Loin pain after ESWL

1. HKCEM College Tutorial Loin pain after ESWL author Dr CO Tang, Dr MK Tam Revised by Dr Li Yu kwan July 2013

2. Triage Note • Male 54 • History of renal stone • Received ESWL today • Complaint of increased right loin pain after ESWL

3. Vital Sign • BP 178/109 mmHg • Pulse 81/min • Temp 36.5

4. General Moderately distress Abdomen Abdomen soft and non-tender Mild percussion tenderness over right loin System survey No skin bruise Physical Exam

5. Urine analysis • RBC---large • WBC---negative • Nitrite—negative • Protein---negative

6. Likely Diagnosis?

7. Common complications • Renal colic with stone fragment passage • Haematuria

8. Less common but important complications • “Steinstrasse” Stone street(1-30% depending on size of stone) • Urinary tract infection / urosepsis (0.3%) • Subcapsular / retroperitoneal hematoma (0.25 - 30%) (clinical significant haemorrhage <1%) • Injury of neighbour organs (less than 1%)

9. Don’t forget other DDx of loin pain that are unrelated to ESWL AAA, Aortic dissection………..,etc

10. What investigations will you request? KUB Look for opacity along renal tract suggestive of stone Kidney/Psoas shadow USG Focused renal USG CBC (Hb, Hct, platelet) RFT, clotting profile Blood

11. Focused USG for Post-ESWL loin/flank pain • Look for hydronephrosis/pyonephrosis • Signs of complete obstruction • Look for renal/perirenal/hepatic subcapsularhaematoma (focal solid area or area with complex cystic changes / para-renal anechoic to echogenic collection / haemoperitoneum)

12. You can choose your scenario: A B C

13. Scenario A

14. Scenario A • Good past health except right ureteric stone • Previous investigation showed a 1cm right ureteric stone at L4 level causing partial obstruction of the urinary tract. • Loin pain radiate to right groin • Mild haematuria noted

15. KUB

16. USG(Right kidney)

17. USG(Left kidney)

18. Ureteral jets

19. Blood tests • Hb, Hct and plt normal • RFT normal • Clotting normal

20. Diagnosis? Likely Dx: Stone passage with renal colic and hydronephrosis

21. What is your management?

22. Management • Parental analgesic (NSAID or nacrotic) • Refer urologist for further management. • Advise to come back if fever or refractory pain • For refractory pain, need to admit for further investigations to R/O important complications like haematoma

23. Scenario B

24. Scenario B • Good Past Health except right renal stone • Previous investigation showed 3 right renal stones with largest one measuring 2.5 cm (largest diameter) • Right loin pain shift to right flank and groin region

25. KUB Findings and diagnosis?

26. USG Right Kidney

27. Ureteral jets

28. Blood tests • Hb, Hct and plt normal • RFT normal • Clotting normal

29. Diagnosis? Steinstrassepost-ESWL with hydronephrosis Management?

30. Steinstrasse • Stone street • Acolumn of stone fragments retained in the ureteral lumen that obstructs the PC system after ESWL • 1-4% of patients with small sized stones • 5%-10% of patients with large (>2 cm2) stone burdens

31. Steinstrasse: Management • Spontaneous expulsion of steinstrasse (~37% of cases) ; otherwise, ureteroscopy, percutaneous nephrolithotomy (PCN), or additional ESWL treatment will be required • Investigations: KUB, USG, urine analysis and RFT • In the absence of UTI, complete obstruction, renal impairment and intractable pain, conservative treatment with α-blocker may be considered

32. Back to our patient • Manage conservatively with pain relieved • Tamsulosin started for aiding expulsion • Stone successfully passed 2 wks later

33. Scenario C

34. Scenario C • Past Health: Known HT • He has consulted a GP and received IMI analgesic before AED attendance • Persistent pain despite treatment

35. KUB

36. USG Doppler USG Diagnosis?

37. Blood tests • Hb 12.1; Hct 39%; Plt normal • Wbc 4.3 • Cr 80 • Clotting normal

38. Management • NPO • IVF • Admit Urology What investigation will likely be arranged after admission?

39. CT abdomen To assess extent of injury A large perinephric collection compatible with perinephrichaematoma

40. Haematoma formation should be suspected if…. • Persistent pain despite analgesics • Suspicious for hypovolemic shock (e.g. syncope, orthostatic hypotension, decreased hemoglobin level) • Especially in patients with risk factors including HT, previous hx of ESWL session, clotting problems, obesity, advanced age >60

41. Management Stable patient • Conservative • Transfusion prn Haemodynamic instability • Embolization • Drainage

42. Prognosis • Most patient has preserved renal function • Spontaneous radiological resolution occur within 2 yrs

43. Summary • We have covered: • how to evaluate a patient with flank pain after ESWL • the common complications including renal colic and haematuria • how not to miss important complications including steinstrasse, haematoma formation

44. Reference: • Acute complications during and after extracorporeal shock wave lithotripsy. Indian J Urol 2001;17:118-20 • Tamsulosin as an expulsive therapy for steinstrasse after extracorporeal shock wave lithotripsy: a randomized controlled study.Scand J Urol Nephrol. 2010 Nov;44(5):315-9 • Perirenal Hematomas Induced by Extracorporeal Shock Wave Lithotripsy (ESWL). Therapeutic Management. ScientificWorldJournal. 2007 Sep 17;7:1563-6.

45. Q&A