Nephrolithiasis Differential Diagnoses

  • Author: J Stuart Wolf Jr, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Jan 23, 2012
 
 

Diagnostic Considerations

The diagnosis is often made on the basis of clinical symptoms alone, although confirmatory tests are usually performed. At this point, the goals and opinions of physicians in different specialties diverge.

From the point of view of the emergency department (ED) physician, making the diagnosis of a renal or ureteral stone and excluding appendicitis or abdominal aortic aneurysm (AAA) is sufficient. A urologist, who must ultimately make the decision about possible surgery, may require additional information. Before such a decision can be made, a urologist must know about the size, orientation, radiolucency, composition, and location of the stone and must know about overall kidney function, the presence of any infection, and other clinical information.

It is important to distinguish nephrolithiasis from the many other conditions (gynecologic and nongynecologic) that can cause flank pain (see Causes of Flank Pain).

Beware of the patient older than 60 years with an apparent first kidney stone. Consider the possibility of symptomatic AAA in the older patient, and rule out this possibility before pursuing the diagnosis of nephrolithiasis. Use bedside ultrasonography if the patient’s condition is potentially unstable. CT scan is a reasonable alternative in the stable patient.

Failure to diagnose or delay in diagnosing symptomatic AAA may lead to medicolegal liability. The pain of a leaking AAA often is misdiagnosed initially as renal colic. In one series of 134 patients with symptomatic AAA presenting to the ED, the following statistics were reported[9] :

  • Eighteen percent had an initial misdiagnosis of nephrolithiasis.
  • All were older than 60 years and none had a prior history of renal calculi.
  • Eighty percent had a pulsatile mass noted by at least one examiner.
  • Forty-three percent had microhematuria on urinalysis.
  • Delay of diagnosis of AAA in the ED was associated with higher mortality and morbidity rates than in the group who received the correct diagnosis promptly.

Failure to diagnose and promptly treat a urinary tract infection (UTI) proximal to a ureteral stone is also a potential source of medicolegal liability. Urgent urologic intervention must be sought in these patients.

Other conditions to consider include the following:

  • Pyonephrosis
  • Renal artery embolus

Differential Diagnoses

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Contributor Information and Disclosures
Author

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

David S Howes, MD  Professor of Medicine and Pediatrics, Emergency Medicine Residency Program Director Emeritus, Head, Phemister Society, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sandy Craig, MD  Residency Program Director, Carolinas Medical Center; Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine

Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Stephen W Leslie, MD, FACS  Founder and Medical Director, Lorain Kidney Stone Research Center; Associate Professor of Surgery at Creighton University School of Medicine, Chief of Urology at Creighton University Medical Center

Stephen W Leslie, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, National Kidney Foundation, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard H Sinert, DO  Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

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Small renal calculus that would likely respond to extracorporeal shockwave lithotripsy.
Complete staghorn calculus that fills the collecting system of the kidney (no intravenous contrast material in this patient). Although many staghorn calculi are struvite (related to infection with urease-splitting bacteria), the density of this stone suggests that it may be metabolic in origin and is likely composed of calcium oxalate. Percutaneous nephrostolithotomy or perhaps even open surgical nephrolithotomy is required to remove this stone.
Distal ureteral stone observed through a small, rigid ureteroscope prior to ballistic lithotripsy and extraction. The small caliber and excellent optics of today's endoscopes greatly facilitate minimally invasive treatment of urinary stones.
Two calculi in a dependent calyx of the kidney (lower pole) visualized through a flexible fiberoptic ureteroscope. In another location, these calculi might have been treated with extracorporeal shockwave lithotripsy (ESWL), but, after being counseled regarding the lower success rate of ESWL for stones in a dependent location, the patient elected ureteroscopy. Note that the image provided by fiberoptics, although still acceptable, is inferior to that provided by the rod-lens optics of the rigid ureteroscope in the previous picture.
Nephrolithiasis: acute renal colic. Anatomy of the ureter.
Nephrolithiasis: acute renal colic. Distribution of nerves in the flank.
Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
Nephrolithiasis: acute renal colic. Renal colic and flank pain.
Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
Nephrolithiasis: acute renal colic. Distribution of renal and ureteral pain.
Noncontrast helical CT scan of the abdomen demonstrating a stone at the right ureterovesical junction.
Intravenous pyelogram (IVP) demonstrating dilation of the right renal collecting system and right ureter consistent with right ureterovesical stone.
Renal sonogram showing a dilated renal collecting system consistent with ureteral obstruction.
Transabdominal sonogram revealing a ureteral stone at the ureterovesical junction.
Table. Intravenous Pyelography Versus CT Scanning: Which Is Better?
Imaging Study (Pro/Con) Details
CT scanPro
  • Fast
  • No IV contrast necessary, so no risk of nephrotoxicity or acute allergic reactions
  • With only rare exceptions, shows all stones clearly
  • May demonstrate other pathology
  • Can be performed in patients with significant azotemia and severe contrast allergies who cannot tolerate IV contrast studies
  • Clearly shows uric acid stones
  • Shows perinephric stranding or streaking not visible on IVP and can be used as an indirect or secondary sign of ureteral obstruction
  • No radiologist needs to be physically present
  • Preferred imaging modality for acute renal colic in most EDs
Con
  • Without hydronephrosis, cannot reliably distinguish between distal ureteral stones and pelvic calcifications or phleboliths
  • Cannot assess renal function
  • No nephrogram effect study to help identify obstruction
  • Size and shape of stone only estimated
  • Lacks surgical orientation*
  • Unable to identify ureteral kinks, strictures, or tortuousities
  • May be hard to differentiate an extrarenal pelvis from true hydronephrosis
  • Gonadal vein sometimes can be confused with the ureter
  • Does not indicate likelihood of fluoroscopic visualization of the stone, which is essential information in planning possible surgical interventions
  • May require addition of KUB radiograph†
  • Cannot be performed during pregnancy because of high dose of ionizing radiation exposure
  • Usually more costly than an IVP in most institutions
  • Higher radiation dose than IVP
IVPPro
  • Clear outline of complete urinary system without any gaps
  • Clearly shows all stones either directly or indirectly as an obstruction
  • Nephrogram effect film indicates obstruction and ureteral blockage in most cases, even if the stone itself might not be visible
  • Shows relative kidney function
  • Definitive diagnosis of MSK
  • Ureteral kinks, strictures, and tortuousities often visible
  • Can modify study with extra views (eg, posterior oblique positions, prone views) to better visualize questionable areas
  • Stone size, shape, surgical orientation, and relative position more clearly defined
  • Orientation similar to urologists’ surgical approach
  • Limited IVP study can be considered in selected cases during pregnancy, although plain ultrasonography is preferred initially
  • Lower cost than CT scan in most institutions
  • Includes KUB film automatically
Con
  • Relatively slow; may need multiple delay films, which can take hours
  • Cannot be used in azotemia, pregnancy, or known significant allergy to intravenous contrast agents
  • Risk of potentially dangerous reactions to IV contrast material‡
  • Cannot detect perinephric stranding or streaking, which is visible only on CT scans
  • Harder to visualize radiolucent stones (eg, uric acid), although indirect signs of obstruction are apparent
  • Presence of a radiologist generally necessary, which can cause extra delay
  • Cannot be used to reliably evaluate other potential pathologies
*Many urologists find CT scans inadequate to help plan surgery, predict stone passage, or monitor patients.† This causes a delay, which may be significant in some institutions, and adds additional patient radiograph exposure and cost.‡ These include significant allergic responses and renal failure.
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