Chief Complaint: ”My right side hurts”
On a busy night in the ED you encounter a 48-year-old male with right flank pain. Onset was sudden, severe, 10/10, waxing and waning pain. You obtain a urine dip which shows 3+ blood.
Here is his non-contrast CT abdomen/pelvis:
What is the diagnosis?
This man has a 0.6cm stone in his ureter. The CT scan shows two slices, one visualizing a hyper dense spherical structure in the ureter and the other demonstrating hydronephrosis with perinephric stranding. This is considered an obstructing stone.
Kidney stone causing acute pain is one of the most common, most satisfying ED diagnoses. These patients usually are in significant pain, sometimes sweating bullets from their pain! And we can and usually make them better. In fact, IV ketorolac is one of the most efficacious medicines available for stones. I personally love the kidney stone…I feel like I can make a difference with this diagnosis.
Emergency Medicine Practice (one of my favorite CME publications) in July 2011 provided a great review of renal calculi. In particular it quoted an an article which found a 98.3% sensitivity and a 100% specificity of ultrasound in patients suspected of having renal colic. CT had a sensitivity and specificity approaching 100%. The article also discusses admission criteria, special cases such as pregnancy and pediatrics, as well as recommendations for those patients sent home from the ED. I will refer you to the article for details.
1. Carter MR, Green BR. Renal Calculi: Emergency Department Diagnosis and Treatment. Emergency Medicine Practice; 13 (7), 2011.
Author: Russell Jones, M.D.
Imaging Study: CT abdomen/pelvis without contrast