Renal colic

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Steven C. Campbell, M.D., Ph.D.Soumya Sachdeva Luke Rusowicz-Orazem, B.S.

Overview

Renal colic is a type of pain commonly caused by kidney stones or accumulation of crystals. These kidney stones cause interference with the flow of urine and the kidney may swell up causing pain (colic).

The pain typically begins in the kidney area or below it and radiates through the flank until it reaches the bladder. The pain is colicky in nature, meaning that it comes on in spasmodic waves as opposed to being a steady continuous pain. It may come in two varieties: dull and acute; the acute variation is particularly unpleasant and has been described as one of the strongest pain sensations felt by humans.[2]

Depending on the type and sizes of the kidney stones moving through the urinal tract the pain may be stronger in the renal or bladder area or equally strong in both.

Differential diagnosis

Classification of acute abdomen based on etiology		Presentation	Clinical findings								Diagnosis		Comments
Classification of acute abdomen based on etiology		Presentation	Fever	Rigors and Chills	Abdominal Pain	Jaundice	Hypotension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Common causes of Peritonitis		Spontaneous bacterial peritonitis	+		Diffuse	−	−	−	−	Hypoactive	Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism	Ultrasound for evaluation of liver cirrhosis	–
		Perforated gastric and duodenal ulcer	+		Diffuse	−	+	+	+	N	Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl	Air under diaphragm in upright CXR	Upper GI endoscopy for diagnosis
		Acute suppurative cholangitis	+	+	RUQ	+	+	+	+	±
		Acute cholangitis	+	−	RUQ	+	−	−	−	N	Abnormal LFT	Ultrasound shows biliary dilatation	Biliary drainage (ERCP) + IV antibiotics
		Acute cholecystitis	+		RUQ	+		−	−	Hypoactive	Hyperbilirubinemia Leukocytosis	Ultrasound shows gallstone and evidence of inflammation	Murphy’s sign
		Acute pancreatitis	+		Epigastric	±		−	−	N	Increased amylase / lipase	Ultrasound shows evidence of inflammation	Pain radiation to back
		Acute appendicitis	+		RLQ	−		+	+	Hypoactive	Leukocytosis	Ultrasound shows evidence of inflammation	Nausea & vomiting, decreased appetite
		Acute diverticulitis	+		LLQ	±		+	−	Hypoactive	Leukocytosis	CT scan and ultrasound shows evidence of inflammation
Hollow Viscous Obstruction		Small intestine obstruction	−		Diffuse	−		+	±	Hyperactive then absent	Leukocytosis	Abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention
		Gall stone disease/Cholelithiasis	±	−
		Volvulus	–		Diffuse	–		+	–	Hypoactive	Leukocytosis	CT scan and abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention
		Biliary colic	–		RUQ	+		–	–	N	Increased bilirubin and alkaline phosphatase	Ultrasound	Nausea & vomiting
		Renal colic	–		Flank pain	–		–	–	N	Hematuria	CT scan and ultrasound	Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders	Ischemic causes	Mesenteric ischemia	±		Periumbilical	–		–	–	Hyperactive	Leukocytosis and lactic acidosis	CT scan	Nausea & vomiting, normal physical examination
	Ischemic causes	Acute ischemic colitis	±		Diffuse	–		+	+	Hyperactive then absent	Leukocytosis	CT scan	Nausea & vomiting
	Hemorrhagic causes	Ruptured abdominal aortic aneurysm	–		Diffuse	–		–	–	N	Normal	CT scan	Unstable hemodynamics
	Hemorrhagic causes	Intra-abdominal or retroperitoneal hemorrhage	–		Diffuse	–		–	–	N	Anemia	CT scan	History of trauma
Gynaecological Causes	Fallopian tube	Acute salpingitis	+		LLQ/ RLQ	−		±	±	N	Leukocytosis	Pelvic ultrasound	Vaginal discharge
	Ovarian cyst complications and endometrial disease	Torsion of the cyst	–		RLQ / LLQ	–		±	±	N	Increased ESR and CRP	Ultrasound	Sudden onset sever pain with nausea and vomiting
		Endometriosis	–		RLQ/LLQ	–		+/-	+/-	N	Normal	Laproscopy	Menstrual-associated symptoms, pelvic symptoms
		Cyst rupture	–		RLQ / LLQ	–		+/-	+/-	N	Increased ESR and CRP	Ultrasound	Sudden onset sever pain with nausea and vomiting
	Pregnancy	Ruptured ectopic pregnancy	–		RLQ / LLQ	–		–	–	N	Positive pregnancy test	Ultrasound	History of missed period and vaginal bleeding
Functional	Irritable Bowel Syndrome		–		Diffuse	–	–	–	–	N	Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria	–	High dietary fiber Osmotic laxatives Antispasmodicdrugs

Causes

Common Causes

Causes by Organ System

Cardiovascular	Renal artery embolism
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Probenecid
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	Chilaiditi syndrome, Wilson’s disease
Genetic	No underlying causes
Hematologic	Papillary necrosis
Iatrogenic	No underlying causes
Infectious Disease	No underlying causes
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	No underlying causes
Nutritional/Metabolic	No underlying causes
Obstetric/Gynecologic	Endometriosis, Müllerianosis
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	Analgesic nephropathy syndrome, Chronic interstitial nephritis, Cystinuria, Danubian endemic familial nephropathy, Hydatiduria, Medullary sponge kidney, Nephrocalcinosis, Nephrolithiasis, Oxalosis, Papillary necrosis, Pyelocalyceal diverticulum, Renal artery embolism, The primary hyperoxalurias, Urinary blockage
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

Treatment and Prognosis

Most small stones are passed spontaneously and only pain management is required. For this type of pain, strong Non-steroidal anti-inflammatory drugs (NSAID) such as Diclofenac provide better pain relief than opiates. Lying down on the non-aching side and applying a hot bottle or towel to the area affected may help. If the pain is not too intense, a more speedy release of the stones may be achieved by walking.

Larger stones may require intervention for their removal.