Emergency Medicine

ACUTE ABDOMEN

Surgical Emergencies 269

(i) CT can determine the presence of calculi, their size, degree of

ureteric obstruction and exclude other important differential

diagnoses, particularly an AAA.

9 Alternatively request a renal ultrasound, particularly in a younger patient or
for recurrent colic.

10 An IVP is best reserved for post complex urological surgery only.

MANAGEMENT

1 Start analgesia:
(i) Give morphine 0.1 mg/kg i.v. with an antiemetic such as
metoclopramide 10 mg i.v. particularly if the pain is intense and
incapacitating.
(ii) Alternatively, use diclofenac 75 mg i.m. or indomethacin
(indometacin) 100 mg p.r.
(iii) NSAIDs are as effective as opiates, but are not controlled drugs,
and will also discourage those who are simply ‘seeking’
narcotics.

2 Admit patients with resistant pain, a stone >6 mm in diameter with an
ob s t r u c t e d k id ne y (t he s e a re u n l i k e l y to p a s s s p ont a ne ou s l y), or a ny e v id e nc e
of infection.
(i) An infected obstructed kidney is a urological emergency needing
immediate drainage.
(ii) Call the urology team urgently for percutaneous nephrostomy
insertion.

3 Discharge the remainder to their GP or urology outpatients for follow-up,
and recommend a reduced sodium and low-protein diet that decreases the
likelihood of recurrent calcium-based stones.

Pyelonephritis

DIAGNOSIS

1 Typically symptom onset is rapid and characterized by frequency, dysuria,
malaise, nausea, vomiting and sometimes rigors.

2 Raised temperature, renal-angle tenderness, and vague low abdominal pain
are found.

3 Dipstick urinalysis shows blood, protein and nitrites.

4 Insert an i.v. cannula and send blood for FBC, U&Es, blood sugar and blood
cultures in any patient who is significantly ill.

5 Send an MSU to look for bacteria, leucocytes and red blood cells on micro-
scopy and for culture.