No blood no stones…..challenge dogma

From a previous Post…..

A 60-year old man leaves home with the hint of an impending UTI. Pre-emptively he started a course of antibiotics from a repeat left over from a previous successfully treated UTI. He travels across Australia gradually getting worse. He stops for advise at a mainland country hospital. There he is given the diagnosis of pyelonephritis treated with oral antibiotics and analgesia. Shortly after arriving on KI he presented to quite unwell, febrile, tachycardic and dehydrated with marked left abdominal pain. My working diagnosis was diverticulitis and I admitted him, hoping that he would settle with IV antibiotics and not require a journey with the flying doctor to Adelaide. Two days latter with CRP risen from 60 to 220, rising creatinine, still requiring morphine for his pain, bowels not open, with no blood in his urine, he is transferred to the care of a friendly surgical registrar at a big teaching hospital. A CT scan revealed a large mid-uretric stone, hydronephrosis and perinephric stranding. He was stented 2 days latter by urology registrar who happily told me 30% of patient with stones don’t have blood in their urine!!

Okay so what can I learn.

Oxford Handbook of Clinical Medicine suggests that a mid-uretetic renal stone may mimic diverticulitis.

Through the mists of time I had accepted that if you don’t have blood in the urine then you can’t have a kidney stone.

Maybe I have been prejudiced by the ED mantra

“moaning & groaning drug seeker, no blood in the urine, cant be renal colic, no opiates for you, just a paracetamol & indomethacin suppository….. oh, your leaving are you?”

So is my friendly urology registrar right?

To quote Up To Date (add the American accent)

“On the other hand, the absence of hematuria in the setting of acute  flank pain does not exclude the presence of nephrolithiasis. Hematuria is not detected in approximately 10 to 30 percent of patients with documented nephrolithiasis.  One factor that may undermine the sensitivity of hematuria is the  interval from the onset of acute pain to the time of urine examination.  In a retrospective study of over 450 patients with CT-documented acute  ureterolithiasis, hematuria was present in 95 percent on day one and 65  to 68 percent on days three and four.”

Press and Smith reviewed 140 patients who presented with flank pain to their emergency department from January 1, 1992, through December 31, 1992, and underwent intravenous urogram. No haematuria was found in 14.5% of patient proven to have stones. They also found that by considering a negative combination (urinalysis plus urine dipstick test) as a new definition of negative hematuria, the incidence of negative hematuria in patients with acute stones was only 5.5% (P < 0.031). Press SM, Smith AD. Incidence of negative hematuria in patients with acute nephrolithiasis presenting to the emergency room with flank pain. Urology. 1995;45(5):753.

Bove et al reviewed the medical records of 267 consecutive patients with acute flank pain referred for unenhanced helical CT. Microscopic and dipstick urinalysis data were obtained in 195 patients. Using helical CT as the gold standard, we calculated the sensitivity, specificity, predictive value and accuracy of hematuria for diagnosing ureterolithiasis. Of the patients with ureterolithiasis 33% had 5 or less, 19% had 1 or less and 11% had no red blood cells per high power field. Bove P, Kaplan D, Dalrymple N, Rosenfield AT, Verga M, Anderson K, Smith RC. Reexamining the value of hematuria testing in patients with acute flank pain.  J Urol. 1999;162(3 Pt 1):685.

 So, maybe the off the cuff remark was a little overstated. Regardless I had succumbed to my own personal dogma that no blood no stone. Lesson learnt.

Trial of labour or elective section….what to choose?

I help to provide a low risk obstetric service in a remote area. I work in private practice and provide my services to the local hospital on a fee for service basis.

Imagine a 36-year-old woman who has had four babies by vaginal delivery in another location without any complications.  Her last was an elective section for a breech presentation in a teaching hospital. It was a routine delivery.

Now she comes and asks me where she could have her next baby. If she wants a repeat section would be prepared to do it at our local hospital.

Significant obstetric risks for her include;

  • 1:4 to 1:10 risk of placenta accreta if she has placenta previa
  • 3:100 risk of placenta accreta if there is even if there no placenta previa
  • 3:100 that the next baby also being breech at term

In choosing the mode of delivery the NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights published in 2010 provides some guidance in making this decision. In a hypothetical group of 100,000 women of any gestational age who undergo either procedure the table below shows the complication risks

Trial of labour after a Caesarean section

Elective repeat Caesarean section,

Maternal deaths

4

13

Uterine rupture at term

778

22

Hysterectomy

157

280

Blood transfusion

1200

900

Deep vein thrombosis

40

100

Perinatal deaths

130

50

Neonatal birth trauma

180

30

Neonatal hypoxic ischemic encephalopathy

46

0

The rates of maternal hysterectomy, haemorrhage, and transfusions did not differ significantly between trial of labour and elective repeat Caesarean delivery. I wonder how many GP obstetricians are able to manage the 0.28% of women who will need a hysterectomy?

Currently our hospital only provides elective repeat Cesarean section. This was a decision which predates my arrival and primarily it was a decision based upon the concern that a uterine rupture may overwhelm local resources. Thus the decision becomes complicated by whether the woman wants to go to town or stay home. Generally, the journey to town to await the onset of labour is recommended at around 37 weeks. This is a long time to be potentially apart from support networks and can be a financial drain on families.

Now, something to stir a conversation.

In private practice you can often make a decision not to look after a patient. After all, they may well be seeing you by a quirk of the appointment system. You skill set may not be appropriate to the patients needs. Obviously if the patient has anaemia and melena they need someone who can do an gastroscopy and sort out the bleeding. If they have paranoid schizophrenia they need the help of a psychiatrist.

What if you feel like you have failed engaged with this theoretical pregnant patient and not been able to establish a therapeutic relationship. You can, I believe, suggest that they would be better served by seeing a colleague. But what do you do in a remote setting were the alternative to you providing care may involve a distant journey?

Or do you suck up your reservations and continue to treat her despite your feelings.