Nephrolithiasis

Abrahim Syed

February 2013

Paul Lewis MD

History

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• 65 y/o woman with a history of nephrolithiasis who presents with intermittent gross hematuria for several weeks. Not typically associated flank in the past. Referred to urology.

• PMH: HTN, A-fib, CAD, OA, lymphocytic colitis• PSH: Brain surgery (abscess), coronary stent• Meds: Tramadol PRN, Vit D2, lyrica, lisinopril,

rosuvastatin, metoprolol, Plavix, alendronate• NKDA• ROS: No urinary incontinence, dysuria previously

• Vitals: 130/90, HR:65, T:98F, BMI:23.08• Back: No CVA tenderness• Abdomen: Soft, non-distended, non-tender,

normal bowel sounds

Physical Exam

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• 2/14/13– Abnormal Urine Culture:• Positive for K. Pneumoniae

Labs

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• 1/19/13:– NA: 142– K: 4.4– Cl: 108– HCO3: 22– Ca: 9.9– BUN: 14– Cr: 0.92

• Differential Diagnosis:– Kidney stone– Polycystic kidney disease, hydronephrosis– Cancer: kidney, ureter, bladder– Intrinsic glomerular disease– Pyelonephritis, urethritis

• Plan: – Imaging

Management

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Imaging

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Imaging

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KUB

Abdominal Plain Film (x-ray)

acc 5200827

Normal KUB

Abdominal Plain Film (x-ray)

IVP

Abdominal Plain Film (x-ray)http://drugline.org/medic/term/kub/

KUB

Abdominal Plain Film (x-ray)

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Abdomen

CT Abdomen with IV Contrast - Axial

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CT Abdomen with IV Contrast - Axial

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Abdomen

CT Abdomen with IV Contrast - Coronal

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Abdomen

CT Abdomen with IV Contrast - Coronal

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Abdomen

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CT Abdomen with IV Contrast - Saggital

Abdomen

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CT Abdomen with IV Contrast - Saggital

• Imaging modalities– Non-Contrast Helical CT– Intravenous Pyelography– Plain Radiography (KUB)– Ultrasonography

Diagnosis

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• Gold Standard– 95-100% Sensitivity, 94-96% Specificity– Can distinguish radiolucent stones– Detects secondary signs of urinary tract obstruction

• Hydronephrosis, ureteral dilatation, perineprhic fat stranding and/or fluid collection

• Soft-tissue rim sign– Circumferential edema from ureteral lithiasis– Differentiates from phlebolith

• Disadvantages– Expense, x-ray exposure, cannot assess renal function

Non-Contrast Helical CT

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Non-Contrast Helical CT

2010.1148/radiol.2291020690Radiology 2003; 229:239

• Previous Gold Standard– Up to 87% Sensitivity, 94% Specificity– Provides information on anatomy and function of

kidneys

• Disadvantages– Variable quality– Requires use of contrast media– Poor visualization of non-genitourinary conditions– Delayed images for high-grade obstruction– Radiation exposure

IVP

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IVP

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• Advantages:– Accessible, inexpensive– Less radiation exposure

• Disadvantages– Will miss radiolucent stones, small stones, and those

obscured by bone– Will not detect obstruction– Up to 70% Sensitivity and 77% Specificity– Phleboliths

KUB

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• Advantages– No radiation exposure– Readily available– Use of color Doppler– Good for hydronephrosis– Can detect radiolucent stones– Up to 70% Sensitivity, 97% Specificity

• Disadvantages– May miss small stones and ureteral stones– Skill of ultrasonographer

Ultrasound

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Ultrasound

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Stones seen as echogenic foci and produce distal acoustic shadowing

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Hematuria.htm

• ≤5 mm in diameter pass spontaneously• Conservative management: pain control, hydration

• Stones ≥10 mm in diameter, less likely to pass• Medication: nifedipine, tamsulosin• Shock wave lithotripsy (SWL), ureteroscopic lithotripsy with

electrohydraulic or laser probes, percutaneous nephrolithotomy and laparoscopic stone removal

Treatment

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Begg, James D. "How to Look at an Abdominal X-ray." Abdominal X-rays Made Easy. Edinburgh: Churchill Livingstone, 2006. 1-38. US Elsevier Health Bookshop. Elsevier. Web. 26 Feb. 2013

http://www.uptodate.com/contents/diagnosis-and-acute-management-of-suspected-nephrolithiasis-in-adults?source=search_result&search=kidney+stone+differential&selectedTitle=1%7E150#H17

http://www.aafp.org/afp/2001/0401/p1329.html

http://emedicine.medscape.com/article/437096

References

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