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CT KUB FOR ACUTE RENAL COLIC

Published on Nov 21, 2015

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PRESENTATION OUTLINE

1.

CT KUB FOR ACUTE RENAL COLIC

Louise Hartley (Radiology ST1)
2.

Background

  • Renal colic lifetime incidence 12%
  • Unenhanced CT KUB 1st line investigation for acute renal colic
  • Exponential increase in CT KUBs over last decade.... 2012 - 2013 9.7% increase 2013 - 2014 16.1% increase
  • Are we still using CT KUBs appropriately?
3.

Audit targets

4.

Methodology

  • Retrospective analysis of consecutive inpatient CT KUBs undertaken at Ayr University Hospital using RIS
  • Sept '14 - Feb '15
  • Reviewed request details, images, formal report & previous examinations
  • Excluded patients with imaging positive for urolithiasis in last 6 months
5.

Results

  • 137 patients; 55% male, 45% female
  • 55% male, 45% female
  • aged 17-79; mean 49
  • 97% appropriately underwent CT KUB requested by A&E, Urology & Gen Surgery
  • 92% CT KUBs within 24 hours
  • mean CT dose
"70 yo male, frank haematuria"
"RIF pain, septic"
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Imaging for Renal Colic

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CT KUB Results

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Untitled Slide

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Calculi +ve

  • 47% presented with obstructive uropathy
  • 3 patients recently passed stones
  • max 11 mm in size; mean 5mm
  • 49% ureteric, 25% renal, 16% VUJ, 10% PUJ
  • 3 patients recently passed stones
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Alternate diagnoses

  • ovarian pathology (57% F)
  • acute cholecystitis
  • acute diverticulitis
  • acute pancreatitis
  • mesenteric panniculitis
  • bladder carcinoma
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Discussion

  • Target for alternate diagnoses met (8.8%)
  • Target for calculi detection in males met (44%)
  • Target for calculi detection in females missed (all F 38%, fertile F 30.6%)
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AXR 1st line?

  • Conflicting recommendations for acute renal colic (iRefer vs BAUS)
  • 50.4% AXR prior to CT KUB
  • sensitivity of AXR (vs CT) 20% (46% including "possible calculi")
  • 3 false +ve interpreted by A&E
  • 0.7 mSv really worth it?
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Is haematuria reliable?

  • 56.2% of ?calculi requests stated haematuria in clinical history
  • "review of the case notes suggests that the urinalysis is negative for haematuria contrary to the clinical information provided"
  • sensitivity of haematuria (vs CT) 59.7%
  • specificity 46.3%
14.

Changing practice?

  • "Ultrasonography vs computed tomography for suspected nephrolithiasis" NEJM, Sept '14
  • 3000 patients acute renal colic bedside US vs. formal US vs. CT
  • US as the initial imaging modality decreased radiation exposure and did not increase adverse outcomes
  • uncomplicated renal colic -> US first
Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations.

caution with extremes of age, septic, congenital abnormality/single kidney, renal failure
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Untitled Slide

16.

Interventions

  • if high clinical suspicion of renal colic, avoid AXR
  • consider US 1st line especially in young female patients
  • present findings to referring departments
  • re-audit in 6 months
17.

References

  • Smith-Bindman, Rebecca, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. New England Journal of Medicine. 2014: 1100-1110.
  • Moore et al. Sonography first for acute flank pain?. Journal of Ultrasound in Medicine. 2012: 1703-1711.
  • Xafis K et al. Forget the blood, not the stone! Microhaematuria in acute urolithiasis and the role of early CT scanning. Emerg Med J. 2008 Oct;25(10):640-4.
  • http://www.irefer.scot.nhs.uk/adult
18.

Any Questions?

Louise Hartley

https://www.facebook.com/app_scoped_user_id/648136165665/