Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD

History 2 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 3

2/14/13 – Abnormal Urine Culture: Positive for K. Pneumoniae Labs 4 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 5

Imaging 6

7

KUB Abdominal Plain Film (x-ray) acc

Normal KUB Abdominal Plain Film (x-ray)

IVP Abdominal Plain Film (x-ray)

KUB Abdominal Plain Film (x-ray) acc

Abdomen CT Abdomen with IV Contrast - Axial acc

CT Abdomen with IV Contrast - Axial acc

Abdomen CT Abdomen with IV Contrast - Coronal acc

Abdomen CT Abdomen with IV Contrast - Coronal acc

Abdomen acc CT Abdomen with IV Contrast - Saggital

Abdomen acc CT Abdomen with IV Contrast - Saggital

Imaging modalities – Non-Contrast Helical CT – Intravenous Pyelography – Plain Radiography (KUB) – Ultrasonography Diagnosis 18

Gold Standard – % 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 19

Non-Contrast Helical CT /radiol Radiology 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 21

IVP 22

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 23

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 24

Ultrasound 25 Stones seen as echogenic foci and produce distal acoustic shadowing

≤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 26

Begg, James D. "How to Look at an Abdominal X-ray." Abdominal X-rays Made Easy. Edinburgh: Churchill Livingstone, US Elsevier Health Bookshop. Elsevier. Web. 26 Feb nephrolithiasis-in- adults?source=search_result&search=kidney+stone+differential&selectedTitle=1% 7E150#H References 27