1. Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD

2. 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

3. 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

4. 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

5. Differential Diagnosis: – Kidney stone – Polycystic kidney disease, hydronephrosis – Cancer: kidney, ureter, bladder – Intrinsic glomerular disease – Pyelonephritis, urethritis Plan: – Imaging Management 5

6. Imaging 6

7. 7

8. KUB Abdominal Plain Film (x-ray) acc 5200827

9. Normal KUB Abdominal Plain Film (x-ray)

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

11. KUB Abdominal Plain Film (x-ray) acc 5200827

12. Abdomen CT Abdomen with IV Contrast - Axial acc 5200827

13. CT Abdomen with IV Contrast - Axial acc 5200827

14. Abdomen CT Abdomen with IV Contrast - Coronal acc 5200827

15. Abdomen CT Abdomen with IV Contrast - Coronal acc 5200827

16. Abdomen acc 5200827 CT Abdomen with IV Contrast - Saggital

17. Abdomen acc 5200827 CT Abdomen with IV Contrast - Saggital

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

19. 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 19

20. Non-Contrast Helical CT 20 10.1148/radiol.2291020690 Radiology 2003; 229:239

21. 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

22. IVP 22

23. 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

24. 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

25. Ultrasound 25 Stones seen as echogenic foci and produce distal acoustic shadowing http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Hematuria.htm

26. ≤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

27. 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 27