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).
Adrian has a really nice set of “rules” to guide us when working up suspected renal colic patients. It goes something like this:
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
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!
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact