ReviewThe evaluation and management of urolithiasis in the ED: A review of the literature
Introduction
Urolithiasis is a common condition evaluated and managed in the emergency department (ED). Nephrolithiasis refers to stones within the kidney, while ureterolithiasis refers to stones within the ureter. Urolithiasis refers to stones within the kidneys, ureters, bladder, or urethra. This review will focus on urolithiasis. Approximately 11–16% of men and 7–8% of women will experience symptoms from urolithiasis by age 70 [1], [2], [3], [4], [5]. Over 70% of the population affected with urolithiasis is between 20 and 50 years [3], [4], [5], [6], [7], with a recurrence rate approaching 50% over 10 years [6], [7], [8]. The prevalence of urolithiasis in 1994 was 5.2%, which has more than doubled in 2017. This increase in prevalence is associated with over one million ED visits annually, with over 40,000 surgical interventions [8], [9], [10], [11], [12]. Annual costs approach $5 billion, which will likely continue to increase [9], [10], [12], [13]. One major issue with urolithiasis is the morbidity due to renal colic, which may result in sudden, intense pain. Severe sequelae can include sepsis and death from an obstructed, infected stone. Recent prospective data suggest increase in infected urolithiasis incidence and rates of sepsis and severe sepsis, though mortality rates have remained stable [14]. Recurrence is also common, occurring in 15% of patients during the first year and 30–50% within 10 years [2], [12], [13], [14], [15], [16], [17].
Men experience stones in a 2:1 ratio when compared with females, predominantly due to diet, climate, and other risk factors [1], [2], [12], [16]. Additional risk factors for stone disease include obesity, decreased fluid intake, increasing age, Caucasian race, lower socioeconomic status, diabetes, and gout [1], [2], [5], [12], [16]. Conditions such as inflammatory bowel disease, pancreatitis, short gut syndrome, and hyperparathyroidism also increase the risk of stone formation due to the associated metabolic abnormalities [1], [2], [12], [18]
Section snippets
Methods and objectives
In light of new evidence for both the evaluation and treatment of urolithiasis, this review was designed to summarize the current literature regarding the treatment of urolithiasis for the emergency physician. Authors searched PubMed and Google Scholar for articles using a combination of the following keywords and Medical Subject Headings: “kidney stone”, “renal stone”, “nephrolithiasis”, and “urolithiasis”. The literature search was restricted to studies published in English. Authors decided
Anatomy and pathophysiology
Stone formation is predominantly due to an imbalance of urinary solute and solvent [19], [20], [21]. Solutes normally dissolve in a solution until a specific saturation point. Once the saturation point is exceeded, stones can form in the urine. Citrate, glycoproteins, and magnesium inhibit crystal formation, while other materials, referred to as ‘nucleating centers’ (eg, epithelial cells, urinary casts, and red blood cells), form areas for crystal collection [12], [18], [19], [20], [21], [22].
Conclusions
Urolithiasis is a common medical condition, resulting in over one million ED visits annually. The most common presentation includes flank pain, hematuria, nausea, and vomiting. However, classic symptoms may not always be present. Urinalysis should not be relied on for diagnosis or exclusion of urolithiasis. Risk assessment tools and advanced imaging may facilitate the diagnosis of urolithiasis. Imaging options include x-ray, CT, ultrasound, and MRI. While CT is often considered the gold
Conflicts of interest
None.
Acknowledgements
MG, BL, and AK conceived the idea for this manuscript and contributed substantially to the writing and editing of the review. Dr. White approved this topic for review. This manuscript did not utilize any grants, and it has not been presented in abstract form. This clinical review has not been published, it is not under consideration for publication elsewhere, its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and
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