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OBJECTIVE: (1) To determine the accuracy of accident and emergency (A&E) doctors' diagnosis of radio-opaque ureteric calculi on plain abdominal radiographs; (2) to study the predictive value of haematuria with a history suggestive of ureteric colic. DESIGN: A prospective study of all patients seen in a three month period with a provisional diagnosis of ureteric colic. Intravenous urography (IVU) was used as the gold standard for diagnosis of ureteric calculi. SETTING: The accident and emergency department and medical unit of a large teaching hospital. SUBJECTS: 60 patients who were admitted with an initial diagnosis of ureteric colic, 51 subsequently undergoing intravenous urography. RESULTS: A&E doctors achieved a calculated sensitivity of 29% (95% confidence intervals 13% to 49%) and a specificity of 73% (52% to 90%) for identification of renal calculi on plain abdominal radiograph, compared with figures of 68% (48% to 84%) and 96% (78% to 100%) respectively for consultant radiologists. The difference between these results was highly significant (P = 0.0011). No patient with a definitive diagnosis of ureteric colic had a negative result for haematuria on urinary dipstick analysis. CONCLUSIONS: A&E doctors are poor at identifying radio-opaque ureteric calculi on plain abdominal radiographs. If haematuria is absent on urinalysis then ureteric colic is an unlikely diagnosis.

Editor—The article by Wright et al on managing the pain of ureteric colic in the community has raised some concerns.1 The paper implies that a strategy of administering intramuscular diclofenac in the community would reduce the need for admitting patients to emergency departments. Although we welcome any attempt to reduce the number of unnecessary admissions to emergency departments, we raise the following points about using intramuscular diclofenac. Firstly, diclofenac causes pain on injections with a concomitant rise in serum phosphokinase activity. Cases of necrotising fasciitis have been recorded.2 Secondly, other non-steroidal anti-inflammatory drugs may be used, such as sublingual piroxicam or intramuscular keterolac, that may prove as effective as diclofenac without damaging tissues.3,4 Thirdly, cyclo-oxygenase 2 inhibitors may also prove effective in the treatment of renal colic and confer benefits in terms of their gastric protective effects. While clinical information is lacking in this area we believe that it is worthy of further analysis. The defence unions have stated that intramuscular injections of diclofenac into the thigh are the least safe. The Committee on Safety for Medicines has received reports concerning this issue. None of the cases that were opened were defensible, and one of the recommendations suggested that alternative routes of administration be used where possible.5 Such practice must therefore be able to withstand scrutiny in the event of a complaint or litigation. Our trust has taken the step of withdrawing intramuscular diclofenac from the trust formulary. We prefer to use rectal diclofenac or one of the cyclo-oxygenase 2 inhibitors.

1 Xie HG, Kim RB, Wood AJ, Stein CM. Molecular basis of ethnic differences in drug disposition and response. Annu Rev Pharmacol Toxicol 2001; 41: 815–50. 2 Lin JH, Chiba M, Baillie TA. Is the role of the small intestine in first-pass metabolism overemphasized? Pharmacol Rev 1999; 51: 135–58. 3 Lown KS, Mayo RR, Leichtman AB, et al. Role of intestinal P-glycoprotein (mdr1) in interpatient variation in the oral bioavailability of cyclosporine. Clin Pharmacol Ther 1997; 62: 248–60. 4 Lindholm A, Welsh M, Alton C, Kahan BD. Demographic factors influencing cyclosporine pharmacokinetic parameters in patients with uremia: racial differences in bioavailability. Clin Pharmacol Ther 1992; 62: 359–71. 5 Andrews PA, Sen M, Chang RW. Racial variation in dosage requirements of tacrolimus. Lancet 1996; 348: 1446. diagnose non-stone causes for pain, and commonly takes many hours to complete, CTU generally takes less than 5 min to do, uses no contrast (and is therefore safe in patients with renal insufficiency or at risk of contrast reactions), and can diagnose other causes of flank pain, such as leaking aortic aneurysms and other serious intra-abdominal disorders. A substantial number of patients with acute colic have stones (eg, uric acid calculi) that are radio-opaque on plain radiography. CTU shows most such stones. All these advantages are achieved at the cost of a higher radiation dose, but, when faced with a patient with suspected ureteric colic, I would always go for CTU as the diagnostic test of choice.

Summary A clinicopathologic correlation of 2 patients with crossed renal ectopia presenting with ureteric colic and 4 cases collected from the literature is presented. The correlation serves to reaffirm the theory of ureteral and not renal, migration as the primary aberration resulting in this defect.

The effectiveness of parasympathicolytic drugs in the treatment of ureteric colics is doubtful. Bencyclane is a new myotropic substance. Its spasmolytic effect on smooth muscle is five times stronger than that of papaverine. The results of the clinical use of Bencyclane in cases of ureteric colic are described and discussed.

A retrospective study of 1097 male in-patients with ureteric colic was conducted to try and define the aetiological effect of climate on the disease. The overall monthly incidence for the study period of 10 years was found, on statistical analysis to correlate with ambient temperature thus: (1) directly with the mean temperature of the preceding month, (2) directly with the difference between mean maximum and mean minimum temperatures of the same month, and (3) inversely with the mean maximum temperature of the same month. The correlation was interpreted on the basis that hot ambient temperatures promoted stone generation whereas cold ones promoted stone descent through cold-induced diuresis. This trend, among its other implications, could pinpoint the reason for the increase in nephrolithiasis with industralisation.

Ten cases of campylobacter bacteraemia, which were diagnosed over a three-year period, are described. Four patients presented with acute gastrointestinal illness, three patients had acute febrile illnesses, two patients had cellulitis and one patient presented with ureteric colic. Two patients had lifelong agammaglobulinaemia, two were undergoing corticosteroid therapy and there was one nosocomial infection. In contrast with previous reports, the most common species that was isolated was Campylobacter jejuni, which was found in eight cases, and this includes the first report of cellulitis that was most probably caused by C. jejuni. All of these isolations of campylobacter have occurred since the introduction of the radiometric technique of processing blood cultures.

Forty-six ureteroscopies were carried out over a 12-month period. A simple technique is described. The desired level was reached in 72% of cases and the pre-operative objective achieved in 60% of cases overall. Fifty per cent of all ureteric stones were safely retrieved by ureteroscopy. The instrument was used to establish a diagnosis of upper urinary tract abnormality in 16 of 23 cases. The overall complication rate was low, most problems relating to short-lived ureteric colic (23%) which was seen mainly after stone manipulation. Transurethral ureteroscopy is a safe procedure with a number of diagnostic and therapeutic possibilities.

Two cases of cystic dilatation of the intrahepatic biliary tree are described. Both patients succumbed to recurrent bile stasis, cholangitis and septicaemia. The pre-operative diagnosis is not easy but should be considered in patients who have symptoms of biliary tract disease and recurrent urinary tract infections, ureteric colic or haematuria; particularly if urography demonstrates renal cysts or medullary sponge kidney.

Summary— In this study the analgesic effect of indomethacin in ureteric colic was demonstrated in 15 patients. Of the 15 patients, 12 had prompt and effective pain relief. It is concluded that indomethacin suppositories offer a safe and effective alternative to pethidine in the treatment of ureteric colic.

High-energy shock waves were used to disintegrate kidney stones in dogs and man. In 96% of 60 dogs with surgically implanted renal pelvic stones, the fragments were discharged in the urine. The same effect was achieved in 20 out of 21 patients with renal pelvic stones. In the twenty-first patient, a staghorn calculus was broken up to facilitate surgical removal. 2 patients with upper ureteric stones also received shock waves, but their stones had to be removed surgically; in 1 of these the stone had been embedded in the ureteric wall by connective tissue. The procedure can in many cases be done under epidural instead of general anaesthesia. Side-effects consisted of slight haematuria and, occasionally, of easily treatable ureteric colic. They were probably due to passage of fragments down the ureter. Disintergration of kidney stones by shock waves seems to be a promising form of treatment that reduces the need for surgery.

Summary— Experiments have been carried out with isolated ring preparations of human ureter. The tissue displayed spontaneous activity and contracted when exposed to barium chloride (0.5-4 mM) but no responses were obtained with carbachol (0.1 micromolar-0.1 mM). This raises questions about the value of treating ureteric colic with anti-muscarinic drugs.

When a calculus travels from the renal pelvis into the ureter, complete or partial ibstruction result, with characteristic accompanying symptoms. The predominant feature is colic, usually an acute event leading to early medical intervention. As the colic subsides the aim of further treatment becomes the reduction of obstruction, be it by conservative drug therapy, by instrumention or by the surgery. Where shape, level and size of the stone are favorable, specific conservative therapy will result in spontaneous passage in about 60–90% of cases (BACH et al. 1983; BANDHAUER 1970; MADERSBACHER et al. 1975; SCHNEIDER 1985; VAHLENSIECK 1970, 1973; VAHLENSIECK and BASTIAN 1973). Any conservative treatment of ureteric colic or to promote spontaneous passage should be founded on pathophysiological understanding of the obstructed ureter.

Ureteric colic is a painful emergency. This paper examines the relative benefits of plain x-rays of the kidney/ureter/bladder (KUB) region and pyelograms in an emergency setting.

A randomised prospective double-blind study of the effect of 1 mg glucagon intravenously was done on 51 consecutive patients with acute uretic colic. No significant difference between glucagon and placebo could be demonstrated as to pain relief or passage of calculi.

Ureteric obstruction causes increased synthesis and release of prostaglandins. As a result renal pelvic pressure rises, causing renal colic. This double-blind study in 66 patients with acute renal colic shows that intramuscular injection of a potent prostaglandin-synthetase inhibitor (diclofenac sodium) is more effective and has fewer side-effects than a narcotic drug commonly used to treat ureteric colic.

Implantation of a stone in the ureter of the dog by ureterotomy results in focal hyperperistalsis which is accentuated by administration of norepinephrine, and reduced by administration of phenoxybenzamine or isoproterenol. Administration of dipyrone reduces the hyperperistalsis, but this action does not appear to be that of either a beta-agonist of an alpha-antagonist.

Diagnostic accuracy in identifying calculi in patients with ureteric colic is poor. Lower ureteric calculi may be confused with other pelvic calcific opacities. A characteristic appearance of some larger lower ureteric calculi is described and likened to the root of a tooth. It is hoped that the tooth-root sign will be of assistance in the diagnosis of distal ureteric stones.

The management of pain from ureteric colic (UC) has depended until now upon antispasmodic agents (AA) and, if ineffective, opiates. However, the high failure rate with AA and the risk attached to opiates makes this approach inadvisable. It has recently been proposed that UC be treated with indomethacin1, a nonsteroidal anti-inflammatory drug (NSAID), which inhibits PG biosynthesis thereby counteracting the effects of PGE2 on ureteric wall tone and glomerular filtration rate, both of which increase the pressure above the stone and evoke pain2,3.

The literature concerning the investigation of ureteric colic is reviewed. I have compared previous papers with the results of a prospective study of 50 patients who underwent emergency urography and testing for haematuria. Haematuria was present in 88% of all patients and in 97% of those with proven ureteric colic. The high haematuria figure is thought to be due to patient selection. Thirty-four patients (68%) had abnormal urographic findings consistent with ureteric colic. Seven of these patients (20%) had no plain film abnormality and the contrast films therefore confirmed the diagnosis. Haematuria is a useful indication of ureteric colic. However, since ureteric obstruction occurs without haematuria, and a normal urogram may be associated with haematuria, emergency urography is essential to confirm ureteric colic. This should be performed soon after the onset of pain if maximal information is to be obtained, thereby avoiding unnecessary investigation.

Une observation chez une malade de 57 ans. Douleurs evoquant une colique nephretique mais pas d'antecedents ni de symptomatologie urologique. Le diagnostic correct de rupture d'anevrysme est fait tardivement au moyen des ultrasons

We performed a retrospective study of 134 patients presenting at an Accident and Emergency department with ureteric colic, to determine if the presence of dipstick haematuria could be used as a screening test for the presence of a calculus.

We report on three children who were referred with episodic incapacitating loin pain and normal intravenous urograms. All three had been off from school and had given up all sports. Manipulation of the 11th or 12th rib reproduced the pain exactly. Following resection of the appropriate rib and costal cartilage all three children are completely pain-free, and have returned to normal activities. The Floating Rib Syndrome, which is an easy clinical diagnosis, must not be forgotten in the differential diagnosis of loin pain in children.

Glucagon may act as a relaxant of smooth muscle and it has been suggested that this action may assist in the passage of ureteric calculi and diminish ureteric colic. These effects may be of clinical use to avoid inpatient admission to hospital for the symptomatic relief of ureteric colic. Ten successive patients with acute ureteric colic were given 1 mg of glucagon and two litres of fluid administered by the intravenous route and analgesia as required over three hours. Progress was monitored radiologically and clinically. In no case did significant progression or passage of stones occur and seven patients required parenteral analgesia. We conclude that glucagon is not effective for the management of ureteric colic in a casualty department.

In a double-blind prospective trial 26 consecutive patients with proved ureteric colic were allocated at random to receive 100 mg pethidine or 0.3 mg buprenorphine by intramuscular injection. Pain relief was assessed by standard linear analogue and ordered categories scales. The mean pain relief on the linear analogue scale was 3.80 +/- SEM 0.64 in patients receiving pethidine and 6.86 +/- 0.40 in those receiving buprenorphine (p less than 0.001). The corresponding values for mean pain relief in the ordered categories scale was 1.78 +/- 0.26 v 2.76 +/- 0.20 (p less than 0.01). These observations suggest that buprenorphine is superior to pethidine as analgesia in ureteric colic.

In 1995, Smith and colleagues first proposed the use of low-dose CT KUB for the diagnosis of ureteric colic [1]. Since then, popularity of this imaging modality has increased due to a number of reasons: a sensitivity of 94 to 97%, a specificity of 96 to 99%, lack of intravenous contrast injection and speed of examination. The UK College of Emergency Medicine considers CT KUB as best practice for radiological investigation of renal colic. A review of the literature suggests that the true positive rate (number of patients diagnosed with an obstructing or symptom causing calculus) should be between 47.5 and 67% and alternative diagnoses should be confirmed in approximately 10% of patients imaged [2].