INTERACTIVE CASE DISCUSSION: CASE 11

INTERACTIVE CASE DISCUSSION:CASE 11University of Santo TomasFaculty of Medicine and SurgeryDepartment of Radiology

Clk. Alexander L. Gonzales II1CASE 11224/M: Right sided flank painPatient with flank painHistory and physical examinationRenal colic suspectedDiagnostic imaging ???Patient is pregnant, or cholecystitis or gynecologic process is suspectedPatient has history of radiopaque calculiAll other patients324/M: Right sided flank pain424/M: Right sided flank pain5524/M: Right sided flank pain624/M: Right sided flank painPatient with flank painHistory and physical examinationRenal colic suspectedDiagnostic imagingPatient is pregnant, or cholecystitis or gynecologic process is suspectedPatient has history of radiopaque calculiAll other patients7IVCAORTACeliacaxisSMARenal arteryRenal veinHepaticVeinsRightkidneyLeft kidneyLiverSpleen8Renal arteryRenal veinUreterRenal capsuleCortexMedullary pyramidsMinor CalyxKidney AnatomyMedullaSinusMajor Calyx9Ultrasound ExaminationStone detected

Stone not detected

Plain-filmradiographyIntravenous pyelography if CT is not availableNoncontrast helical CTStone not detected

Clinical suspicion of urolithiasis

Stone detected

10

LiverDiaphragmSinusCortexAnteriorPosteriorSuperiorInferiorRight Kidney Long Axis11Left Kidney Long Axis

AnteriorPosteriorSuperiorInferiorSpleenKidneyRib Shadow1224/M: Right sided flank pain

13 Imaging modality Sensitivity (%) Specificity (%) Advantages LimitationsAccessible Poor visualization of Good for diagnosing of ureteral stonesHydronephrosis and renal stones Requires no ionizing radiationUltrasonography 19 9724/M: Right sided flank pain14Ultrasound ExaminationStone detected

Stone not detected

Plain-filmradiographyIntravenous pyelography if CT is not availableNoncontrast helical CTStone not detected

Clinical suspicion of urolithiasis

Stone detected

1524/M: Right sided flank painNORMAL STUDY

PATIENT16This abdominal flat plate demonstrates a possible renal stone on the patient's right at the level of L3 and L4. 16 Imaging modality Sensitivity (%) Specificity (%) Advantages LimitationsAccessible Stones in middle section& inexpensive of ureter, phleboliths, radiolucent calculi, extraurinary calcificationsand nongenitourinary conditionsPlain radiography 45 to 59 71 to 7724/M: Right sided flank pain17Ultrasound ExaminationStone detected

Stone not detected

Plain-filmradiographyIntravenous pyelography if CT is not availableNoncontrast helical CTStone not detected

Clinical suspicion of urolithiasis

Stone detected

1824/M: Right sided flank pain

NORMAL STUDY 1924/M: Right sided flank painPRIOR TO IVP1 MINUTE

20Immediately after the contrast is administered, it appears on an x-ray as a 'renal blush'. This is the contrast being filtered through the cortex2024/M: Right sided flank pain15 MINUTES5 MINUTES

21At an interval of 3 minutes, the renal blush is still evident (to a lesser extent) but the calices and renal pelvis are now visible. AtThe first IVP image is taken at 5 minutes following IV contrast. This shows prompt excretion of contrast from the left kidney. Contrast is seen excreted from the right kidney, but the ureter is not well visualized suggesting an obstruction in ureter. The calyces are blunted indicating hydronephrosis. The second IVP image is taken at 20 minutes following IV contrast. This shows delayed retention of contrast on the right. The calyceal blunting of the right kidney indicating hydronephrosis is more evident. There is a narrowing of the ureter on the right in the area of the suspected stone. 2124/M: Right sided flank pain45 MINUTES40 MINUTES

2224/M: Right sided flank painPOST VOIDFULL BLADDER

23To visualise the bladder correctly, a post micturition x-ray is taken, so that the bulk of the contrast (which can mask a pathology) is emptied. coned bladder view. Regular smooth appearance and complete voiding.23 Imaging modality Sensitivity (%) Specificity (%) Advantages LimitationsAccessible Variable-quality imagingProvides informationRequires bowel preparationon anatomy and & use of contrast mediafunctioning of both Poor visualization of non-kidneys genitourinary conditionsDelayed images required in high-grade obstructionIntravenous 64 to 87 92 to 94 pyelography24/M: Right sided flank pain24Ultrasound ExaminationStone detected

Stone not detected

Plain-filmradiographyIntravenous pyelography if CT is not availableNoncontrast helical CTStone not detected

Clinical suspicion of urolithiasis

Stone detected

2524/M: Right sided flank pain

AXIAL VIEWCORONAL VIEW26 Imaging modality Sensitivity (%) Specificity (%)Advantages LimitationsMost sensitive & specific Less accessible and radiologic test (i.e., facilitates relatively expensivefast, definitive diagnosis) No direct measure ofIndirect signs of the degree of renal function.obstructionProvides information on non-genitourinary conditionsNoncontrast helical 95 to 100 94 to 96computed tomography24/M: Right sided flank pain2724/M: Right sided flank painIMPRESSION:Obstructing Ureterolithiasis , with resultant hyrdroureter and hydronephrosis

28UROLITHIASISDISCUSSION29EPIDEMIOLOGY2-4% of general population2-3 x more common in malesCaucasian > Oriental > African AmericanHot climates > temperateTypes of Stones:Calcium StonesUric Acid StonesStruvite StonesCystine StonesNephrolithiasis - stones in the kidneyUreterolithiasis stones in the ureter

30Calcium Stones75%-85% of all renal calculiConsists of:Calcium oxalateCalcium phosphateCalcium urateCommon in males, 3rd decade of lifeRecurrence rate 2 to 3 yearsFamilialAssociated with:Idiopathic hypercalciuria - 50%Hyperuricosuria 20%primary hyperparathyroidism - 5%Idiopathic 20%31Struvite StonesMagnesium ammonium phosphate 10%-15% of all renal calculiDchronic urinary tract infections with gram-negative urease-producing bacteria Chronic bladder catherization Common in women Organisms: ProteusPseudomonasKlebsiella species. Visualized on radiograph calcium carbonate or calcium phosphateProduces staghorn calculi

Uric Acid Stones5%-8% of renal calculi Radiolucent,common in malesFamilialOccur primarily in patients in whom a persistently acid urine (pH 5 mm05 mm57< 5mm53Middle section of ureter> 5 mm05 mm20< 5mm38Distal ureter> 5 mm255 mm45< 5mm744242Stone passesStone fails to passwithin 2-4 weeksWeekly KUB radiographsTrial of conservativemanagementUreteral stone < 5 mmRenal stone or ureteralstone > 5 mmSymptoms amenable to medical managementConsider hospital admission:Refractory pain, Refractory nausea,Extremes of age, Debillated condition Emergency:UROSEPSIS, Anuria, Renal FailureConfirmed stoneUrgent urologic consultationYESNOUrologic consultationYESNOReferral to urologic clinicTREATMENT43