Kidney stone differential diagnosis

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:

Category	Disease	Risk factors	Symptoms					Signs						Paraclinical studies
			Pain	N/V	Anorexia	Constipation	Urinary symptoms	Fever	HR	BP	Tenderness	Abdominopelvic exam	Rectal exam	CBC	Urinalysis	BUN	Cr	Urine Beta−hCG	LFT	Serum amylase & lipase	CT
Renal Pathology	Nephrolithiasis	Inadequate dietary calcium intake Renal tubular acidosis Infection	Flank/back pain radiating to groin	+	±	−	+	−	↑	Nl	−	Nl	Nl	Nl	Hematuria Hypercalciuria Hyperoxaluria Cystinuria	Nl	Nl	−	Nl	Nl	Radiolucent stone
	Pyelonephritis	Urinary tract obstruction Pregnancy Urinary instrumentation	Costovertebral angle	+	±	−	+	+	↑	↓	Positive renal punch sign Costovertebral angle tenderness	Urethritis Vaginitis	Nl	Leukocytosis	Microscopic hematuria Pyuria Positive leukocyte esterase	Nl	Nl	Might be +	Nl	Nl	Decreased contrast uptake Foci from abscess pockets
	Renal infarct	Sickle cell disease or trait Trauma	Flank pain	+	−	−	−	+	↑	↑	−	Nl	Nl	Leukocytosis	Hematuria Proteinuria	Nl to ↑	Nl	−	Nl	Nl	Decreased contrast uptake
	Renal papillary necrosis	Analgesic use Sickle cell disease Tuberculosis Cirrhosis Diabetes Vasculitis Renal vein thrombosis	Flank pain	−	−	−	+	+	±	↑	−	Nl	Nl	Nl	Bacteriuria Pyuria Microscopic hematuria	Nl to ↑	Nl	−	Nl	Nl	Blunted renal calyces Non−enhanced lesions surrounded by rings of excreted contrast material Hyperattenuated medullary calcifications
	Renal cell carcinoma	History of smoking Von−Hippel Lindau disease	Flank pain	+	+	±	−	−	−	↑	−	Flank mass	Nl	Anemia	Microscopic hematuria Renal cell casts Urinary aquaporin−1 (AQP1) and adipophilin (ADFP)	Nl	Nl	−	Nl	Nl	Soft tissue attenuation  Calcification and necrosis Homogenous to irregular contrast enhancement
	Urethral stricture	Prior urinary tract surgery Congenital Urinary catheterization Direct penile trauma	−	−	−	−	+	−	−	Nl	−	Nl	Nl	−	Hematuria	Nl to ↑	Nl	−	Nl	Nl	Nl
Category	Disease	Risk factors	Pain	N/V	Anorexia	Constipation	Urinary symptoms	Fever	HR	BP	Tenderness	Abdominopelvic exam	Rectal exam	CBC	Urinalysis	BUN	Cr	Urine Beta−hCG	LFT	Serum amylase & lipase	CT
Gynecological pathology	Pelvic inflammatory disease	Cesarean section Septic abortion Tuberculosis Actinomycosis	Right/left upper quadrant	−	+	−	+	+	+	↓	Cervical motion tenderness Adnexal tenderness	Foul smelling vaginal/urtetheral discharge	Nl	Leukocytosis	Bacteriuria (Neisseria gonorrhoeae or Chlamydia trachomatis, polymicrobial) Pyuria	Nl	Nl	Might be +	Nl	Nl	Thickening of the uterosacral ligaments Periovarian stranding Enhancement of the adjacent peritoneum
	Ovarian torsion	NA	Acute unilateral poorly localized lower abdominal sharp colicky pain aggravated by walking	+	−	−	−	−	+	Nl	−	Adnexal tenderness Adnexal mass	Nl	−	−	−	−	−	Nl	Nl	Twisted and distended ovarian pedicle Enlarged ovary (>4.0 cm)
	Ectopic pregnancy	History of previous ectopic pregnancy Tubal surgery Intrauterine device usage History of pelvic surgery Increased maternal age Cigarette smoking	Lower abdominal Unilateral shoulder or neck pain (referred)	+	+	−	+	−	+	↓ (if ruptured)	Positive abdominal tenderness (if ruptured)	Vaginal bleeding	Nl	Low platelet distribution width (decreased platelet activation) Monocytosis	−	−	−	+	Might be abnormal	Nl	NA
Category	Disease	Risk factors	Pain	N/V	Anorexia	Constipation	Urinary symptoms	Fever	HR	BP	Tenderness	Abdominopelvic exam	Rectal exam	CBC	Urinalysis	BUN	Cr	Urine Beta−hCG	LFT	Serum amylase & lipase	CT
Prostate pathology	Prostatitis	Bacterial infection Prior history of prostatitis Urinary catheterization	Perineal pain Lower back pain Suprapubic pain	−	−	−	+	+	+	Nl	−	Nl	Enlarged prostate Rectal pain	Leukocytosis	Bacteriuria Pyuria Microscopic hematuria	−	−	−	Nl	Nl	Edema of the prostate gland with diffuse enlargement
	Prostatic cancer	Family history of prostate cancer Germline mutation of HOXB13 Black ethnicity Age > 50 years	−	−	+	−	+	−	−	Nl	−	Nl	Enlarged prostate Firm and hard	Nl	Hematuria Positive prostate specific antigen High levels of TMPRSS2:ERG and PCA3	Nl	Nl	−	Nl	Nl	Focal areas of mass−like enhancement in the peripheral prostate Calcifications
Testicular pathology	Testicular torsion	Age 12 − 16 years Family history of testicular torsion Prematurity Undescended testes	Sudden onset unilateral testicular pain	+	±	−	±	−	+	Nl	−	Absent cremasteric reflex Testicle may be swollen, tender, and high−riding, with an abnormal transverse lie.	Nl	Nl	−	Nl	Nl	−	Nl	Nl	Doppler ultrasound > CT scan for diagnosis (absence of blood flow in the affected testis)
	Orchitis	Unprotected sexual intercourse Mumps, coxsackie virus infection Congenital abnornmalities Prostatic hypertrophy or calculi	Abrupt onset of testicular pain	+	−	−	±	+	+	Nl	−	Testicular swelling and tenderness Normal cremasteric reflex	Nl	Leukocytosis	−	Nl	Nl	−	Nl	Nl	Ultrasound > CT scan for diagnosis (testicular masses or swollen testicles with hypoechoic and hypervascular areas)
Category	Disease	Risk factors	Pain	N/V	Anorexia	Constipation	Urinary symptoms	Fever	HR	BP	Tenderness	Abdominopelvic exam	Rectal exam	CBC	Urinalysis	BUN	Cr	Urine Beta−hCG	LFT	Serum amylase & lipase	CT
Abdominal pathology	Cholecystitis	Female gender Obesity Pregnancy Rapid weight loss Total parenteral nutrition	Right upper abdominal quadrant pain Flank pain	+	+	−	−	+	+	Nl	−	Nl	Nl	Leukocytosis	Bilirubin (pigment) stones Cholesterol stones	Nl	Nl	−	Might be abnormal	Might be abnormal	Gallbladder distention Wall thickening Pericholecystic fat stranding or fluid Gallstones
	Appendicitis	Adolescents Diet low in fiber and high in refined carbohydrates	Pain in umblical area Radiating to right lower abdominal quadrant	+	+	−	±	+	+	Nl	+	Nl	Nl	Leukocytosis	−	Nl	Nl	−	Nl	Abnormal (if perforation)	Appendiceal wall thickening Phlegmon Abscess Adenopathy
	Diverticulitis	Diverticulosis Low fiber diet Old age	Left lower abdominal quadrant	+	+	+	−	+	+	Nl	−	Nl	Bleeding Rectal mass Rectal tenderness	Leukocytosis	−	Nl	Nl	−	Nl	Abnormal (if perforation)	Colonic wall thickening Pericolic fat stranding
	Abdominal aortic aneurysm	Cigarette smoking Hypertension	Epigastric pain Deep boring pain in the back May radiate to flank	−	−	−	−	−	+	Nl	Positive abdominal tenderness (if rupture)	Pulsatile abdominal mass	Nl	−	−	Nl	Nl	−	Nl	Nl	CT scan accurately predict the aneurysmal size
	Disease	Risk factors	Pain	N/V	Anorexia	Constipation	Urinary symptoms	Fever	HR	BP	Tenderness	Abdominopelvic exam	Rectal exam	CBC	Urinalysis	BUN	Cr	Urine Beta−hCG	LFT	Serum amylase & lipase	CT
	Portal vein thrombosis	Coagulopathies Oral contraceptive use Cirrhosis Pregnancy and post−partum	Abdominal or lumbar pain	+	+	−	−	+	+	↓	Positive abdominal tenderness (if bowel ischemia or infarction)	Nl	Hematochezia	Anemia Thrombocytopenia	−	Nl	Nl	−	Might be abnormal	Abnormal (if bowel infarction, perforation)	Hyperdense thrombus on non−contrast CT Non−enhancing defect of bland thrombus on contrast CT
	Duodenal ulcer	Helicobacter pylori infection Tobacco smoking NSAID use EtOH use	Epigastric pain which relieved by intake of food	+	−	−	−	+	+	↓	Positive abdominal tenderness (if perforation)	Nl	Melena	Anemia	−	Nl	Nl	−	Nl	Abnormal (if bowel perforation)	Endoscopy > CT scan for diagnosis
	Ischemic colitis	Advanced age Hemodialysis Hypertension Diabetes mellitus	Acute−onset abdominal cramping	+	+	+	−	+	+	↑ or ↓ (if necrosis or sepsis)	Positive abdominal tenderness (if transmural necrosis)	Nl	Hematochezia	Leukocytosis (if necrosis) Anemia (if perforation and bleeding)	−	Nl to ↑	Nl	−	Nl	Abnormal (if bowel perforation)	Bowel wall thickening Thumbprinting Double halo or target sign  Submucosal edema or hemorrhage Pneumatosis coli (if infarction)
Category	Disease	Risk factors	Pain	N/V	Anorexia	Constipation	Urinary symptoms	Fever	HR	BP	Tenderness	Abdominopelvic exam	Rectal exam	CBC	Urinalysis	BUN	Cr	Urine Beta−hCG	LFT	Serum amylase & lipase	CT