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
acc 5200827
Abdomen
CT Abdomen with IV Contrast - Coronal
acc 5200827
Abdomen
CT Abdomen with IV Contrast - Coronal
acc 5200827
Abdomen
acc 5200827
CT Abdomen with IV Contrast - Saggital
Abdomen
acc 5200827
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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