UK Guidelines Update in Primary Care: Renal and Ureteric Stones


  • Clinical Guidance Summaries
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Presented by Professor Fahad Rizvi, a senior GP in Leicester and Tutor Leicester medical school. He completed 6 years of surgical training and is a member of the royal college of surgeons. Professor Rizvi is currently involved in delivering minor surgery and urological services in primary care. He is also a medical student teaching lead at Leicester city academy and recipient of awards from university of Leicester and the Royal college of General Practitioners.
 
Today we will talk about Renal and Ureteric stones in the view of NICE guidelines. It is a very complex problem in primary care, and we will try and tackle it in the next few minutes.
I am Professor Fahad Rizvi. I am a GP in Leicester. My Background was Urology training, all over the country and currently, I am involved in teaching in a couple of universities and also, I do a lot of urological procedures in primary Care.
 

 
This short film will aim to provide the latest Nice guidelines for the management of renal and ureteric stones. It will be useful for the GP’s and trainees to understand these new guidelines.
Renal stones are found in the kidneys and they travel down this thin tube, the Ureter, coming down into the bladder from where they are expelled out of the Urethra.
 

They are mainly formed of calcium, Oxalate and Phosphate which accounts to 80% of them. The rest 20% are mainly Uric acid, struvite and cystine.
The most painful part of the kidney stones are as they are traversing through the Ureter. This causes intense pain and bleeding caused by the injury to the Ureters.
So NICE have provided guidelines to standardise care and quality across the country.
 
Renal and Ureteric stones are quite common with a prevalence of around 10%. Males are affected more common than females and the age group is between 30 and 50 during the first presentation.
 
The cause for renal stones is often unknown but they are quite common in people who have a high calcium levels in their blood which can be because of hyperparathyroidism or people who have renal infections, they may get Struvite stones.
It is also linked with family history and people who are house-bound, or bed bound. People who don’t drink enough liquids. They may cause stagnation of urine and lead to kidney stones.
Stones are important because they are very painful. Some people mention that they are worse than childbirth. Now, we also have complications linked with kidney stones and they could be things like sepsis which could be life threatening or you may get a ureteric stricture or irreversible kidney damage.
 

As a clinician, you see loads of patients with abdominal pain and one of those reasons could be a renal or ureteric stone. These patients present with a loin to groin pain which radiates to the perineum.
 
The pain is often a sudden onset and lasts from minutes to hours. It can come in spasms or maybe they are constant.
Patients will often have nausea and vomiting along with this pain which is caused by the pain itself.
The diagnoses of renal and Ureteric stones is mainly done on the basis of a good history, examination (e.g. dipstick urine for haematuria) and the use of imaging (e.g. CT scans and ultrasound scans for pregnant women.
 
This is a lot of differential diagnoses of people coming in with loin to groin pain and there could be a problem in the kidney itself which could be like pyelonephritis or a blocked kidney with some other reason.
It could be because of a gynaecological cause like a ruptured ovarian cyst. I could also be things like Diverticulitis or appendicitis or a ruptured aneurysm.
It is quite distressing seeing patients with renal or ureteric colic in primary care.
 
The initial management is to provide them with NSAID’s which will be like IM diclofenac or PR diclofenac. And we also need IM anti emetic like metoclopramide.
If the pain is controlled, then I would send them home with some baseline investigations which includes the kidney function test, serum calcium and organise an urgent CT scan.
If the patients are not stable and they are still in pain, they may need some more analgesic (like morphine) or intravenous paracetamol as with the NICE guidelines so they would require hospital admission.
 
I would organise urgent hospital admission if the patient is at risk or the kidney is at risk.
So it could be like for example if someone is pregnant and has a renal stone, they should be offered admission to hospital. Patients who are in septic shock or with a high fever and tachycardia and high respiratory rate should be offered admissions. Similarly, people with transplanted kidneys or having a single kidney are at high risk.
The recommended imaging for kidney and ureteric stones is CT KUB. This CT scan is a low dose, high contrast CT scan, which can be done in minutes and can provide good quality images and can locate the size and shape of the kidney stone.
 
In patients who can’t have a CT KUB, can have an ultrasound scan and this is for patients like pregnant females.
We can look further into NICE guidelines which provide a detailed chart of management and prevention of stones. It is a very useful tool to look at. I am sure clinicians and patients will find it useful.
 
So my advice to my colleagues and patients is to drink plenty of water, which is 8 glasses every day, which equates to 2 litres. They may wish to add some lemon for taste and also to decrease the formation of stones.
 
NICE guidelines also advise to consider us to add Potassium citrate for patients who are recurrent stone formers. And may consider adding a thiazide diuretic to the medications.
 
NICE provides clear a very easy guidance for management and prevention of kidney stones.
I hope you found this video useful. Thank you for watching.