Left-side Ureteric Colic Case Study

Case Study – Group B

Introduction

A 46 year old secretary was admitted to emergency with left-side ureteric colic. She had a similar case 3 years ago and she passed a small calculus spontaneously. She has been taking cimetidine (for the last 6 months), for dyspepsia treatment. Physical examination revealed a tenderness in the left loin.

Symptoms

Left-side ureteric colic.

Small calculus passed spontaneously (3 years ago).

Tenderness in the left loin.

Medication Taken

Cimetidine (last 6 months) for dyspepsia treatment.

Serum Results (compared to ‘normal’)

Creatinine 150 umol/L (50-110)

Na⁺ 141mM (135-145)

K⁺ 4.2mM (3.5-5.1)

Total CO₂ 20nM (23-29)

Urea 8.1Mm (4.0-8.2)

Albumin 40g/L (35-50)

Calcium 3.49mM (2.1-2.5)

Phosphate 0.60mM (1.0-1.5)

ALP Activity 160U/L (20-140)

Results that differ from ‘normal’ levels are underlined.

Suspected/Differential Diagnosis

This patient has been admitted to emergency with 3 major symptoms, all of which occurred within the last 3 years (symptoms are stated above). Along with this the patient has been subscribed cimetidine for the last 6 months which is advised to not be taken when the patient is known to have kidney problems, this could potentially be increasing the problematic symptoms.

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The most recent symptom, to which the patient was initially admitted, is left-side ureteric colic. This is caused by movement of the calculus that produces unpleasant sensations of abdominal pain often in waves (colicky) or sometimes a constant pain, both of which will typically move until it reaches the hypochondrium (or groin area). This supports the results from the physical examination which state that there was a tenderness in the patients left loin, due to the movement of the calculus and pain from there-forth.

These symptoms are most commonly developed after passing of a kidney stone, such as the small calculus that this patient passed 3 years ago. These stones can be static or moving, the latter of which can be more painful and cause more symptoms as it travels.

Renal calculi are generally formed when the urine is overly saturated with minerals and salts such as calcium and others. This is supported by the patient’s blood-serum results which indicate a high amount of calcium (3.49mM) where the ideal level is around 2.1-2.5mM. Kidney stones are primarily made out of 60-80% calcium, so the excess amount found in the patient’s blood can easily result in a build-up of a calculus.

In addition to the excess of calcium, there is also an excess of other substrates in the blood. One of which is creatinine which is ideally found between 50-110 umol/L but the patient contains excess of 150 umol/L. High amounts of creatinine is known to effect the ability for the kidneys to filter fluid within the body. This will lead to a build-up of certain substrates in the blood such as the calcium mentioned previously. Therefore, high amounts of creatinine can cause a ‘domino effect’ where high amounts of creatinine = high amounts of other substrates, this could cause major problems in the body if not treated immediately.

Also within the results of the patient’s blood-serum test is the abnormality of low amounts of CO₂ (20nM) known as hypocapnia, this is can be used to indicate that the patient may be beginning to show signs of kidney failure.

Similarly, low amounts of phosphate are shown (0.60mM), this is also an indication of kidney failure due to inadequate filtration of substrates by the kidney to be excreted as urine. The parathyroid hormone (PTH) regulates the amount of phosphate and calcium in the blood, typically the substrates react oppositely: as phosphate increases, calcium will decrease. Due to there being a great excess in calcium the PTH hormone reacts to decrease the amount of phosphate in the blood serum.

Finally, as phosphate is used to repair bones, help the function of nerves and muscle contraction, low amounts of it can cause a severe problem in the patient. This links into the high amounts of ALP activity that are found in this patient’s blood-serum at 160U/L which can be caused by stones such as the small calculus being obstructive. This can lead to problems with bones, which being linked to low amounts of phosphate also, could cause severe problems in the patient and even bone cancer. However, high amounts of ALP have been found in women in the third trimester of pregnancy, which could be the case with this patient, but this is currently unknown.

Further Tests to confirm the diagnosis

Urine examination can be used to find if there is any blood in the patient’s urine (haematuria) which often occurs after passing a stone. Also the pH of the urine can be examined to indicate either the urine is ‘normal’, acidic (<6.0) which has the potential to result in a uric acid stone, or alkaline (>8.0) indicating that an infection could be present from organisms such as Proteus or Pseudomonas. As well as this, the urinalysis can show substrate crystals such as calcium oxalate- quite likely due to excess calcium in the patient.

Imaging (X-ray, Ultrasound etc.) Firstly, KUB x-rays can be used to show abnormalities in the kidneys, ureters or bladders, these are indicated by dark shadows in the renal-tract but can be mistaken for phleboliths which is venous and not a form of calculus.

Ultrasounds are easy and quick and does not use any form of radiation, this method will indicate stones that are of 0.5cm in diameter or larger.

Next, Intravenous Pyelogram (IVP) provides a clear outline of the urinary tract system and shows-up many indicators of kidney problems such as mild hydronephrosis, however this test can cause unwanted reactions in the patient that are best avoided.

Finally, a test for the PTH hormone can be undertaken with the calcium, phosphate and ALP blood tests. This will help to identify hyperparathyroidism, which is a hyperactivity of the hormone, as well as finding the cause for the high amounts of calcium in this patient.

Treatments and Prognosis

The patient that is suffering from left-side ureteric colic, small calculi and tenderness in the left loin should drink plenty of liquids, primarily water. This will encourage any further renal stones to be passed and it will also begin to reduce any possible damage to the functionality of urinary/renal tracts.

If there are further stones found in the patient (possible due to high calcium amongst other substrate fluctuations) then with liquids they should pass spontaneously, unless they are large in-which they will need specific removal that could involve surgery. Spontaneous movement and passing of stones may take as long as 40 day so the patient is likely to be under a lot of pain that is often compared to being worse than child birth, therefore pain killers such as paracetamol at a standard dosage of 1 or 2 tablets up to 4 times a day for an adult such as this patient, may be required to alleviate the pain.

If by taking further tests, such as the urinary examination, it is found that the patient is suffering from an infection (pyonephrosis) then treatment is required such as percutaneous nephrostomy. This is usually an emergency procedure that is used to relieve an obstructed and infected renal collecting system by percutaneous puncture with ultrasound guidance.

Also, Medical Expulsive Therapies can be used such as calcium antagonists. These work by blocking the calcium ion channels to supress the fast component for contracting the ureter, this in turn will help relax the smooth muscles and help stones to pass more easily.

Overall, the patient is likely to be in a lot of pain for some time, therefore, strong painkillers will be required and if in the case of infections then antibiotics could also be necessary to overcome the patient’s symptoms and to finally be cured.

References

1. Clinical chemistry-Marshall, William J.,Bangert, S. K.,Lapsley, Marta2012. Referenced 05.01.14
2. Clinical biochemistry: an Illustrated Colour Text-Gaw, Allan, eauthor2013. Referenced 05.01.14
3. Royal College of Physicians and Surgeons of Canada. Normal Values. Referenced 05.01.14 [royalcollege.ca]
4. Salman S, Castilla C, Vela N R. Action of calcium antagonists on ureteral dynamics.Actas Urol Esp1989. [PubMed] Referenced 05.01.14
5. Freeman SJ, Sells H, Investigation of loin pain, Imaging (2005) 17, 19-33, British Journal of Radiology. Referenced 05.01.14
6. Miller OF, Kane CJ; Time to stone passage for observed ureteral calculi: a guide for patient education. J Urol. 1999. Referenced 05.01.14
7. Amiel J, Choong S; Renal stone disease: the urological perspective. Nephron Clin Pract. 2004. Referenced 05.01.14