Avoiding Computed Tomography Scans by Using Point-of-Care Ultrasound When Evaluating Suspected Pediatric Renal Colic

Carrie Ng, MD; James W. Tsung, MD, MPH

Disclosures

J Emerg Med. 2015;49(2):165-171. 

In This Article

Abstract and Introduction

Abstract

Background: Although renal colic in children in the United States remains relatively uncommon compared to in adults, its incidence has nearly doubled from 1999 to 2008. Noncontrast computed tomography (CT) is the current standard for the evaluation of suspected renal colic, given its high sensitivity and specificity. However, the greater lifetime risk of radiation-induced cancer from CT in pediatric patients has led to efforts to minimize radiation exposure. Additionally, pediatric renal colic is often recurrent, which might require multiple imaging studies during their lifetime. Point-of-care ultrasound (POCUS) by emergency physicians avoids radiation, has a low marginal cost, can be performed concurrently with other management, and allows for earlier diagnosis and more rapid treatment of renal colic. Adult randomized controlled trial evidence supports using POCUS as the initial approach to imaging and management of suspected renal colic. However, there remain limited data on POCUS in children for renal colic.

Case Report: This is a case series where the sonographic findings of hydronephrosis, ureteral jets, "twinkling artifact," and the identification of urinary tract stones were used to evaluate adolescent and pediatric patients with renal colic. We report five cases of renal colic in adolescent and pediatric patients where urolithiasis was confirmed by using POCUS and irradiation by CT was avoided in all 5 patients.

Why Should an Emergency Physician be Aware of This?: POCUS can provide information about the presence or absence of urinary tract stones as well as obstruction of the collecting system without the cost and radiation exposure of CT.

Introduction

Although renal colic among children in the United States remains relatively uncommon compared to adults, its incidence has risen in the past decade and a half.[1–3] Emergency department (ED) visits for pediatric renal colic have nearly doubled from 1999 to 2008, from 0.05% to 0.09%.[1]

Noncontrast computed tomography (CT) is the current standard for evaluation of suspected renal colic, given its high sensitivity of 97% to 98% and high specificity of 96% to100%.[4,5] However, the greater lifetime risk of radiation-induced cancer from CT in pediatric patients should prompt pediatric health-care providers to avoid harmful radiation-exposure from CT, when possible.[6,7] Additionally, renal colic is often recurrent, with one studying showing 67% of pediatric patients with nephrolithiasis having two or more renal colic episodes in a 5-year span.[8] Given the frequent need for diagnostic imaging in such patients, a valuable alternative to CT that avoids radiation is ultrasound (US).

Point-of-care ultrasound (POCUS) by emergency physicians has a low marginal cost, can be performed concurrently with other management, and allows for earlier diagnosis and more rapid treatment of renal colic.[9] Adult randomized controlled trial evidence supports using POCUS as the initial approach to the imaging and management of suspected renal colic.[10] However, there remain limited data on POCUS in children for renal colic. We report five cases of renal colic in adolescent and pediatric patients who were evaluated using POCUS to identify the presence or absence of hydronephrosis, ureteral jets and "twinkling artifact."

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