollyon]

Fairly recently I had a guy who presented with classic kidney stone symptoms, 19 years old. We CT'd him ( we CT everyone who comes in with symptoms of kidney stones unless they are extremely young ) and found... a severely inflamed appendix. He had surgery 2 hours later. We CT for kidney stones in my shop. Cheers,
M
Oh, we do use bedside ultrasound but not everyone in the department is trained - I'm doing the course Easter day. This may change things slightly.

On a noncontrasted CT? So, now, I can tell my radiologists that, even across the pond, they don't need contrast!

 

[ER-ER-Oh]

I only DON'T scan those with known kidney stone history that present with typical signs/symptoms unless there's signs of infection. I usually do a bedside US anyway, just to keep practicing, and to look for hydronephrosis. If hx and exam and past hx all look like stone I defer CT because they've usually had the knee jerk CT every time they've come in for the symptoms. The chances of missing something worse, I feel, is negligable in these patients.

I do agree though with the fact that getting people through quickly, with the correct diagnosis and with the proper treatment and instructions equals better patient satisfaction, which equals people feeling you're a great doctor. Unfortunately, all the NEXUS stuff, and clinical decision trees, and research are like masturbation for us. I spend huge amounts of time talking to my patients about what's going on and how it all works. Usually what they comment on in my Press Ganey stuff is how funny I am...GOD!!! If they only knew what I really think of THEM...

 

[southerndoc]

On a noncontrasted CT? So, now, I can tell my radiologists that, even across the pond, they don't need contrast!

We now do non-contrast CT's for rule out appy's. Contrast only for really thin patients or if we are suspecting something else going on (mesenteric ischemia, SBO, etc.).

 

[xaelia]

On a noncontrasted CT? So, now, I can tell my radiologists that, even across the pond, they don't need contrast!

Lots of literature to support neither oral, rectal, or IV contrast for appendicitis.
"Diagnosis of acute appendicitis with sliding slab ray-sum interpretation of low-dose unenhanced CT and standard-dose i.v. contrast-enhanced CT scans"
"Evaluation of a low-dose CT protocol with oral contrast for assessment of acute appendicitis."
"Can computed tomography scan be performed effectively in the diagnosis of acute appendicitis without the added morbidity of rectal contrast?"
etc.

Of course, when they tell you to "read it yourself", you'll probably let them give whatever contrast they prefer.

 

[Apollyon]

Lots of literature to support neither oral, rectal, or IV contrast for appendicitis.
"Diagnosis of acute appendicitis with sliding slab ray-sum interpretation of low-dose unenhanced CT and standard-dose i.v. contrast-enhanced CT scans"
"Evaluation of a low-dose CT protocol with oral contrast for assessment of acute appendicitis."
"Can computed tomography scan be performed effectively in the diagnosis of acute appendicitis without the added morbidity of rectal contrast?"
etc.

Of course, when they tell you to "read it yourself", you'll probably let them give whatever contrast they prefer.

I know all that. My point is that old-school rads, in my limited experience, who trained with contrast for appy eval, are (logically) resistant to non-contrasted CTs for appy - I understand the idea of missing something, so you go with what you know. I'm just saying that they even do it across the Atlantic.

 

[TysonCook]

Agree with southerndoc, and the above. It is only on a few select patients that we can skip CT's on.

One big problem we have out in the sticks is that we have a TON of narcotic abuse (and sales), and very very very few paying patients (the hospital has let go of 1/3 of ALL staff, and cut a lot of pay this year).

We've come to a medical crux of really having to weigh the costs (yes, including missed surgical abdomens etc), vs the benefits.

Unfortunately, we have lots of people that hospital shop out here, but thanks to Al Gores invention of the internet, we can see what scans they've had (some over 300).

So, (as always) it depends. We all have the anecdotal "incidentaloma" that we're glad that we caught, but what threshold do/should we have?

How many scans, dollars, hours, visits, pills, etc should be limited?

This can be applied to chest pain (see other discussion), TIA, Syncope, diabetic cellulitis....and on, and on, and on.....

My brother is a radiologist and we joke about how on those patients that get 300+ scans, we're going to be sued for giving them cancer, not missing something.

(sorry about the long diatribe)

 

[diamondbum]

I'm actually doing my residency scholarly project on the utilization of renal protocol CT's for suspected renal colic. We are in the midst of collecting data right now, so I don't have much new info for you, but from my lit search, whether or not they have hydronephrosis really isn't all that important as someone with two healthy kidneys can have unilateral hydro for weeks without any long term damage. A congenital unilateral kidney, horseshoe kidney, etc. is very important to know. Currently at my institution, we scan all first time stones, old people with suspected stones, and those where things just don't quite all match up. My project is collecting data on 30 day outcomes, physician suspicion of nephrolithiasis, and other mitigating factors, such as reported hx of stone, infected urine, fever, etc. I give you all a heads up when we start to analyze some of the data.

 

[med2UCC]

On a noncontrasted CT? So, now, I can tell my radiologists that, even across the pond, they don't need contrast!

Yes, a noncontrast CT. We don't usually use CT for appendicitis (one of the 1st CT's I ever saw was for appendicitis and the take home message was "Don't order these for this!". I then did an elective back home and got dragged off to see a CT of an inflamed appendix and got told "If you order a CT to diagnose appendicitis we will laugh at you".), we use ultrasound. We were expecting a honking kidney stone in this guy though, so he got the CT.
We do a lot of non-contrast exams. Our radiologists seem to prefer to hold the contrast unless it is absolutely necessary, and we can usually get enough information to diagnose without iatrogenically poisoning the kidneys.
Cheers,
M

 

[Apollyon]

Yes, a noncontrast CT. We don't usually use CT for appendicitis (one of the 1st CT's I ever saw was for appendicitis and the take home message was "Don't order these for this!". I then did an elective back home and got dragged off to see a CT of an inflamed appendix and got told "If you order a CT to diagnose appendicitis we will laugh at you".), we use ultrasound. We were expecting a honking kidney stone in this guy though, so he got the CT.
We do a lot of non-contrast exams. Our radiologists seem to prefer to hold the contrast unless it is absolutely necessary, and we can usually get enough information to diagnose without iatrogenically poisoning the kidneys.
Cheers,
M

When I suggested ultrasound for appy in South Carolina, the radiologist roundly, completely shot me down. No question, period.

 

[med2UCC]

When I suggested ultrasound for appy in South Carolina, the radiologist roundly, completely shot me down. No question, period.

Wow. We're kind of like that for CT for appendicitis - Rads will do them but they scream and protest a bit first. THe combination of clinical suspicion, high white count and positive ultrasound seems to produce the same kind of clinical outcome as CT without the whopping radiation dose (and the expense - socialised health care likes to keep the expense down). We have an acceptable level of false positives and we keep our CT's for more serious pathology. Maybe your radiologist will retire...
M

 

[deleted65604]

I think that if you have friendly, happy ultrasound techs that aren't too overworked and are comfortable with looking for the appendix, US is a great option.

In other words, for the vast majority of us, this isn't available.

US techs have the radiologist by their private parts. If they are angry, they quit and go get cuh jobs working for OB offices for out-patient 20 week OB US, or out-patient imaging centers for thyroid and breast US.

Not many radiologists can order around the techs and get away with it.

I know that in my small community, there are only 3 US techs, which means that they pull q 3 call their entire lives. If I called them in for every suspected appy, they would quit and we would be US techless...not a fun place to be.