Ferri's Clinical Advisor 2018

Urolithiasis (Nephrolithiasis) Download PDF

 Lama Nazzal M.D., M.SC.

 and Peter L. Steinberg M.D.

Ferri's Clinical Advisor 2018, 1323-1325.e6

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Basic Information
Definition
Urolithiasis is the presence of calculi within the urinary tract from the kidney to the
urethra. The five major types of urinary stones are calcium oxalate (70%-80%), calcium
phosphate (10%-20%), uric acid (10%), struvite (7%), and cystine (1%) ( Table 1 ).

TABLE 1
Stone Composition and Relative Occurrence
Stone Composition Occurrence (%)
Calcium-containing stones
Ca oxalate 60
Mixed Ca oxalate/hydroxyapatite 20
Brushite 2
 Stone Composition Occurrence (%)
Non–calcium containing stones
Uric acid 7
Magnesium ammonium phosphate (struvite) 7
Cystine 1-3 (10% of stones in children)
Xanthine <1
Medication-related stones <1
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From Lipshultz LI et al: Urology and the primary care practitioner, ed 3, Philadelphia, 2008, Elsevier.
Synonyms
 Kidney stones

 Kidney calculi

 Ureteral stones

 Ureteral calculi

 Nephrolithiasis

 Ureterolithiasis

ICD-10CM CODES
N20.9 Urinary calculus, unspecified
N20.0 Calculus of kidney
N20.1 Calculus of ureter
N20.2 Calculus of kidney with calculus of ureter
N21.0 Calculus in bladder
N21.1 Calculus in urethra
N21.8 Other lower urinary tract calculus
N21.9 Calculus of lower urinary tract, unspecified
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Epidemiology & Demographics

 •
 In the U.S., the lifetime prevalence of nephrolithiasis is approximately 10% in males and
females.

 •

Peak incidence occurs in the fourth to sixth decade of life.

 •

Stone prevalence is increasing and females now have stones almost as often as males.

 •

Between 1 and 2 million emergency department visits annually are due to kidney stones
and renal colic.

 •

The incidence of symptomatic nephrolithiasis is greatest during the summer as a result

of increased temperature, with an increased risk of dehydration and urinary
concentration.

 •

Calcium oxalate or mixed calcium oxalate/calcium phosphate stones account for nearly
70% to 80% of stones.

Physical Findings & Clinical Presentation

Stones may be asymptomatic, or they may cause the following signs and symptoms as a
result of obstruction:

 •

Acute, often severe, flank pain (renal colic).

 •

Nausea and vomiting.

 •

Hematuria, gross or microscopic.

 •

Patients are unable to find a position of comfort.

 •
 Pain radiating from the flank downward and anteriorly with referred pain to the groin
and genitalia with stone progression down the ureter.

 •

Urinary urgency and frequency with distal ureteral stones can mimic a urinary tract
infection.

 •

Fever and chills may accompany acute colic with superimposed infection.

Etiology
 •

Urine supersaturation of various solutes and stone constituents is the driving force in
kidney stone formation. All urine contains dissolved stone solutes, which can precipitate
under conditions that supersaturate the urine, such as low urine volume, low or high
urine pH, and elevated urine solute levels.

 •

Low urine volume is a common issue in many stone formers.

 •

Idiopathic hypercalciuria.

 •

Hyperparathyroidism with resulting hypercalcemia and hypercalciuria.

 •

Malabsorption (e.g., inflammatory bowel disease) with increased oxalate absorption.

 •

Chronic diarrheal states.

 •

Gastric bypass surgery.

 •

Primary hyperoxaluria: genetic, rare, and usually presenting as a childhood disorder.

 •

Low urine pH due to metabolic syndrome (e.g., overweight, diabetes), often causes uric
acid stones.

 •

Medullary sponge kidney.

 •

Hyperuricosuria (e.g., metabolic defects, dietary excess) ( Box E1 ).

 •

Type I (distal tubule) renal tubular acidosis (>1% of calcium phosphate stones).

 •

Chronic infections with urease-producing organisms (e.g., Proteus, Providencia,

Pseudomonas, Klebsiella ). Struvite, or magnesium ammonium phosphate crystals, is
produced when the urinary tract is colonized by bacteria, producing elevated
concentrations of ammonia ( Box E2 ).

 •

Cystinuria, autosomal recessive, and 1% of stones.

 •

Medications including protease inhibitors (e.g., indinavir, ritonavir), topiramate, and

chronic laxative overuse.

 •

Anatomic changes predisposing to urinary stasis, including malrotated and horseshoe

kidney.

BOX E1
Low urine pH (≤5.5)

High animal protein diet

Diarrhea

Insulin resistance (high body mass index, metabolic syndrome, type 2 diabetes)

Low Urine Volume

 Inadequate fluid intake

Excessive extrarenal fluid losses

Diarrhea

Insensible losses (e.g., perspiration)

Hyperuricosuria
Excessive dietary purine intake

Hyperuricemia

Gout

Intracellular-to-extracellular uric acid shift

Myeloproliferative disorders

Tumor lysis syndrome

Inborn errors of metabolism

Lesch-Nyhan syndrome

Glucose-6-phosphatase deficiency

Uric Acid Stones

From Floege J et al: Comprehensive clinical nephrology, ed 4, Philadelphia, 2010,
Saunders.
BOX E2
 Urease-producing bacteria ∗ :

 Proteus

 Haemophilus

 Yersinia species

 Staphylococcus epidermidis

 Pseudomonas

 Klebsiella

 Serratia

 Citrobacter
 Ureaplasma

 Elevated urinary pH

Factors Associated With Struvite Stone Formation

From Floege J et al: Comprehensive clinical nephrology, ed 4, Philadelphia, 2010,
Saunders.

Diagnosis
Differential Diagnosis
 •

Urinary tract infection

 •

Pyelonephritis

 •

Diverticulitis

 •

Pelvic inflammatory disease

 •

Ovarian pathology

 •

Dysmenorrhea

 •

Factitious (illicit substance-seeking behavior), often with recurrent stone formers

 •

Appendicitis

 •

Small-bowel obstruction

 •
 Ectopic pregnancy

 •

Constipation

 •

Malignancy (primary urinary tract or retroperitoneal lymphadenopathy causing

ureteral/kidney obstruction)

 •

Musculoskeletal back pain

The differential diagnosis of obstructive uropathy is described in Section II.

Workup
 •

Fig. E1 describes an algorithm for evaluation of suspected renal colic.

 •

Stone composition of recovered stones should be determined by infrared spectroscopy

or X-ray crystallography.

 •

A clinical algorithm for the evaluation of nephrolithiasis is described in Fig. E2 .

 •

Box E3 describes events in the medical history that may be significant with regard to
urolithiasis.

Open full size image

FIG. E1
Algorithm for evaluation of suspected renal colic.
SWL, Extracorporeal shock wave lithotripsy.
From Goldman L, Schafer AI: Goldman’s Cecil medicine, ed 24, Philadelphia, 2012, Saunders.
Open full size image
FIG. E2
Evaluation of patients with suspected nephrolithiasis (flank pain, ureteral colic, hematuria, fever).
AMP, Adenosine monophosphate; CT, computed tomography; PTH, parathyroid hormone.
Modified from Stein JH [ed]: Internal medicine, ed 5, St Louis, 1998, Mosby.
BOX E3
 •
 Diseases associated with disturbances of calcium metabolism: primary
hyperparathyroidism, Wilson’s disease, medullary sponge kidney, osteoporosis,
immobilization, sarcoidosis, osteolytic metastases, plasmacytoma, neuroendocrine
tumors, Paget’s disease

 •

Dietary history: purine gluttony, calcium excess, milk alkali, oxalate excess, sodium
excess, low citrus fruit intake

 •

Medications: uricosurics, diuretics, analgesics, vitamins C and D, antacids (especially

phosphorus-binding agents), acetazolamide, calcium channel blockers, triamterene,
estrogens, theophylline, protease inhibitors (indinavir), sulfonamides

 •

Diseases associated with disturbances of oxalate metabolism: primary hyperoxaluria

types I and II, Crohn’s disease, ulcerative colitis, intestinal bypass surgery (especially
jejunoileal bypass), ileal resection

 •

Diseases associated with disturbances of purine metabolism

 •

Intrinsic metabolic disorders: anemia, neoplastic disorders (especially leukemias),

intoxication, myocardial infarction, irradiation, cytotoxic chemotherapy

 •

Enzyme deficiency: primary gout, Lesch-Nyhan syndrome

 •

Altered excretion: renal insufficiency, metabolic acidosis

 •

Infectious history: organisms (particularly Proteus and Klebsiella ), febrile, upper tract
involvement, and dates (if hospitalized)

Components of the Medical History That Are Significant for Urolithiasis

Modified from Nseyo UO (ed): Urology for primary care physicians,Philadelphia,
1999, Saunders.
 Laboratory Tests
 •

Urinalysis: Hematuria may be present, but its absence does not exclude stones. Urine
pH may help identify stone type: pH >7.5 is associated with struvite stones; pH <5.5 is
generally associated with uric acid stones, and low serum bicarbonate concentration
with urine pH ≥6 is consistent with a renal tubular acidosis.

 •

Urine culture and sensitivity results should be obtained in all patients.

 •

Serum chemistries include electrolytes, BUN, creatinine, calcium, phosphate, uric acid,
and may consider parathyroid hormone.

 •

Additional tests: 24-hr urine collection for volume, creatinine, calcium, uric acid,
phosphate, oxalate, and citrate excretion is generally reserved for patients with
recurrent stones, young patients, or bilateral stones. A 24-hr urine collection may be
appropriate for motivated, first-time stone patients interested in preventing recurrent
stones.

Imaging Studies
 •

Common diagnostic modalities for renal colic are summarized in Table 2 . Noncontrast
CT scanning has the greatest sensitivity and specificity. Ultrasonography may be an
adequate initial study in many instances, especially in patients known to have a history
of stones and in patients where radiation should be avoided (e.g., pregnancy and
children).

TABLE 2
Common Diagnostic Imaging Modalities for Renal Colic
Modality Information Provided Radiation Contrast Approximate Time
Dose Cost
CT Renal stones, including size 4-10 mSv No $750-$1000 Less than 5 min
and position of stones and perform, 30 min
evidence of obstruction interpretation
Alternative diagnoses, such
as AAA, appendicitis, and free
air
CT with IV Same as noncontrast CT 4-10 mSv Yes $750-$1000 Less than 5 min
 Modality Information Provided Radiation Contrast Approximate Time
Dose Cost
contrast Delineation of renal mass delay to measur
lesions creatinine
Additional information about
vascular dissections and
mesenteric ischemia
CT with IV and Same as CT with IV contrast 4-10 mSv Yes $750-$1000 Less than 5 min
oral contrast Potentially improved delay of approxi
diagnosis of bowel hr to ingest oral
abnormalities
Intravenous Structural and functional 1.5 mSv Yes $350 Approximately 7
urogram information about obstruction
Rarely, identification of other
pathology, such as AAA
X-ray Possible identification of 0.5-1 mSv No $250 Less than 5 min
stone, but not useful for
hydronephrosis or most other
pathology
Ultrasound Identification of No No $150 Approximately 1
hydronephrosis or —bedside ultras
hydroureter quicker
Possible identification of
stone
Used to assess for AAA or
biliary disease
View full size
CT, Computed tomography; IV, intravenous.
From Lipshultz LI et al: Urology and the primary care practitioner, ed 3, Philadelphia, 2008, Elsevier.
 •

Kidney ultrasound ( Fig. 3 ): Initial ultrasonography is associated with lower cumulative

radiation exposure than initial CT, without significant differences in serious adverse
events, pain scores, return emergency department visits, or hospitalizations. It is
reasonable to use ultrasonography as the initial imaging modality in suspected
nephrolithiasis; however, a CT scan is the optimal test for planning surgical
management of stones. Accuracy of sonography in detecting distal ureteral stones is
variable due to variable stone size, body habitus, and expertise of the technician and
radiologist. The absence of an ipsilateral ureteral jet supports for a condition of renal
blockage, but is not pathognomonic.

Open full size image

FIG. 3
 Ultrasound of renal stone.
Ultrasound can be used to assess for renal stones and complications such as hydronephrosis.
Stones can be difficult to detect, whereas hydronephrosis is usually readily observed. Because
stones are dense, they reflect sound and prevent its through transmission. As a result, stones are
echogenic (bright) on ultrasound, and cast an acoustic shadow (black). A, Short-axis view of
kidney. B, Close-up.
From Broder JS: Diagnostic imaging for the emergency physician , Philadelphia, 2011, Saunders.
 •

Unenhanced (noncontrast) helical CT scanning ( Fig. E4 ), is rapid and accurate

(sensitivity, nearly 100%; specificity, 94%-96%) and can identify all stone types in all
locations except for indinavir stones, which are now quite rare, since indinavir is no
longer commonly used. These stones are not radiopaque and contrast-enhanced CT may
be required to diagnose them.

 •

Abdominal radiography can identify radiopaque stones (e.g., calcium-containing but not
radiolucent uric acid stones), and 20 to 30% of stones will not be visible.

 •

CT scans may be ordered by urologists planning surgical intervention because a CT

yields information on adjacent organs and stone density that ultrasound and plain film
radiography cannot reveal.

Open full size image

FIG. E4
Kidney, ureter, and bladder (KUB) radiograph in a patient presenting with hematuria shows a
radiopaque shadow (arrow) along the course of the distal right ureter that proved to be a calculus.
From Nseyo U, Weinman E, Lamm DL: Urology for primary care physicians, Philadelphia, 1999, WB
Saunders.
Treatment
Acute General Rx
 •

Diagnosis with labs and imaging

 •

Pain control: NSAIDs are excellent drugs for managing renal colic (e.g., ketorolac).
Opiates may be required for severe pain.

 •

IV fluids and antiemetics may be required.

 •
 Patients that cannot be pain controlled may require urgent kidney drainage (ureteral
stent by a urologist or nephrostomy tube placement). For patients that have a stone with
a high probability of passage, medical expulsive therapy with α-blockers or calcium
channel blockers (used less often due to side effects) may be helpful. New Level 1
evidence suggests that medical expulsive treatment may not be superior to placebo;
however, numerous older studies have shown benefit to passage of distal stones >5 mm
in size with the use of medical expulsive therapy.

Prevention
 •

Increase low-calorie fluid intake. Generally, patients at increased risk for the
development of stones should increase fluid intake to maintain a urine volume of 2.5 to
3 L/day.

 •

RDA of dietary calcium 800-1200 mg/day is recommended. Lower calcium

consumption results in less gut oxalate binding and more colonic oxalate absorption,
which in turn increases urinary oxalate and risk for calcium-based stones. Limiting
animal protein to one serving daily is often recommended.

 •

Greater fruit and vegetable intake increases urinary excretion of citrate (stone
inhibitor).

 •

Dietary sodium restriction is recommended to <2 g daily because this decreases calcium
excretion.

 •

Dietary oxalate restriction in patients with hyperoxaluria.

 •

Increased dietary citrate (e.g., lemons, oranges).

 •

Stone specific therapy:

o 1.

Uric acid calculi can be prevented or even dissolved with urine pH over 6 to 6.5. This is
often accomplished with potassium citrate, taken two or three times daily with food.
o 2.

Calcium stones:

 •

In general, cannot be dissolved and either remain, pass, or are removed.

 •

With hypercalciuria, thiazide diuretics and low-sodium diet are appropriate. Potassium
citrate supplementation for patients with calcium stones and low 24-hr urine citrate
excretion. Potassium citrate may also be effective with calcium stones even when urine
citrate excretion is not low.

 •

Urate-lowering treatment for patients with hyperuricosuria but not hypercalciuria.

o 3.

Struvite stones:

 •

Surgical interventions are usually required. Shock wave lithotripsy (SWL), percutaneous
nephrolithotomy (PCNL), and/or ureteroscopy will usually be needed, depending on
stone size and configuration.

 •

Urease inhibitor treatment by acetohydroxamic acid in patients who are not rendered
stone free or are poor surgical candidates. This agent is poorly tolerated and
infrequently used in contemporary practice.

o 4.

Cystine stones

 •

High fluid intake of 3 to 4 L daily is the principal therapy. Urine alkalinization to pH

>6.5–7 with potassium citrate. Thiol drugs such as penicillamine and tiopronin reduce
the poorly soluble cystine to a soluble cysteine–drug complex. Tiopronin is better
tolerated than penicillamine.

 •

Surgical Therapy:
o ○

Surgical treatment is needed for patients with: severe pain unresponsive to medication,
possible infection from an obstructing stone, acute kidney injury from ureteral
obstruction, refractory nausea/vomiting, and prolonged kidney obstruction (i.e., risk of
irreversible renal damage).

o ○

Ureteral stones can often be managed with ureteroscopy or SWL.

o ○

Stones in the kidney can be managed with ureteroscopy or SWL if <1 to 2 cm in size and
in a favorable location. As a stone become larger and more complex, PCNL becomes the
preferred means of management.

o ○

Indications for PCNL are described in Table E3 .

 •

Fig. E5 describes the management of ureteral stones.

 •

Guidelines for ureteral stone treatment:

o 1.

Proximal ureteral stones <1 cm diameter: SWL or ureteroscopy preferred.

o 2.

Proximal ureteral stones >1 cm diameter: SWL, ureteroscopy, or PCNL for complex
and/or large stones.

o 3.

Distal ureteral stones <1 cm diameter: SWL or ureteroscopy, although ureteroscopy is

generally preferred.

o 4.

Distal ureteral stones >1 cm diameter: SWL or ureteroscopy. Ureteroscopy is generally

preferred.

Fig. E5 describes an approach to the management of ureteral calculi.

 TABLE E3
Indications for Percutaneous Nephrolithotomy
Indicator Description Treatment
Stone size >2-3 cm or staghorn
Composition ∗ Struvite stones Complete removal necessary to eliminate infection an
minimize stone recurrence
Calcium oxalate Difficult to pulverize by SWL
monohydrate stones
Cystine stones Difficult to pulverize by SWL
Stone position Lower pole stones Fragments less easily evacuated from dependent low
calyces, especially if collecting system dilated
Anatomic PUJ obstruction; calyceal Prevent passage of fragments after SWL
abnormalities diverticula
Patient Morbid obesity; ureteral Stone cannot be placed in focal point of SWL machin
characteristics obstruction
View full size
SWL is the first choice for stone intervention, except in those circumstances that may favor PCNL.
SWL, Extracorporeal shock wave lithotripsy; PCNL, percutaneous
nephrolithotomy; PUJ, pelviureteral junction.
From Floege J et al: Comprehensive clinical nephrology, ed 4, Philadelphia, 2010, Saunders.
∗ Stone composition can be defined with certainty only by direct stone analysis, but
advances in imaging may ultimately provide a means to accurately assess stone
composition in situ before treatment, thus allowing the urologist to select the treatment
most likely to be successful.

Open full size image

FIG. E5
Management of urinary calculi.
PNL, Percutaneous nephrostolithotomy; SWL, shock wave lithotripsy.
From Noble J: Primary care medicine, ed 3, St Louis, 2001, Mosby.
Chronic Rx
Maintenance of proper hydration and dietary restrictions (see “ Acute General Rx ”)

Disposition
 •

>50% to 80% of patients will pass a ureteral stone within 4 to 6 weeks of presentation

 •
 Stone recurrence is variable and based on size, location, and number of stones, along
with patient comorbidities and stone-forming tendencies. The Recurrence of Kidney
Stone (ROKS) nomogram was developed to predict recurrence in first-time stone
formers.

Referral
Urology referral is appropriate when spontaneous passage is unlikely, when a patient
cannot be discharged from the emergency department, or when patients have
complicated or recurrent stones.

Pearls & Considerations

Comments
 •

Use the ROKS nomogram to calculate recurrence risk in first-time stone-formers.

 •

Approximately 75% to 80% of patients will not need admission or surgery for a ureteral
stone.

 •

Patients should be referred to a urologist if they have multiple stones at presentation,

complex stones, or have had multiple prior episodes.

Suggested Readings
Available at www.expertconsult.com

Suggested Readings
 Assimos D., et. al.: Surgical management of stones: American Urological
Association/Endourological Society Guideline, PART I. J Urol 2016; 196: pp. 1153-1160.
 Dropkin B.M., et. al.: The natural history of nonobstructing asymptomatic renal
stones managed with active surveillance. J Urol 2015; 193: pp. 1265.
 Fink H.A., et. al.: Medical management to prevent recurrent nephrolithiasis in
adults: a systematic review for an American College of Physicians clinical guideline. Ann
Intern Med 2013; 158: pp. 535-543.
 Frassetto L., Kohlstadt I.: Treatment and prevention of kidney stones: an update. Am
Fam Physician 2011; 84: pp. 1234-1242.
 Moesbergen T.C., et. al.: Distal ureteral calculi: US follow-up. Radiology 2011; 260:
pp. 575.
 Pearle M.: Shock-wave lithotripsy for renal calculi. N Engl J Med 2012; 367: pp. 50-
57.
 Pearle M.S., et. al.: American Urological Association. Medical management of kidney
stones: AUA guideline. J Urol 2014; 192: pp. 316-324.
 Pickard R., et. al.: Medical expulsive therapy in adults with ureteric colic: a
multicentre, randomised, placebo-controlled trial. Lancet 2015; 386: pp. 341-349.
 Scales C.D., et. al.: Urologic Diseases in America Project. Prevalence of kidney stones
in the United States. Eur Urol 2012; 62: pp. 160-165.
 Smith-Bindman R., et. al.: Ultrasonography versus computed tomography for
suspected nephrolithiasis. N Engl J Med 2014; 371: pp. 1100-1110.
 Worcester E.M., Coe F.L.: Calcium kidney stones. N Engl J Med 2010; 363: pp. 954-
963.
 Zhang W., et. al.: Retrograde intrarenal surgery versus percutaneous
nephrolithotomy versus extracorporeal shockwave lithotripsy for treatment of lower
pole renal stones: a meta-analysis and systematic review. J Endourol 2015; 29: pp. 745-
759.
Evidence-Based Medicine
Abstract [1]

Background
There is a lack of consensus about whether the initial imaging method for patients with
suspected nephrolithiasis should be computed tomography (CT) or ultrasonography.

Methods
In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned
patients 18 to 76 years of age who presented to the emergency department with
suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an
emergency physician (point-of-care ultrasonography), ultrasonography performed by a
radiologist (radiology ultrasonography), or abdominal CT. Subsequent management,
including additional imaging, was at the discretion of the physician. We compared the
three groups with respect to the 30-day incidence of high-risk diagnoses with
complications that could be related to missed or delayed diagnosis and the 6-month
cumulative radiation exposure. Secondary outcomes were serious adverse events,
related serious adverse events (deemed attributable to study participation), pain
(assessed on an 11-point visual-analogue scale, with higher scores indicating more
severe pain), return emergency department visits, hospitalizations, and diagnostic
accuracy.

Results
A total of 2759 patients underwent randomization: 908 to point-of-care
ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of
high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not
vary according to imaging method. The mean 6-month cumulative radiation exposure
was significantly lower in the ultrasonography groups than in the CT group (P < 0.001).
Serious adverse events occurred in 12.4% of the patients assigned to point-of-care
ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of
those assigned to CT (P = 0.50). Related adverse events were infrequent (incidence,
0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group
(P = 0.84). Return emergency department visits, hospitalizations, and diagnostic
accuracy did not differ significantly among the groups.

Conclusions
Initial ultrasonography was associated with lower cumulative radiation exposure than
initial CT, without significant differences in high-risk diagnoses with complications,
serious adverse events, pain scores, return emergency department visits, or
hospitalizations.

Currently, kidney stones are typically diagnosed with high sensitivity and specificity via
a CT scan of the abdomen and pelvis.2 Will, or should, the results of this large,
geographically diverse, randomized, multicenter, trial be viewed as establishing the
“comparative therapeutic equivalence” of these tools and thereby alter our diagnostic
approach to suspected nephrolithiasis? To answer this question, we must carefully
understand the results of this study.

To evaluate the relative effectiveness of various imaging modalities, eligible patients

were randomized to either receive ultrasonography by an ultrasound-certified
emergency physician, a radiologist, or an abdominal CT. The diagnostic accuracy was
assessed via either stone passage or a patient report of surgical stone removal.

The key primary outcome was not diagnostic accuracy per se but rather focused on
missed predefined high-risk diagnoses, complications potentially related to a delay in
diagnosis (occurring within 30 days of examination), and the cumulative radiation
exposure.

The number of high-risk diagnoses with complications was small, and although it
tended to be slightly higher in the emergency department (ED) ultrasound group, it did
not reach statistical significance, nor did any of the other outcome parameters studied.

The statistics were handled using an intention-to-treat model. Ultimately, about 41% of
the patients in the ED ultrasound group and about 27% of the patients in the radiology
ultrasound group required CT imaging to establish a diagnosis of stone disease. When
this is taken into account, the sensitivity of ultrasonography to detect renal stones is less
than that of CT at 54% (95% confidence interval [CI]: 48-60); for point-of-care
ultrasonography, it is 57% for radiology ultrasonography (95% CI: 51-64), and 88% for
CT (95% CI: 84-92; P < .001).

Thus, there are several important caveats to this study. First, as the authors clearly point
out, their results do not suggest that at-risk patients should undergo only ultrasound
imaging. Instead, their findings suggested that ultrasonography is the most appropriate
initial diagnostic imaging test for the detection of renal stones. Additional images may
be required based on the clinical judgment of the physician.

The second caveat is that eligibility criteria were carefully defined. Several groups of
patients were deemed ineligible for inclusion. These included anyone being evaluated
for an alternative diagnosis such as appendicitis, cholecystitis, or aneurysm, and
patients who were obese, pregnant, had a solitary kidney, were receiving dialysis, or had
a prior transplantation. The third is that the ED physicians performing the study were
certified in ultrasonography, and therefore the results may not be generalizable to other
clinical settings.

Nonetheless, the results of the study are important. CT imaging and stone evaluations
can involve significant exposure to ionizing radiation. In fact, Ferrandino and colleagues
found that the typical acute stone evaluation at an academic medical center (which
included an intravenous pyelogram, an abdominal radiograph, and a CT of the abdomen
and pelvis) had a mean radiation exposure of 29.7 mSv.3 The International Commission
on Radiation Exposure recommends a total annual exposure of under 50 mSv.4 In
addition to using ultrasonography as a first-line approach to the diagnosis of stone
disease, the applicability of low-dose CT 5,6 scans should continue to be explored.

R. Garrick, MD

Evidence-Based References
 1. Smith-Bindman R., et. al.: Ultrasonography versus computed tomography for
suspected nephrolithiasis. N Engl J Med 2014; 371: pp. 1100-1110.
 2. Coursey C.A., Casalino D.D., Reimer E.M., et. al.: ACR appropriateness criteria:
acute onset flank pain and suspicion of stone disease. Ultrasound Q 2012; 28: pp. 227-
233.
 3. Ferrandino M.N., Bagrodia A., Pierre S.A., et. al.: Radiation exposure in the acute
and short-term management of urolithiasis with biases at two academic centers. J Urol
2009; 181: pp. 668-672.
 4. National Research Council : Health Risks from Exposure to Low Levels of Ionizing
Radiation: BEIR VII Phase 2. 2006. National Academies Press Washington, DC
 5. Ciaschini M.W., Remer E.M., Baker M.E., Lieber M., Herts B.R.: Urinary calculi:
radiation dose reduction of 50% and 75% at CT effect on sensitivity. Radiology 2009;
251: pp. 105-111.
 6. Poletti P.A., Platon A., Rutschmann O.T., Schmidlin F.R., Iselin C.E., Becker C.D.:
Low dose versus standard-dose CT protocol in patients with clinically suspected renal
colic. AJR Am J Roentgenol 2007; 188: pp. 927-933.