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 noncalcified 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. October2003.