Nephrolithiasis - Kidney Stones - MedPix™ Patient: 9737

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Clinical Presentation: 40 y.o. man

History

40-year-old male with complaint of right flank pain.

Physical Examination and Laboratory

Abdomen soft and nondistended. Normoactive bowel sounds all four quadrants of the abdomen. No rebound tenderness or involuntary guarding. Positive mild right costovertebral angle tenderness to percussion.

UA: glucose negative, bilirubin negative, ketones negative, specific gravity 1.025, trace blood, pH 5.0, urobilinogen 0.2 E.U./dL, nitrite negative, leukocyte esterase negative.

WBC 4.2, HGB 15.8, HCT 46.4, PLTs 188, glucose 86, BUN 20, creat 1.1, Na+ 139, K 3.8, Cl- 105, CO2 26, anion gap 8, Ca++ 9.5, total protein 7.3, alk phos 94, AST 16, ALT 24, total bili 0.7, direct bili 0.3.

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Nephrolithiasis - Kidney Stones

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Image Findings

Noncontrast axial computed tomographic images of the abdomen and pelvis demonstrate a 3 mm calculus within the right ureter at the ureterovesical junction with mild dilitation of the right renal pelvis and right ureter suggesting a degree of obstruction. Two nonobstructing calculi within the upper pole of the right kidney and a single nonobstructing calculus within the interpolar region of the left kidney are also demonstrated. There are no solid or cystic renal lesions. The left ureter is of normal caliber and follows a normal course without evidence of ureterolithiasis.

Differential Diagnosis

Nephro- and uretero-lithiasis

Diagnosis

Nephrolithiasis - Kidney Stones :: Diagnosis Topic Read Topic
Diagnosis Confirmed by: Characteristic computed tomographic findings. The patient passed a stone, which was subsequently analyzed by the pathology department ("tan granular calculus 0.4 cm in greatest dimension," 16.9 mg, 20% calcium oxalate dihydrate, 70% calcium oxalate monohydrate, 10% calcium phosphate).

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Treatment and Followup

Tx and Followup:
Pain control, hydration (2-3 L/day), strain urine to recover the stone.

Additional Discussion:
None.

Topic Discussion

Discussion Author(s): Gael J. Lonergan, M.D.

Urinary Tract Stone Disease - Nephrolithiasis
(Lith - Gr. for stone or rock)
Sx: Renal Colic (impacted or moving stone)
Stones hangup at ureteropelvic junction (UPJ), where ureter crosses the iliac vessels, ureterovesicle junction.

Regarding the stones:
90% have Ca++
About 60% visible on plain film
Virtually ALL visible on CT - and may be precisely localized

Evaluation:
Plain Film - good first step to screen for other disease
IVP/IVU - evaluates possible obstruction (stone in ureter)
CT - Best Exam, but highest radiation dose to patient

CT Evaluation:
Rapid - some scans < 5 min.
Plain (unenhanced CT) otherwise contrast may mask stone
May detect other coexistent pathology:
- Appendicitis
- Diverticulitis
- Adnexal Disease (in women)

Localization of Stones:
- 22% proximal ureter (-> ESWL)
- 71% distal (extraction or ESWL)

Size of Stones:
< 5mm likely to pass
> 5mm Â» Get a Urology Consult
> 7mm unlikely to pass

CT Findings:
- Dilated Ureter
- Perinephric/periureteral stranding
- Ca++ density in ureter w/rim of soft-tissue

TREATMENT:
ESWL (Extra-Corporeal Shockwave Lithotripsy) is effective for most stones < 2cm in the renal pelvis and < 1 cm in the ureter. NOTE: NSAIDS are a contraindication prior to ESWL because of possible perinephric bleeding.

Larger stones in the renal pelvis may be extracted by ureteroendoscopy or percutaneous nephrolithotomy.

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Contributor Credits

Topic Author(s): Gael J. Lonergan, M.D.
Submitted by: Mark M Morton -
Case/Image Editor: Lynn Marie Bergren -

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The MedPix™ Medical Image Teaching File Database and Atlas is sponsored by:
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Clinical Presentation :: History and Physical Exam - Close/Open | Print -

Clinical Presentation: 40 y.o. man

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