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:

Category	Disease	Risk factors	Symptoms									Signs							Paraclinical studies
			Pain	N/V	Fever	Tachycardia	Hypotension	Hypertension	Anorexia	Constipation	Urinary symptoms	Fever	HR	BP	Abdominal tenderness	Costovetebral angle tenderness	Pelvic 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	+	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 (Phenacetin, acetaminophen, NSAIDs) Pyelonephritis Urinary tract obstruction Sickle cell disease Tuberculosis Cirrhosis Diabetes Vasculitis Renal vein thrombosis	Flank pain	-	+	+/-	-	+	-	-	+				-	-	Nl	Nl		Bacteriuria Pyuria Microscopic hematuria			-	Nl	Nl	Blunted renal calyces Contrast material–filled clefts in the renal medulla Non-enhanced lesions surrounded by rings of excreted contrast material Hyperattenuated medullary calcifications
	Renal cell carcinoma	Weight loss History of smoking Obesity Von-Hippel Lindau disease Night sweats Malaise Flank mass	Flank pain	+	-	-	-	+	+	+/-	-				-	-	Nl	Nl	Anemia	Microscopic hematuria Renal cell casts Urinary aquaporin-1 (AQP1) and adipophilin (ADFP)- proximal renal tubular cancer			-	Nl	Nl	Non-contrast CT: Lesions are soft tissue attenuation  Areas of calcification and necrosis Contrast-enhanced: Homogenous (small lesions) to irregular (large lesions) contrast enhancement
	Uretral stricture	Prior urinary tract surgery Congenital Urinary catheterization Direct penile trauma	-	-	-	-	-	-	-	-	+				-	-	Nl	Nl	-	Hematuria			-	Nl	Nl	-
Gynecological Pathology	Pelvic inflammatory disease	Endometritis Saplingitis Cesarian section Septic abortion Urinary tract infection 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	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	Unilateral poorly localized lower abdominal	+	-	+	-	-	-	-	-				-	-	Adnexal tenderness Adnexal mass	Nl	-	-	-	-	-	Nl	Nl	Twisted ovarian pedicle Enlarged ovary (>4.0 cm) Distended pedicle Possible underlying ovarian lesion
	Ectopic pregnancy	History of previous ectopic pregnancy Tubal surgery Intrauterine device usage History of pelvic surgery History of pelvic inflammatory disease Sub-fertility Sternous excercise Increased maternal age Cigarette smoking	Lower abdominal Unilateral shoulder or neck pain (referred)	+	-	+	-	-	+	-	+				+ (if ruptured)	-	Vaginal bleeding	Nl	Low platelet distribution width (decreased platelet activation) Monocytosis	-	-	-	+	Might be abnormal	Nl	N/A
Prostate Pathology	Prostatitis	Bacterial infection by: Ureaplasma urealyticum Proteus Chlamydia Gonorrhea E.Coli Pseudomonas Mycoplasma Prior history of prostatitis Urinary tract infection Urinary catheterization	Perineal pain Lower back pain Suprapubic pain	-	+	+	-	-	-	-	+				-	-	Nl	Enlarged prostate Rectal pain	Leukocytosis	Bacteriuria Pyuria Microscopic hematuria	-	-	-	Nl	Nl
	Prostatic cancer	Family history of prostate cancer (1st degree relatives) Germline mutation of HOXB13 (G84E variant) Black ethnicity Age > 50 years	-	-	-	-	-	-	+	-	+				-	-	Nl	Enlarged prostate Firm and hard	-	Hematuria Positive prostate specific antigen (PSA) High levels of TMPRSS2:ERG and PCA3			-	Nl	Nl	Focal areas of mass-like enhancement in the peripheral prostate Calcifications
Testicular Pathology	Testicular torsion	Age 12 - 16 years Previous history of testicular torsion Family history of testicular torsion Prematurity Undescended testes Low birth weight	Sudden onset unilateral testicular pain	+	-	+	-	-	+/-	-	+/-				-	-	Absent cremasteric reflex Testicle may be swollen, tender, and high-riding, with an abnormal transverse lie.	Nl	-	-	-	-	-	Nl	Nl	Doppler ultrasound > CT scan for diagnosis (abscence of blood flow in the affected testis)
	Orchitis	Unprotected sexual intercourse Mumps, coxsackie virus infection Concurrent epididymitis Congenital abnornmalities Prostatitis Prostatic hypertrophy or calculi	Abrupt onset of testicular pain	+	+	+	-	-	-	-	+/-				-	-	Testicular swelling and tenderness Normal cremasteric reflex	Nl	Leukocytosis	-	-	-	-	Nl	Nl	Ultrasound > CT scan for diagnosis (Testicular masses or swollen testicles with hypoechoic and hypervascular areas)
Abdominal Pathology	Cholecystitis	Female gender Obesity Pregnancy (increased progesterone promotes biliary stasis) Rapid weight loss Oral contraceptive use Increasing age Total parenteral nutrition	Right upper abdominal quadrant pain Flank pain	+	+	+	-	-	+	-	-				-	-	Nl	Nl	Leukocytosis	Bilirubin (pigment) stones Cholesterol stones	-	-	-	Might be abnormal	Might be abnormal	Gallbladder distention Wall thickening Mucosal hyperenhancement, Pericholecystic fat stranding or fluid Gallstones
	Appendicitis	Male gender Adolescents Diet low in fiber and high in refined carbohydrates History of appendicitis in first degree relatives	Pain in umblical area Radiating to right lower abdominal quadrant	+	+	+	-	-	+	-	+/-				+	-	Nl	Nl	Leukocytosis	-	-	-	-	Nl	Abnormal (if perforation)	Larger than 6 mm in diameter, Appendiceal wall thickening Wall enhancement after contrast media infusion Inflammatory fat stranding Phlegmon Free fluid Free air bubbles Abscess Adenopathy
	Diverticulitis	Diverticulosis Low fiber diet Old age	Left lower abdominal quadrant	+	+	+	-	-	+	+	-				-	-	Nl	Bleeding Rectal mass Rectal tenderness	Leukocytosis	-	-	-	-	Nl	Abnormal (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	Hypertension Cigarette smoking Pulsatile abdominal mass	Epigastric pain Deep boring pain in the back May radiate to flank	-	-	+	+	-	-	-	-				+ (if rupture)	-	Nl	Nl	-	-	-	-	-	Nl	Nl	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	Mutated JAK2 V617F Anti-phospholipid syndrome Paroxysmal nocturnal hemoglobinuria Homocysteinuria Factor V Leiden Prothrombin mutation G20210A Protein C or S deficiency Oral contraceptive use Cirrhosis Pregnancy and post-partum	Abdominal or lumbar pain	+	+	+	+	-	+	-	-				+ (if bowel ischemia or infarction-secondary to extension of thrombus to superior mesenteric vein)	-	Nl	Hematochezia	Anemia Thrombocytopenia	-	-	-	-	Might be abnormal	Abnormal (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	Pain relieved by intake of food Helicobacter pylori infection Tobacco smoking NSAID use EtOH use Older age Female gender Family history of duodenal ulcers	Epigastric pain	+	+	+	+	-	-	-	-				+ (if perforation)	-	Nl	Melena	Anemia	-			-	Nl	Abnormal (if bowel perforation)	Endoscopy > CT scan for diagnosis
	Ischemic colitis	Age > 60 years Hemodialysis Hypertension Hypoalbuminemia Diabetes mellitus	Acute-onset abdominal cramping	+	+	+	+ (if necrosis and sepsis)	+	+	+	-				+ (if transmural necrosis)	-	Nl	Hematochezia	Leukocytosis (if necrosis) Anemia (if perforation and bleeding)	-			-	Nl	Abnormal (if bowel perforation)	Bowel wall thickening Thumbprinting Pericolonic stranding with or without ascites. Double halo or target sign  Submucosal edema or hemorrhage Pneumatosis coli (if infarction)