Approach to the Patient with

Suspected Kidney Stones

Bradley Thomas Oliver
The University of South Carolina
12/14/05
Overview
Renal calculi occur in 5-12% of the American population
bilateral in 10-15% of patients.

80% of patients with urolithiasis form calcium stones
Most are composed of calcium oxalate
Less often calcium phosphate

The other main types include:
uric acid
struvite (magnesium ammonium phosphate)
cystine stones


Overview Cont
The same patient may have a mixed stone

Another type limited to HIV patients
Indinavir-induced stones
The drug crystalizes and the stones are composed almost completely of
the protease inhibitor.
Happens in 4% to 22% of patients treated with the standard dose of
indinavir (800mg three times a day)

Stones can cause renal scarring, damage, or even renal failure if
they are bilateral.

In 10% of patients, stones recur within 1 year. This percentage
increases to 50% within 10 years.
Calcium Stones
In general, calcium phosphate stones are
associated with the same risk factors as
calcium oxalate stones

Excepttions: Calcium phosphate stones
more typical of Type I RTA and primary
hyperparathyroidism


Uric Acid Stones
Occur primarily in patients in whom a
persistently acid urine (pH<5.5) promotes
uric acid precipitation

Example: gout patients that are uric acid
overproducers (10-20%)

Also in states of chronic diarrhea

Struvite Stones
Chronic urinary tract infection due to a urease
producing organisms such as Proteus or
Klebsiella

Often have multiple magnesium ammonium
phosphate crystals in the urine sediment

If not adequately treated can develop into a
staghorn or branched calculus involving the
entire renal collecting system

Cystine Stones
Develop in patients with cystinuria due to the
insolubility of cystine in the urine

Diagnosis
Initially suspected by the clinical presentation

Should be suspected in all patients with the acute onset of
atraumatic flank pain
Particularly if no abdominal tenderness and with hematuria

Classically: severe colicky flank pain
Often with radiation to the groin, testicles, back, and periumbilical
region.

Gross or microscopic hematuria occurs in the majority of patients
with symptomatic nephrolithiasis
Other than actually passing a stone or gravel, single most discriminating
predictor of a stone in patients with AUFP
Symptoms Cont.
Hematuria, however, is not detected in
approximately 10 to 30% of patients with
documented stones

Other symptoms: nausea, vomiting,
dysuria, and urgency
Passage
Stones smaller than 4 mm pass spontaneously in
approximately 80% of patients.

Stones that are 4-6 mm pass in approximately
50% of patients

Stones larger than 8 mm pass in only
approximately 20% of patients.
Differential Diagnosis
1). Bleeding within the kidney

2). Ectopic Pregnancy

3). Aortic Aneruysm

4). Acute Intestinal Obstruction

5). Malingering
Abdominal Plain Film
Will identify radiopaque stones
Struvite stones
Calcium stones
Cystine stones

Will miss radiolucent uric acid stones

May not detect small stones or stones overlying bony
structures

Will not detect obstruction
Abdominal Plain Film Cont.
Reasonable initial test in patients with
history of radiopaque calculi and acute
pain that is similar to previous episodes

May, however, also miss stones in the
ureter
Intravenous Pyelogram
Higher sensitivity and specificity than a
abdominal film alone

Provides information about the degree of
obstruction

Can produce contrast reactions

Therefore, has been replaced by non-contract
enhanced helical CT as the test of choice


IVP showing right kidney completely obstructed by a 7
mm radiopaque calcium oxalate stone in the proximal
ureter

The right kidney appears dense due to accumulated
radiocontrast that cannot be excreted.

The left kidney shows a normal excretory phase of the
study with contrast in the renal pelvis and ureter.

Non-contrast Helical CT Scan
Gold Standard

Can detect both the stone and urinary tract
obstruction

Can also define an alternate significant diagnosis
In one report of patients with their first episode of a
suspected kidney stone, 33% had an alternate
diagnosis, not suspected on clinical grounds (50% of
these had significant disease)
Non-contrast Helical CT
compared to IVP
Higher sensitivity and specificity
regardless of its size, location, and chemical composition

Faster
26 versus 69 minutes

Only slightly more expensive
$600 versus $400

** Chen, MY, Zagoria, RJ. Can noncontrast helical computed tomography replace intravenous
urography for evaluation of patients with acute urinary tract colic?. J Emerg Med 1999;
17:299.


Numbers
Standard CT cuts are generally 8mm, but
3 to 5mm cuts are optimal for the
detection of stones

Specificity is nearly 100%

Negative study should prompt
consideration of a differential diagnosis
An Exception
Nephrolithiasis secondary to HIV protease
inhibitors, primarily indinavir

These stones are not radiopaque and signs of
obstruction may be minimal or absent

Contrast-enhanced CT may be needed for
diagnosis



Possible Pitfall
In patients who do not have evidence of
urinary tract obstruction, the occasional
inability to distinguish ureteral stones from
phleboliths overlying the course of the
ureter


Phleboliths are focal calcified venous thrombi

Frequently seen along the normal anatomical course of
the lower ureter.

They are usually the result of injury to the vein wall
commonly from venous hypertension and are composed
of concentric calcified strata around a central kernel.

Typically, phleboliths are rounded with a central lucency
and are seen in the true pelvis often below the distal
ureter.
Circumferential periureteral edema, or the soft tissue
"rim" sign, described as a rim of soft tissue attenuation
seen around the circumference of an intraureteral
calculus on non-contract CT

Theoretically, phleboliths will not show a "rim" sign.

Since larger stones result in stretching of the ureteral
wall, the "rim" sign tends to be more commonly
associated with the presence of smaller stones.

The "comet" sign refers to the adjacent
eccentric, tapering soft-tissue mass
corresponding to the non-calcified portion of
pelvic vein contiguous to a phlebolith.





Ultrasonography
Procedure of choice for patients who
should avoid radiation, i.e. those pregnant

Very sensitive for the diagnosis of
obstruction and can detect radiolucent
stones missed on KUB

May miss small stones and ureteral stones


References
eMedicine. 2005
UpToDate. 2005
Urolithiasisby David S Goldfarb, MD and Fredric
L Coe, MD, Best Practice of Medicine.
October 2003.