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Renal Colic Scans with Dr Adrian Goudie

Patients presenting to the GP or ED with flank pain, colicky pain or pain with haematuria are pretty common.  We know that a lot of these folk will turn out to have the dreaded kidney stones.  We all have our own ways of deciding how to treat these patients.  You may be aware that in September  a big paper was released in the NEJM titled Ultrasound vs. CT for Suspected Nephrolitiasis.  For many ED docs this paper just might be a game-changer.  This was the first really big trial which looked at the bedside US vs. formal US vs. CT for the initial workup of this group of patients.  And it seems to suggest that bedside US is a valid first test for most patients.

As a GP I think this is potentially a big change – if we can scan at the bedside in our clinic with the modern machines – we just might be able to do a pretty fair job of managing simple, uncomplicated renal stone disease without ever needing a hospital – that would be nice!

Anyway – I have been wanting to pick the brain of a much smarter ultrasonically-enhanced doctor about how this changes our practice in 2014 – so I managed to enlist the help of Dr Adrian Goudie [ED Physician, Ultrasound Village teacher, SMACC Sonowars combatant, Ultrasound Leadership Academy Professor and immediate past President of the Australasian Society of US in Medicine…  and great bloke! ]

We had a natter about the paper, his practice and the pragmatic approach to patients with potential stones in the ED (or GP clinic).

Here is the podcast:

DIRECT DOWNLOAD HERE

Adrian has a really nice set of “rules” to guide us when working up suspected renal colic patients.  It goes something like this:

  1. Treat the following groups with caution – you may want to be more aggressive with your imaging if the patient has:
    • Known renal failure, or new renal failure
    • Known congenital anomaly or single (transplanted etc.) kidney
    • Signs of infection / sepsis / obstructed pus is bad.
    • Extremes of age – you are just more likely to find other pathology that you don’t want to miss
  2. As a routine have a look at the aorta – this is low-hanging fruit and an important one to not “miss”.
    • You should also consider the gallbladder, uterus, ovaries, testes and even the appendix if the clinical picture fits.
    • Think outside the KIDNEY BOX – particularly if your renal scan is normal.

You can also check out an older Broome Docs Case [To Frolic with Colic: Case 035]  where we looked at the value of “haematuria” in the investigation for renal colic.  It is interesting to go back a few years and see the smart docs who anticipated this research with their comments- Dr Goudie was one of them!

Also check out the Renal Ultrasound talk from Matt Dawson at Castlefest a while back. So you can see what stones etc look like.

There is a great “Cheat sheet” for reference when scanning from my friends at the Sonocavge HERE – Thanks Dr Goudie and Dr Rippey.

Let me know if this will change your practice…. or not.

Casey

Comments

  1. thomas coombs says:

    Hi Casey, love your show
    I work in a rural nth qld hospital setting
    I agree that we need to be circumspect about CTing suspected renal colic patients.
    However, in my mind the size and position of the stone are very useful pieces of information which USS cannot often answer.
    If a patient presents for the first time with typical renal colic pain, haematuria and is found to have a 10mm stone, hydroureter, hydronephrosis on CT then that will effect my disposition plans leaning towards early involvement of a urologist, whereas a 2mm VUJ stone can safely be sent home with analgaesia and a strainer.

    It is true that developing self sufficiency in renal/ ureteric scanning can help in making the diagnosis out of hours, and help exclude other uglier diagnoses but sending patients with large calculi home generally leads to unseemly representations at odd hours.

    I often would use USS to diagnose renal calculi/ hydronephrosis/ hydroureter but then in patients presenting for the first time or the first time in years would follow that with CT to characterize the calculus. The old method of plain film KUB to document movement of the calculus over the next days to weeks is sometimes is helpful when the stone is radioopaque.

    The NEJM article appears to refute my clinical beliefs about renal calculi but i have only been able to read the abstract. Size does matter with calculi doesnt it?

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