Kidney stone differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2] Amandeep Singh M.D.[3]

Overview

Nephrolithiasis should be differentiated from other conditions presenting with acute flank or upper abdominal pain, hematuria, nausea and vomiting.

Differentiating Nephrolithiasis from other Diseases

Nephrolithiasis should be differentiated from other conditions presenting with acute flank or upper abdominal pain, hematuria, nausea and vomiting. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]

Category Disease History Signs and Symptoms Physical Examination Laboratory abnormalities
Nausea/vomiting Hematuria Location of pain Fever Tachycardia Hypotension Hypertension Anorexia Constipation Rebound abdominal tenderness Urinary frequency/Urgency/Dysuria Costovetebral angle tenderness Pelvic Examination Rectal Examination Complete Blood Count (CBC) Urinalysis BUN Creatinine Stone analysis Urine Beta- hCG Abnormal Liver Function Tests (LFTs) Serum Amylase/Lipase Abdominal/Pelvic CT scan Serum Parathyroid hormone levels (PTH)

Renal Pathology

Nephrolithiasis + + - + - - +/- - - + - - - - - - -
  • Non-contrast CT scan may show stone as radiolucency
+/-
Pyelonephritis + + (microscopic) + + + - +/- - + + + - - - - -
  • Globaly decreased contrast uptake
  •  Foci from abscess pockets
-
Renal infarct + + + + - + - - - - - - - - - -
Renal papillary necrosis - + (microscopic) + +/- - + - - - + - - - - - - - -
Renal cell carcinoma + + (microscopic) - - - + + +/- - - - - -
  • Anemia
- - - -
  • Non-contrast CT:
  • Contrast-enhanced:
    • Homogenous (small lesions) to irregular (large lesions) contrast enhancement
-
Uretral stricture - +/- - - - - - - - - + - - - - - - - - - - -

Gynecological Pathology

Pelvic inflammatory disease - -
  • Right/left upper quadrant
+ + + - + - - + - - - - - -
  • Thickening of the uterosacral ligaments
  • Haziness of the pelvic fat
  • Periovarian stranding
  • Enhancement of the adjacent peritoneum
  • Thick-walled, complex fluid collection with septa formation (abscess pockets)
-
Ovarian torsion
  • Sudden acute pain
  • Sharp pain aggravated by walking
  • Intermittent/colicky pain
+ - - + - - - - - - - - - - - - - - - -
  • Twisted ovarian pedicle
  • Enlarged ovary (>4.0 cm)
  • Distended pedicle
  • Possible underlying ovarian lesion
-
Ectopic pregnancy + - - + - - + - + (if ruptured) + - -
  • Low platelet distribution width (decreased platelet activation)
  • Monocytosis
- - - - + +/- - N/A -

Prostate Pathology

Prostatitis - + + + - - - - - + - - - - - - - - -
Prostatic cancer - + - - - - - + - - + - - - - - - - -

Testicular Pathology

Testicular torsion + - - + - - +/- - - +/- - - - - - - - - - - -
Orchitis + - + + - - - - - +/- - - - - - - - - - -

Abdominal Pathology

Cholecystitis + - + + - - + - - - - - - - - - - + +/-
  • Gallbladder distention
  • Wall thickening
  • Mucosal hyperenhancement,
  • Pericholecystic fat stranding or fluid
  • Gallstones
-
Appendicitis + - + + - - + - + +/- - - -
  • Leukocytosis
- - - - - - + (if perforation) -
Diverticulitis + - + + - - + + - - - - - - - - - - + (if perforation)
  • Colonic wall thickening (wall thickness is greater than 3 mm on the short axis of the lumen)
  • Pericolic fat stranding
-
Abdominal aortic aneurysm - - - + + - - - + (if rupture) - - - - - - - - - - - -
  • Ultrasound more sensitive than CT scan
  • CT scan may accurately predict the aneurysmal size
  • Helical CT has faster scanning time (30 to 60 seconds) and the ability to obtain all images in one breath hold
-
Portal vein thrombosis + - + + + - + - + (if bowel ischemia or infarction-secondary to extension of thrombus to superior mesenteric vein) - - - - - - - - + + (if bowel infarction, perforation)
  • On non-contrast CT:
    • Hyperdense thrombus
  • On contrast CT
    • Non-enhancing defect of bland thrombus
    • Tumor thrombus exhibits enhancement
Duodenal ulcer + - + + + - - - + (if perforation) - - - - - - - + (if bowel perforation) -
Ischemic colitis + - + + + (if necrosis and sepsis) + + + + (if transmural necrosis) - - - - - - - + (if bowel perforation) -

References

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