ABSTRACT

Background
Objective: To compare nephrolithiasis at ultrasound and CT.
Material and methods: The data bases PubMed, ProQuest, Google scholar and research gate
were searched with the key words: nephrolithiasis on ultrasound and CT, sensitivity, specificity,
from 2010 to 2021. For inclusion and exclusion of studies independently screened the titles and
abstracts of full and related articles. Articles that had information about nephrolithiasis,
urolithiasis at ultrasound and CT and its sensitivity and specificity were included.
Results :
Conclusions: Ultrasound is the best modality for imaging calculi within the kidney, a well hyper
echoic mass with posterior acoustic shadow is identified as stone on gray scale, color Doppler
can be used for demarcation of stone. At Color Doppler twinkling artifact appears around the
calculi hence it can be differentiated by hyper echoic renal sinuses.

Key words: CT, Nephrolithiasis, ultrasound, sensitivity, specificity.

 CHAPTER 1

Introduction

Nephrolithiasis, also known as kidney stone disease, is the development of renal calculi caused
by an imbalance in the solubility and precipitation of salts in the urinary system and in the
kidneys and in the ureter. White people have the highest rate of occurrence. Between the ages of
20 and 30 Nephrolithiasis is rather common. In the 2013–2014, it was 10.1 percent. The Males
above the age of 50 had the greatest frequency of Nephrolithiasis. Males aged 40–60 years old
accounted for 17.8 percent of those aged less than 61 years. At a rate of 12.6 percent
Nephrolithiasis is classified as a kidney illness. Hypertension, obesity, and type 2 diabetes are all
symptoms of wealth. It is prevalent in developed countries. Urologic intervention is required in
as many as 20% of individuals suffering from renal colic.1
Every year, more than $2 billion US dollars are spent on management. In India, the lifetime
incidence of renal calculi Its 7% among females and 12% among males. Renal calculi
advancement when urine becomes "supersaturated" with insoluble substances phosphate (CaP)
and calcium oxalate compounds (CaOx) caused by dehydration or a genetic predisposition to
eliminate these ions excessively in the urine Approximately 5-10% of This is a genetic tendency
in Indians.
Under normal conditions, the solvent as super saturation, resulting in Nucleation occurs first,
followed by crystal concretions. Crystallization happens when the concentration of two the
concentration of ions in the solution surpasses their saturation point. The pH and temperature
have an effect on the transition from liquid to solid phase. the precise concentrations of
additional ingredients The amount of urinary Saturation in terms of stone-forming components
like as phosphate, calcium, oxalate, uric acid, cysteine, and a low level of The amount of urine is
a possible factor for crystallization. As a result, crystallization process differs depending on
Thermodynamics (which causes nucleation) and kinetics (This covers nucleation and crystal
growth rates) in the case of a supersaturated solution. As a result, lithiasis can be treated. By
avoiding super saturation, this may be avoided.2
supervision of patients having renal and ureteric calculi, and it is critical to select an examination
that is true and safe. 3 nature of the presentation, the patient's bodily habits, the expense of the
inquiry, and the effect of the investigation on the patient all influence the choice of suitable
investigation.4 There are several modalities for examining stone in patients, including ultra-
sonography are commonly utilized. When compared to CT to Ultrasound, it has lower sensitivity
for detecting renal calculi. 5
The Ultrasound is deemed lesser to Computed Tomography in terms of determining size of the
calculus.Tools for increasing precision the ability to accurately estimate the size of a stone has
significant consequences. It has certain variables which can be tweaked to improve the precision
of stone measuring. Changes in gain and depth, as well as other modes such as angling and S
(stone-specific) mode, are key variables increasing accuracy. A computerized automated stone-
sizing algorithm increases stone size computation accuracy while reducing human variability.6
The Ultrasound overestimated stone size as depth increased, as did gain at a given depth. As a
result, proper adjustment of depth and gain enhances the accuracy of stone size estimate. Using
computerized methods to determine size improved accuracy.7
Harmonic imaging, image is generated using greater frequency signal to enhance lateral
resolution. By keeping the focus considerably deep the stone and beam becomes of great
consistent across lowest point. Harmonic imaging in studies to increase the accuracy of stone
measuring. a novel mode in the ultrasound known as mode of stone-specific, which aids in
accurately distinguishing between the stone and the surrounding buildings. S mode ultrasound
has a higher frequency as well as higher scanning line of density with that of 100 lines/frame.
This reduces the sparkling effect generated by the micro bubbles and increases the image's
resolution. When compared to the standard B mode, the S mode US improves sensitivity. 7 The
sensitivity for S mode was 78 percent vs. 61 percent for standard US. Stone and shadow size
measurements in S smode produced findings similar to CT. The S mode may be included into the
majority of existing US computers without any modifications.8
Acoustic shadow width investigated and proved to increase stone measuring accuracy.
Measuring the width on ultrasound of the shadow is accurate and this approach increases the
accuracy with ct. Instead of measuring the front, they measured the region behind the stone
where the waves did not exist. Stone size was calculated with considerably better accuracy using
this approach. In fact, 78 percent of the time, size accuracy was within 1 mm. 9
The twinkling artifact appears is a quick alternating signal of color Doppler which mimics
turbulent flow and is frequently detected when a stationary with irregular surface that is
reflecting, in case of renal stone. In Doppler, it appears as jumbled pattern. A spectrum of
twinkling shows aliasing. Originally characterized the phenomena as an artifact produced by a
highly reflective medium comprised of tiny individual reflectors.10

Fig no 1 showing twinkling artifact on ultrasound

NCCT is officially the method for diagnosing stones. NCCT has certain benefits over usg which
is unaffected by unaffected by intestinal ga. A single abdomen and pelvis expose the patient to
an average radiation dosage of 15 mSv. A low-dose procedure exposes the patient to 3 mSv,
whereas an ultralow-dose treatment exposes the patient to 1–3 mSv. It is predicted that 1 in 1400
people over the age of 60 who receive NCCT may develops a cancer or leukaemia. The
identification of stones smaller than 4 mm was most limited in the Ultrasound. Because of the
lower location of the kidney, visualisation of the right renal system is simpler due to enhanced
acoustic windows from the liver and less need for intercostal scanning. The correlation between
US and NCCT results reduced as stone size and ureteral position dropped and rose as right-sided
laterality increased.11
The primary advantages of US over CT are its lower cost, lack of radiation, and mobility. These
radiations have cumulative effects, and cumulative exposure increases the risk of future cancers.
The impact builds up over time, therefore young individuals and pregnant women should avoid
being exposed to radiation. in a multicentric comparative efficacy study that US was linked with
reduced radiation exposure without a significant influence on diagnosis, severe adverse events,
and rehospitalization rates when compared to CT.11
Shorter skin-to-probe space in peads, the Ultrasound enjoys an edge in the paediatric population.
In pregnant patients and paediatric patients, US is suggested as the first-line imaging modality.
Smith Bindman etal24 reported the STONE study, of renal calculi on ct, bedside ultrasound, or
radiology department ultrasound. problems were recorded across the three groups at the time of
release from the emergency department.12
It is effective in detecting renal, vuj, and calculi, but it is ineffective at diagnosing ureteral
stones, particularly those in the mid ureteral region. It is also insensitive to tiny calculi smaller
than 2 mm in size. Although it can identify urinary calculi and subsequent problems such as
hydronephrosis, some individuals who complain of acute blockage may have lesser or no extra-
or intra renal pelvic might result in a false positive diagnsis.13
The urinary system is responsible for excreting waste products of metabolism and foreign
substances from the body, as well as maintaining a proper water balance and electrolyte balance
in the blood and tissue fluids such as sodium, potassium, calcium, and so on. The kidney is
responsible with maintaining a proper response (acid – base balance) in the blood and tissue
fluids during exercise.
The urinary system is made up of the following components:
1. kidneys function as excretory organs.
2. ureters are the ducts.
3. urinary bladder serves as a urinary reservoir.
4. urethra is channelled to the outside.

The kidneys are a pair of organs that are around 11 cm (4.25 inch) in length, 6 cm (s2.5 inch) in
breadth, and 3 cm (1.25 inch) in thickness. They are arranged obliquely rather than vertically,
with their upper poles closer to the midline than their lower poles, behind the peritoneum of the
posterior abdominal wall. The right kidney is roughly 1.25 cm lower than the left, and its lower
pole can occasionally be felt during complete inspiration on examination of normal people. The
kidneys move up and down with breathing and are approximately 2.5 cm (1 inch) lower in the
upright posture than in the recumbent position. The average adult kidney weighs around 150g in
men and 135g in women. The kidneys are bean-shaped and dark crimson in hue. The hilum
contain vascular system, as well as the renal pelvis.14

Figure no 2 showing normal kidney anatomy

A ureter is a channel that transports urine from the kidney to the bladder. The ureter's pelvis is its
upper enlarged part, which is located mostly in the front of the kidney. It begins with a series of
funnel-shaped canals called calyces that encircle the papillae of pyramids. The ureter is a 26 cm
(10 in) long tube that is made up of an outside fibrous coat, a middle muscle layer, and an
interior layer of transitional epithelium (K. Subburaj, 2011). Bladder urinary: The bladder serves
as a reservoir for urine collected from the kidneys via the ureter. It is a muscle sac lined by
mucous membrane and coated with transitional epithelium. The bladder must be evaluated in
both its empty and full stages. Behind the pubic symphysis is the empty bladder. The neck
remains stationary as it fills, while the superior surfaces rise beyond the symphysis pubic and the
infero-lateral surface becomes the anterior surface of the now ovoid bladder, lying against the
anterior abdominal wall (K. Subburaj, 2011

The urethra is a tube that transports pee from the bladder to the outside. It differs between the
sexes, with the male's primary purpose being reproductive. The male urethra is around 20 cm
long, whereas the female urethra is approximately 4 cm long (K. Subburaj, 2011).
 Figure no 3 is showing normal axial, coronal and sagittal cross sectional
anatomy of none enhanced CT.

figure no 4 is normal ultrasound gray scale image of kidney.

A calculus is a precipitated substance produced from a secretion and deposited in an excretory
duct. The mode of calculus creation is enigmatic. It is often thought that crystalloids are held in
solution in any secretion by absorption on to colloidal particles, and that as the concentration of
crystalloids increases or the colloidal content falls, the crystalloids precipitate out. The colloidal
matrix in which crystalloids of low molecular weight deposit changes depending on secretion; in
urinary calculi, it comprises mostly of muco-protein and muco-polysaccharide, with a little
contribution from plasma proteins. 15
Figure no 5 ultrasound gray scale image showing a mid pole renal calculi
 CHAPTER 2

LITERATURE REVIEW

Sharad Konedekar et al., conducted study in 2020. Nephrolithiasis is occurrence of renal calculi
produced by interference in balance between solubility and precipitation of salts in urinary tract
and in the kidneys. CTU was exposed to be extremely sensitive and specific for ureteric calculi.
Study aimed to determine the (i) sensitivity and specificity of ultrasound (USG) in the detection
of urinary tract calculi, (ii) size of renal calculi detected on USG and comparing with CTU, and
(iii) size of renal calculi not seen on USG but detected on computed tomography urogram
(CTU). Material and Methods: A total of 150 patients’ USG and CTU were compared for
existence of calculi. Sensitivity, specificity, accuracy, positive predictive value and negative
predictive value of USG were calculated with CTU as the gold standard. The results were from
the 150 sample size data was collected, 45 people were identified with calculi on both
Ultrasonograhy and Computed Tomography Urogram. The renal stone sensitivity and specificity
on USG was 53% and on CTU it was 85% respectively. On ultrasound the mean dimension of
the renal calculi on ultrassound was 6.8 mm ± 3.8 mm and on the CTU the renal calculi mean
size was 3.5 mm ± 2.7 mm. The finding of ultrasound about ureteric calculus was sensitivity and
specificity was 12% and on CTU it was 97% respectively. The detection of calculi in urinary
bladder sensitivity and specificity on ultrasound was 20% and on CTU, it was 100%
respectively. They concluded that the present research revealed that precision of ultrasound in
diagnosis renal, ureteric and urinary bladder calculi were 68, 80 and 99 percent respectively.1

Nadya E et al., conducted study in 2019. The aim of her study was for the assessment of stone-
free rates following urs. It was a retrospective research of patients who had flexible URS for
kidney calculi using CT scan for the period of 3 months. Stone fragments were performed when
it was possible. Patients with nephrocalcinosis was “stone-free”. Flexible urs were performed on
two hundered and twenty-one individuals with kidney stones. The median stone size was 6.2 mm
and average kidney was containing 6.4 stones. In 92 % of patients an access sheath was used.
73% were stone free when assessed on CT. the residual fragments among patients were in 2% it
was 1 mm, in 16% it was 2 – 4 mm and in 9 % it was >4 mm of kidneys. It was concluded that
According to precise CT evaluation, the accurate stone-free proportion in people with urs for
renal calculi with of stones was 73%. The majority of remaining pieces in patients with renal
calculi are 2-4 mm in size a therapeutic for renal stones with superior stone-free outcomes. 2

Nathaneil et al., conducted study in 2018.Using a clinical effectiveness method, assess the
prognostic value of kidney US for urolithiasis in children. It was a Health insurance portability
and accountability, retrospective inquiry. Billing data and reports were utilized to identify
children (aged 18) who were examined for nephritis by US and unenhanced CT. The existence,
no, size, and site of stones were determined by reviewing imaging results. The diagnostic
performance of the Ultrasound. In the context of sector analysis, US were deemed really positive
when stone was discovered same as in CT or a neighbouring sector. In 30/69 patients, 68 renal
stones were detected by CT (43 percent). The average age were 14.73.6 yrs, and 35 individual
were boys. The US was 66.7 percent (48.8–80.8 percent ) sensitive and 97.4 percent (86.8–99.9
percent ) specific (positive predictive value=95.2 percent [77.3–99.8 percent ], negative
predictive value was 79.2 percent [65.7–88.3 percent ], positive ratio of likelihood =26.0).
According to the sector, ultrasound were 59.7 percent (46.7–71.4 percent) sensitive and 97.4
percent (95.5 till 98.5 percent ) specific (strong predictive value was 72.3 percent [58.2–83.1
percent ], negative predictive value was 95.4 percent [93.2–96.9 percent ], positive probability
ratio=22.5). They observed that, in clinical practise, the Ultrassound has a high specificity for
identifying nephrolithiasis in children, but only a moderate sensitivity, with many false
negatives.3

Alnour et al., conducted study in 2019. The study was a cross-sectional study of spiral computed
tomography and ultrasound to demonstrate the diagnostic value of computed tomography in
diagnosing the presence and absence of urolithiasis and determining whether computed
tomography and ultrasound can lead to accurate diagnosis of urolithiasis and compare computed
tomography and ultrasound in detection of urolithiasis, which was carried out in Khartoum. The
data was obtained from 100 patients, who were categorised and analysed using SPSS. The study
discovered that males are more afflicted by urolithiasis than females (68-32), thus the age group
between (31-40) is more vulnerable to urolithiasis. The study concluded that the presence of
urolithiasis in the kidney is identified more frequently by both modalities than by a single
modality, and the presence of urolithiasis in the bladder is better detected by computer
tomography. The presence of urolithiasis in the smallest valid size (5mm) is better identified by
ultrasound, the presence of urolithiasis in the (5mm- 10mm) is better detected by computed
tomography, and the presence of urolithiasis in the (15mm) is better detected by computed
tomography. 15

Mohankumar et al., conducted study in 2018. The aim was to use ultrasound for the diagnosis of
stone size in kidney. At the moment, ct scanning (CT) is the standard method for diagnosing
stone disease in a patient. However, CT scans are associated with radiation risks and expensive
costs. Ultrasonography (US) is inexpensive and poses no radiation risk to the patient. However,
its use is constrained by lower accuracy and precision, inaccuracy in estimating stones size, and
observation reliance. In this post, we will look at how to enhance the accuracy of the US in
detecting stone size. The accuracy of the Usg was According to a study, the detection accuracy
for renal stones are 45 percent and 88 percent, respectively, and 45 percent and 94 percent,
respectively, for ureteric calculi. The sensitivity of US dropped when the stone size was three
mm and non-dilated pelvis and it rose as the stone size grew. There are certain variables that can
be modified to evaluate the efficiency of stone measuring. Changes in gain and depth, as well as
other modes were accurate. Measures such as using a shadow to estimate the size of a stone can
also assist to improve accuracy of size measuring. A new algorithm increases stone size
computation accuracy while reducing human variability. They concluded that it is an appropriate
modality because of its less cost, lack of rays, and ease of accessibility. The sole drawback is that
it has lower sensitivity and specificity when compared to CT. The inclusion of newer models can
enhance stone size measuring accuracy.16

Wayne Brisbane et al., conducted study in 2016. Their aim of the study was to access different
modalities in imaging kidney calculi. Different recommendations for the best first imaging
modality to utilize when evaluating patients with suspected stone obstructive. Non-contrast Ct of
abdomenopelvis has accurate reports while usg has poorer sensitivity and specificity than it.
Both modes of transportation have advantages and downsides. Plain film radiography of KUB
was useful stone diagnosis in patients with established stone disease and is less beneficial in the
context of acute stones. MRI allows for 3D imaging without the use of radiation; however it is
expensive and currently difficult to visualize stones. In the near future, new discoveries are likely
to improve each imaging modality for the assessment and treatment of kidney stones. In view of
existing recommendations and a randomized controlled study, a proposed strategy for imaging
patients with acute stones might be useful to physicians.17

Smith bindman et al., conducted study in 2014. Their aim of this research was compare findings
of renal calculi on ultrasound and CT. ultrasonography conducted by a doctor (radiology
ultrasonography), or abdominocentesis ultrasound. Subsequent care, including further imaging,
was left to the physician's discretion. We evaluated the three groups in terms of the 30-day with
consequences that may have been caused by a misdiagnosed. The results showed that a total of
2759 patients with 908 to point-of-care imaging, 893 to ultrasound, and 958 in CT. In the first 30
days, the frequency of high-risk diagnostics with comorbidities was modest (0.4 percent) and did
not differ according to imaging technique. The mean 6-month aggregate radiation dose in the
ultrasound groups was substantially lower than in the CT groups (P0.001). Common adverse
effects occurred in 12.4 percent of patients who received point-of-care ultrasound, 10.8 percent
of those who received radiological ultrasound, and 11.2 percent of those who received CT
(P=0.50). Adverse effects was uncommon (incidence of 0.4 percent) and consistent between
groups. By 7 days, the median pain score in each group was 2.0 (P=0.84). The groups did not
vary substantially in terms of repeat ed visits, hospitalizations, or diagnostic accuracy.12

Barbrina Dunmire et al., conducted study in 2016. The aim was to determine the renal stone size
by measuring its acoustic shadow width on ultrasound. Ultrasound has been shown to overstate
the size of kidney stones. To enhance stone size accuracy, we investigated quantifying the
acoustic were used to image 45 calcium oxalate monohydrate stones at three distinct depths.
Four operators who were blindfolded to the real size of the stone measured width of stone and
the breadth of stone shadow.. The ultrasonic imaging modality had an effect on measurement
accuracy as well. For shadow size, all techniques performed equally, but harmonic imaging was
the best accurate stone size modality. 78 percent of shadow sizes were 1 mm, that was
comparable to clinical computerized tomography resolution.9

Barbrina Dunmire et al., conducted study in 2015. The study's goal was to determine if
ultrasonography (US) estimates stone size when comparing to CT. The goal of study was to
analyse stone size overestimation with everyone with in situ temperature probe model and
discover strategies to decrease overestimation. Images were taken and compared on commercial
US equipment as well as an operating system. The gain changed from medium to high calculi
brightness, while transceiver depth was varied between six and ten cm. high- and low gain, the
average overestimation was 1.90.8 and 2.10. The study overestimation was 1.5 +0.9 mm and did
not differ significantly. With the automated stone-sizing software, the overestimation was
decreased to 0.021.1 mm (p0.001). A defined threshold applicable over depth, system, and
system parameters, on the other hand, could not be determined. They concluded that the size of
the stone is continuously exaggerated in the usg. The commercial machine's overestimation grew
with increasing gain. By using software-based US device, overestimation was minimized and did
not change with depth. By adding a grayscale intensity threshold for determining stone size, the
automated stone-sizing software can decrease overestimation. it may greatly increase accuracy
and ultimately to stone sizing.7

Philip C May et al., conducted study in 2016. The goal of his research was to evaluate the
reliability of stone-specific techniques (S-mode) and the posterior shadow, 34 individuals
examined. S-mode is a gray-scale, adjustment that improves brightness and motion by reducing
density and be an average of while boosting line intensity and frequency. Stone shadow
thickness was compared to CT scan. The outcomes were Overall, 84 percent of CT-identified
stones were spotted on S-mode, with 66 percent of them being shadowed. 73 percent of the stone
measures and 85 percent of the shadow dimensions were within 2 mm of the CT size. A posterior
acoustic shadow was detected in 89 percent of stones larger than 5 mm and 53 percent of stones
less than five mm. S-mode detected 78 percent of calculi. They concluded that S-mode allows
for better visibility and size of renal stones. S-mode provided comparable accurate size of stone
and the posterior shadow. Stones that do not cast a shadow are likely to be of 5 mm in size and
tiny to through suddenly.6

Andrew A et al., conducted study in 2010. Their aim was to assess the accuracy of stone
measuring using computed tomography (CT) and ultrasound (US). evaluation of urinary tract
calculi was axial unenhanced helical CT; however, US was also widely utilized. Since June
2004, who had an abdominal CT scan and ultrasound within a month of each other were
evaluated. The results of 60 individuals, found 71 calculi. When contrasted to CT, the US
exaggerated stone size, which was particularly evident with smaller calculi. Stones of 5 mm in
size, US measures were 1.9 1.2 mm larger than CT (P.001). For 60% of stones with a diameter of
5 mm, US and CT measures were incompatible. Discordance was linked with skin-to-stone
distance measured in the usg (P =.018), but not with body mass index (P =.189) or urinary tract
location (P =.161). A review of the literature indicated that the Ultrasound had a pooled
sensitivity and specificity of 45 percent and 94 percent, respectively, for detecting ureteric
calculi and 45 percent and 88 percent, respectively, for detecting renal calculi. The study
concluded that the Ultrasound overestimates the size of stones in urolithiasis, a result that may
have consequences for stone management. Stone measuring varies on size and is highest in 5 mm
stones. The depth of skin to stone distance in the Ultrasound is a significant predictor of
inaccuracy in the renal calculi mreasurement in the Ultrasound.5

Turo Kano et al., conducted study in 2014. The purpose of their study was to evaluate the
efficiency of ultrasonography (US) for identifying renal calculi on ncct. From January 2009 to
September 2011, we conducted a retrospective analysis on 428 individuals who had NCCT and
US imaging on the same day. The sensitivity of US to identify each individual stone, as well as
at least one stone per kidney, was assessed. The detection rates were also investigated in relation
to location and stone size. The results were NCCT found 474 stones in 361 out of 856 patients,
on the other side usg detect 332 calculi out of the 474 at NCCT, providing a sensitivity was
sventy percent and a specificity of 94.4 percent. Similarly, the Usg found at least one stone in
285, resulting in sensitivity was 78.9 percent and specificity was 83.7 percent. Furthermore, the
stone sizes acquired by US were favorably associated with those by CT, and the stone sizes
measured by NCCT and US in 240 of 332 instances (72 percent ). the size of the stone was only
one of several factors that influenced renal stone diagnosis with US. They Concluded that for
identifying renal stones, US was an useful imaging technique.4

Abdalgader et al., conducted study in 2017. The study was a cross-sectional investigation of
spiral computed tomography and ultrasound in the detection of urolithisiasis. From December
2016 to January 2017, this study was carried out in Khartoum state at (Alturky Diagnostic
Center, Doctors Clinic Hospital, and Al-Rebat University Hospital). The study's difficulty was a
mix-up in identifying stones using computed tomography and ultrasonography.The data was
obtained from 100 patients, who were categorised and analysed using SPSS. The study
discovered that males are more afflicted by urolithiasis than females (71-20), thus the age group
between(49-60) is more vulnerable to urolithiasis, and the majority of cases had a single stone
(54 patients). The study concluded that the presence of urolithiasis in the kidney is identified
more frequently by both modalities than by a single modality, and the presence of urolithiasis in
the bladder is better detected by computer tomography. The existence of urolithiasis in the
smallest valid size ( 5mm) is better identified by ultrasound, the presence of urolithiasis in the
veiled (1cm- 3cm) is better detected by computed tomography, and the presence of urolithiasis in
the veiled (3cm- 5 cm) is better detected by computed tomography. The research advised
everyone to drink lots of water to avoid dehydration, especially those who work outside in the
heat.14

Letafatai et al., conducted study in 2019. Several techniques for detecting kidney stones,
including as simple grafting, ultrasound, and CT scan, have been proposed due to their high
occurrence and significance. a CT scan without contrast, however due to the high cost and usage
of ionizing radiation, other techniques are sometimes utilized. In this study, 110 people with
probable kidney stones were referred to Tabriz University of Medical Sciences facilities. Patients
were subjected to a CT scan, and if the stone was less than 4 mm in size, they were referred for
Color Doppler twinkling artifact ultrasound. Ninety percent of kidney stones were identified with
a CT scan. Sonography was used to diagnose renal stone in 82.7 percent of patients who had a
CT scan and had a renal stone. Color Doppler twinkling artefact was used to detect kidney stones
in 76.7 percent of patients who had a CT scan and had a renal stone. There was a significant
association (P0.05) between the diagnosis of renal stone based on the colour Doppler twinkling
artifact and the patients' posterior shadow. Of course, no significant association was found
between renal stone identification based on Color Doppler twinkling artifact and age, gender,
renal involvement, or location of stones in any of the patients (P>0.05). Color Doppler twinkling
artifact has a substantial diagnostic value in the identification of renal stones (P0.05). So, the
Color Doppler twinkling artifact's sensitivity, specificity, positive and negative predictive value,
and accuracy were 76.8 percent, 100 percent, 100 percent, 32.4 percent, and 79 percent,
respectively. Furthermore, the diagnostic usefulness of Color Doppler twinkling artifact was
significant in the identification of renal stones depending on age, gender, posterior shadow, renal
involvement, and stone placement in the kidney (P0.05).10

Kvan et al., conducted study in 2016. To compare the performance of low-dose NCCT and renal
ultrasonography (US) in detecting and measuring urinary calculi. From 2012 to 2015, a
retrospective study of patients assessed for flank pain with both renal US and NCCT was done at
three hospitals. The presence and size of stones were evaluated across imaging modalities. The
greatest measured diameter was used to calculate the size of the stone. Stones were classified
into three sizes based on NCCT and compared to US standards.They concluded that the US
substantially overestimated stone size, which was especially noticeable for tiny (5 mm) stones.
When weighing end urologic treatment choices, consider the possibility of systematic
overestimation of stone size using conventional US methods.11

Trevor et al., conducted study in 2020.There objective was ot determine if DECT, utilising stone
analysis.To analyze the potential bias and applicability, QUADAS-2 was utilized. A vicariate
spontaneous model was used for meta-analyses. They concluded that DECT is an accurate
replacement test for diagnosing uric acid calculi in vivo, and it has the potential to replace stone
analysis in the diagnostic process. This would allow urine alkalinization to begin sooner.18

Matthew et al., conducted study in 2020. Their objective was to compare the precision of ultra-
low-dose computed tomography (ULDCT) with standard-dose computed tomography (SDCT) in
the assessment of patients with clinically significant cancer. In contrast to secondary symptoms,
renal colic is suspected. research with a comparative design was carried out among patients who
arrive to the emergency room with renal or ureteric colic-like indications and symptoms. Both
SDCT and ULDCT were performed on the patients. Single-blinded. The picture sets were
reviewed separately by three radiologists who are board-certified. The effective radiation dosage
was lower for 21 individuals. ULDCT [mean (standard deviation) 1.02 (0.16) mSv] more than
SDCT [mean] (Standard Deviation) 4.97 (2.02) mSv]. Renal and/or ureteric calculi were
discovered. 57.1 percent (12/21) of patients were found to have it. There were none available.
There are substantial variations in the detection of calculus and the size of the calculus was
estimated of ULDCT and SDCT A greater Concordance was reported for ureteric calculi (75%)
than for renal calculi (38%) are more common, owing to earlier diagnosis. SDCT yielded a
resolution of 3 mm. Calculi that are clinically important (3 mm). ULDCT identified them with
excellent specificity (97.6 percent) and sensitivity (100%) in comparison to total detection
(specificity) 91.2 percent, with a sensitivity of 58.8 percent). ULDCT and SDCT were both
extremely effective. Concordant for secondary feature detection, whereas ULDCT 2 cm renal
cysts were discovered. Inter-observer consensus. SDCT had a detection rate of 93.9 percent for
ureteric calculi. ULDCT has a success rate of 87.8 percent.
They concluded that for calculus detection, ULDCT performed comparable to SDCT. as well as
size estimate with less radiation exposure Based ULDCT should be addressed in this and other
research routinely used as the first-line method for evaluating renal colic practice. 19
 CHAPTER 3

OBJECTIVE

To compare nephrolithiasis on ultrasound and CT.

1.
 CHAPTER 4

MATERIAL AND METHOD

Search Strategy:
The data bases PubMed, ProQuest, Google scholar and research gate were searched with the key
words: renal stones, ureteric calculi, nephroliathiasis,sensitivity, specificity, accuracy and CT,
ultrasound from 2010 to 2021. Only those studies were enrolled in the review which includes the
renal calculi.

Selection Criteria:

For inclusion and exclusion of studies independently screened the titles and abstracts of full-length related
articles. The disparity of the reviewer was fixed by consensus. Studies having information of role of
ultrasound in diagnosis of nephroliathiasis was included. The qualitative data was extracted from the
articles, journals and thesis..

Study Characteristics:
Total 54 studies were found after searching data bases and 23 of them were excluded due to duplication ,
23 studies were excluded due to irrelevant or insufficient data and rest of studies rejected on the basis of
title and abstract. Flow chart summarizes the reviewed flow records in Figure 1. Only original research
articles were included in this research excluding the systematic reviews and meta-analysis reviews. All
the studies included in this review are prospective.

Data Synthesis and analysis Procedure:

The eligible studies were first categorized according to nephrolithiasis and calculate overall
mean of sensitivity, specificity. All mean sensitivity, specificity and accuracy were calculated
according to modality chosen by the researcher for the accurately visualization of calculi either
ultreasound or CT.
 CHAPTER 5

Results:

In total, 24 studies were found on renal calculi at ultrasound and computed

tomography. The overall mean sensitivity of ultrasound was % while overall mean
specificity %. This literature review demonstrates that computed tomography is
characterized by high sensitivity and specificity in diagnosing renal, ureteric as well
as bladder stones while ultrasound has low sensitivity and specificity.

CHAPTER 6

Discussion

Because of its high sensitivity and specificity, precise size measuring ability, capacity to detect
diseases. Unenhanced -contrast CT is most accurate modality of imaging renal stone.
Ultrasonography is less sensitive and specific than Computed Tomography. patients are not
exposed to ionizing radiation and is less costly. Although ultrasound has numerous boundaries, a
randomized experiment found that it performed similarly to CT in the emergency department for
patients with suspected kidney stones. For pregnant women and patients over the age of 14,
ultrasonography is modality of choice. Low-dose CT provides many of the same benefits as
normal ct but lowers exposure to radiation; nevertheless, its accuracy of diagnosing is decreased
in fatty individuals. dosage variation is to be addressed. The current meta-analysis is the first to
quantitatively synthesize the data presented in the literature on the use of ultrasonography in
detecting renal calculi in children. This study found that ultrasonography has a sensitivity of 80%
and a specificity of 100% in detecting renal calculi in children. 20 In other words, ultrasonography
is an effective diagnostic technique for renal calculi, with just one documented incidence of false
positive. It is not, however, a perfect screening tool because its sensitivity is just 80% and 54
false negatives have been reported.
Tasian and Copelovitch said in a comprehensive review that ultrasound should be used as the
primary diagnostic modality for screening of renal calculi in children and that CT scan should be
utilised only when ultrasonography does not able to diagnose, they do not advocate using
21
ultrasonography as the initial modality. Hoppe and Kemper referred to ultrasonography in
another systematic review as a modality with more advantages than other imaging tools in
identifying renal calculi in children, including avoiding ionising radiation exposure, detecting
hydronephrosis easily, and identifying some anatomical aspects of the urinary tract. They did,
however, remark that ultrasonography is not as sensitive as CT scan in detecting tiny stones, and
that the operator's competence plays a significant influence in its diagnostic usefulness. This
research's findings are consistent with those of the current study. Subgroup analysis revealed that
variations in ultrasonography, ultrasonography reporting criteria for renal stone diagnosis, and
study performance year had no effect on sensitivity. Although the influence of these variables on
specificity was statistically significant, it was clinically negligible since Ultrasound specificity
22
decreased by just 1%.
The use of a proper probe is critical in enhancing ultrasonography's sensitivity and specificity.
However, only one of the publications considered in this analysis included information about the
probe utilised. Although the likelihood of employing an incorrect transducer is minimal, failing
to disclose this issue prevents us from making conclusions regarding the significance of probe
type in ultrasonography for paediatric renal calculi diagnosis. The operator dependency of
ultrasonography is a well-known phenomenon.23 However, three trials did not include an
ultrasonography operator. This is a significant drawback since it is impossible to determine
whether or not the ultrasound operator is properly trained in the study done. Although the current
meta-analysis included a subgroup analysis based on ultrasonography operator, comparisons
were performed between studies that reported operator skill and those that did not. In other
words, because the operator's competence is uncertain in some cases, the analysis of this section
cannot be trusted. Various criteria, such as acoustic shadowing, echogenic focus, and twinkling
artefact, have been employed in studies to detect renal calculi. Three of the seven investigations,
however, did not disclose the ultrasonic indicators they employed to diagnose renal calculi.
Furthermore, it should be emphasised that utilising ultrasonography to detect calculi in a
collapsed ureter is challenging. The patient should be adequately hydrated in these instances, and
the bladder functions as a sonic window to detect ureteral stones. As a result, ultrasonography
will be of limited value in detecting urinary tract calculi in emergency circumstances when the
patient is dehydrated and there is little time to hydrate the patient.24

CHAPTER 7

CONCLUSION
Ultrasound is the best modality for imaging calculi within the kidney, a well hyper echoic mass
with posterior acoustic shadow is identified as stone on gray scale, color Doppler can be used for
demarcation of stone. At Color Doppler twinkling artifact appears around the calculi hence it can
be differentiated by hyper echoic renal sinuses.

Recommendation:

Ultrasound is a non-invasive imaging modality and it is cost effective while CT in invasive that

uses ionizing radiations, yet it is difficult on ultrasound to diagnose calculi in ureter hence for

evaluttion of ureteric calculi CT scan is gold standard modality.