Radiological Investigation of Renal Colic in an Emergency Department of a Teaching Hospital Poster No.: C-0892 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit A. Koo; Leeds, West Yorkshire/UK Urinary Tract / Bladder, CT, Radiation safety, Acute, Calcifications / Calculi 10.1594/ecr2014/C-0892 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 7
Aims and objectives Introduction Suspected renal colic is a common presentation to an Emergency Department (ED), which affects 2-3% of the world's population. Computer Tomography Kidney Ureter Bladder scan (CT-KUB) is the investigation of choice when investigating acute renal colic. Aim To assess appropriate investigation of first presentation acute renal colic, as well as the diagnostic yield of CTKUB scans in terms of renal calculi and alternative diagnoses. Images for this section: Fig. 1: Targets Page 2 of 7
Methods and materials An audit was performed on an electronically generated list of patients who presented the ED with a diagnosis of suspected renal colic at St James University Hospital (SJUH) and managed on the renal colic pathway via Clinical Decisions Unit (CDU). Period: 4 months- 1st of January 2013 to the 1st of May 2013 Notes were cross-referenced to ensure an appropriate diagnosis of suspected renal colic. The arrival time was compared to the time the CT-KUBs were performed according to the "PACS" system. Patients who had CT-KUB were reviewed for calculi and any alternate diagnosis if available. If no CT-KUB was performed, the notes were reviewed to identify the reason. Results 264 patients attended the ED at SJUH were diagnosed with renal colic. 28 patients had to be excluded from the audit due to previous presentations, pregnancy and self-discharges. Subject size: 235 with ages between 18 and 99 years old. (134 Males - 57%); (101 Females - 43%) 99% (n=232) of patients had a CT-KUB as first line investigations but 1% (n=3) patients were found not to have had a CT-KUB and had USS KUB instead. 100% (n=232) of patients who had a CT-KUB were performed within 24 hours of presentation. Page 3 of 7
Of all the CT-KUBs performed, 51% (n=119) were calculi positive, 39% (n=91) had no radiological diagnosis and 10% (n=22) had alternate diagnosis. See graph 1 The diagnostic yield of calculi positive CT-KUB was 57% (n=76) in males and 44% (n=43) in all females. Within the group of females between the "childbearing age" age of 18 and 50 years (n=78), achieved a diagnostic yield 40% (n=31). See graph 2 Patients with alternate diagnosis were found to have potentially life-threatening conditions such as leaking abdominal aorta (n=1), perforated peptic ulcer (n=1) and acute pancreatitis (n=1). Images for this section: Fig. 2: Graph 1. All patients with CT-KUB Page 4 of 7
Fig. 3: Graph 2. Diagnostic Yield Page 5 of 7
Conclusion Evaluation All but 3 patients had a CT-KUB investigation for their first time renal colic. These patients were between 18 and 21 years old. Retrospective notes appraisal shown a low level of clinical suspicion with neither microscopic haematuria nor leukocyturia on urine dipstick. Their young childbearing age and level of clinical suspicion facilitated the decision made by both the clinician and radiologist to perform an USS KUB in order to further reduce the likelihood of having a calculi. This was supported by the low calculi positive diagnostic yield of 40% in "fertile" women which is below the recommended standard by 4%. The indication for CT-KUB in "fertile" women presenting with renal colic should perhaps be risk stratified as having high dose radiation might do more potentially avoidable harm. All patients received their scans within 24 hours of presentation. Furthermore, the Clinical Decision Unit (CDU) allowed ambulatory investigations and ensured patients gain access to CT-KUB with timely follow-up, especially in frequent out-of-hours presentations. Some patients had an alternate radiological diagnosis with a few potentially lifethreatening conditions. Although their life-threatening diagnosis did warrant a CT investigation, however underestimating the gravity of these conditions may have delayed appropriate treatment. Recommendations 1.Consider integrating USS KUB in young childbearing age females with low clinical suspicion of renal colic to minimise radiation exposure. 2.CDU to continue with ambulatory renal colic investigations in order to maintain continuity of care Personal information References Page 6 of 7
1. Making best use of a Department of Clinical Radiology, Guidelines for Doctors, Sixth Edition 2007, The Royal College of Radiologists, London 2. British Association of Urological Surgeons (BAUS) guidelines for acute management of first presentation of renal/ureteric lithiasis, December 2008. http://www.bauslibrary.co.uk/pdfs/bsend/ Stone_GuidelinesDec2008.pdf 3. Chowdhury FU, Kotwal S, Raghunathan G et al. Unenhanced multidetector CT (CT KUB) in the initial imaging of suspected acute renal colic: evaluating a new service. Clin Radiol. 2007 Oct;62(10):970-7. 4. Meagher T, Sukumar VP, Collingwood J, et al. Low dose computed tomography in suspected acute renal colic. Clin Radiol. 2001 Nov;56(11):873-6. 5. Greenwell TJ, Woodhams S, Denton ER, et al. One year's clinical experience with unenhanced spiral computed tomography for the assessment of acute loin pain suggestive of renal colic BJU Int. 2000 Apr;85(6):632-6. 6. Abramson S, Walders N, Applegate KE, et al. Impact in the emergency department of unenhanced CT on diagnostic confidence and therapeutic efficacy in patients with suspected renal colic: a prospective survey. Am J Roentgenol. 2000 Dec;175(6):1689-95. Page 7 of 7