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==Overview==
==Overview==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
Nephrolithiasis should be differentiated from other conditions presenting with acute flank or upper abdominal pain, hematuria, nausea and vomiting.
 
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Differentiating Nephrolithiasis from other Diseases==
==Differentiating Nephrolithiasis from other Diseases==

Revision as of 23:17, 19 May 2018

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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]

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 + +
  • Flank/back pain radiating to groin
 - + - - +/- - - + - - - - - - -
  • Non-contrast CT scan may show stone as radiolucency
 +/-
Pyelonephritis
  • Urinary tract infection
  • Immunocompromised state (Diabetes, immunosuppressive medications)
  • Urinary tract obstruction
  • History of pyelonephritis
  • Pregnancy
  • Presence of urinary catheter, stent, nephrostomy tube
 + + (microscopic)
  • Costovertebral angle
  • Positive renal punch sign
 + + + - +/- - + + +
  • Uretheritis
  • Vaginitis
 -
  • Leukocytosis
  • Pyuria
  • Positive leukocyte esterase
 - - - -
  • Globaly decreased contrast uptake
  •  Foci from abscess pockets
 -
Renal infarct
  • Sickle cell disease or trait
  • Thrombosis
  • Trauma
  • Hypertension
  • Cardiac arrhythmia
  • Coagulopathy
  • Atherosclerosis
 + +
  • Flank pain
 + + - + - - - - - - -
  • Leukocytosis
  • Red blood cells
  • Proteinuria
 - - -
Renal papillary necrosis
  • Analgesic use (Phenacetin, acetaminophen, NSAIDs)
  • Pyelonephritis
  • Urinary tract obstruction
  • Sickle cell disease
  • Tuberculosis
  • Cirrhosis
  • Diabetes
  • Vasculitis
  • Renal vein thrombosis
 - + (microscopic)
  • Flank pain
 + +/- - + - - - + - - -
  • Bacteriuria
  • Pyuria
  • Microscopic hematuria
 - - - -
  • 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
 + + (microscopic)
  • Flank pain
 - - - + + +/- - - - - -
  • Anemia
  • Microscopic hemeturia
  • Renal cell casts
  • Urinary aquaporin-1 (AQP1) and adipophilin (ADFP)- proximal renal tubular cancer
 - - - -
  • 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
 - +/- - - - - - - - - + - - - - - - - - - - -

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
 -
  • Leukocytosis
  • Bacteriuria (Neisseria gonorrhoeae or Chlamydia trachomatis, polymicrobial)
  • Pyuria
 - - - -
  • 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
 - - - - - - - - -
  • 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
 -
  • Low platelet distribution width (decreased platelet activation)
  • Monocytosis
 - - - - + +/- - 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
 + + - - - - - + - -
  • Enlarged prostate
  • Rectal pain
  • Leukocytosis
  • Bacteriuria
  • Pyuria
  • Microscopic hematuria
 - - - - - - -
Prostatic cancer
  • Family history of prostate cancer (1st degree relatives)
  • Germline mutation of HOXB13 (G84E variant)
  • Black ethnicity
  • Age > 50 years
 - + - - - - - + - - + - -
  • Enlarged prostate
  • Firm and hard
 -
  • Positive prostate specific antigen (PSA)
  • High levels of TMPRSS2:ERG and PCA3
 - - - -
  • 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.
 - - - - - - - - -
  • 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
 -
  • Leukocytosis
 - - - - - - -
  • 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
 + + - - + - - - - - -
  • Leukocytosis
 - - -
  • Bilirubin (pigment) stones
  • Cholesterol stones
 - + +/-
  • 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
 + + - - + - + +/- - - -
  • Leukocytosis
 - - - - - - + (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
 + + - - + + - - - -
  • Bleeding
  • Rectal mass
  • Rectal tenderness
  • Leukocytosis
 - - - - - - + (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) - - - - - - - - - - - -
  • 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 artery) - - -
  • Hematochezia
  • Anemia
  • Thrombocytopenia
 - - - - - + + (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) - - -
  • Melena
  • Anemia
 - - - - + (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) - - -
  • Hematochezia
  • Leukocytois (if necrosis)
  • Anemia (if perforation and bleeding)
 - - - - + (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)
 -

References

  1. ↑ Worcester EM, Coe FL (June 2008). "Nephrolithiasis". Prim. Care. 35 (2): 369–91, vii. doi:10.1016/j.pop.2008.01.005. PMC 2518455. PMID 18486720.
  2. ↑ Semins MJ, Matlaga BR (February 2010). "Medical evaluation and management of urolithiasis". Ther Adv Urol. 2 (1): 3–9. doi:10.1177/1756287210369121. PMC 3126068. PMID 21789078.
  3. ↑ Venkatesh L, Hanumegowda RK (June 2017). "Acute Pyelonephritis - Correlation of Clinical Parameter with Radiological Imaging Abnormalities". J Clin Diagn Res. 11 (6): TC15–TC18. doi:10.7860/JCDR/2017/27247.10033. PMC 5535453. PMID 28764263.
  4. ↑ Garin EH, Olavarria F, Araya C, Broussain M, Barrera C, Young L (July 2007). "Diagnostic significance of clinical and laboratory findings to localize site of urinary infection". Pediatr. Nephrol. 22 (7): 1002–6. doi:10.1007/s00467-007-0465-7. PMID 17375337.
  5. ↑ Lee DG, Jeon SH, Lee CH, Lee SJ, Kim JI, Chang SG (April 2009). "Acute pyelonephritis: clinical characteristics and the role of the surgical treatment". J. Korean Med. Sci. 24 (2): 296–301. doi:10.3346/jkms.2009.24.2.296. PMC 2672131. PMID 19399273.
  6. ↑ Saeed K (2012). "Renal infarction". Int J Nephrol Renovasc Dis. 5: 119–23. doi:10.2147/IJNRD.S33768. PMC 3437809. PMID 22969301.
  7. ↑ Mahamid M, Francis A, Abid A, Awawde M, Abu-Elhija O (2014). "Embolic renal infarction mimicking renal colic". Int J Nephrol Renovasc Dis. 7: 157–9. doi:10.2147/IJNRD.S59745. PMC 4011809. PMID 24812524.
  8. ↑ Korzets Z, Plotkin E, Bernheim J, Zissin R (October 2002). "The clinical spectrum of acute renal infarction". Isr. Med. Assoc. J. 4 (10): 781–4. PMID 12389340.
  9. ↑ Brix AE (2002). "Renal papillary necrosis". Toxicol Pathol. 30 (6): 672–4. doi:10.1080/01926230290166760. PMID 12512867.
  10. ↑ Eknoyan G, Qunibi WY, Grissom RT, Tuma SN, Ayus JC (March 1982). "Renal papillary necrosis: an update". Medicine (Baltimore). 61 (2): 55–73. PMID 7038374.
  11. ↑ Ng CS, Wood CG, Silverman PM, Tannir NM, Tamboli P, Sandler CM (October 2008). "Renal cell carcinoma: diagnosis, staging, and surveillance". AJR Am J Roentgenol. 191 (4): 1220–32. doi:10.2214/AJR.07.3568. PMID 18806169.
  12. ↑ Ares Valdés Y, Amador Sandoval B, Morales JC, Alonso Domínguez F, Carballo Velásquez L, Fragas Valdés R, Shou Rodríguez A (September 2004). "[The role of CT scan in the diagnosis of renal cell carcinoma]". Arch. Esp. Urol. (in Spanish; Castilian). 57 (7): 737–42. PMID 15536955.
  13. ↑ Leveridge MJ, Bostrom PJ, Koulouris G, Finelli A, Lawrentschuk N (June 2010). "Imaging renal cell carcinoma with ultrasonography, CT and MRI". Nat Rev Urol. 7 (6): 311–25. doi:10.1038/nrurol.2010.63. PMID 20479778.
  14. ↑ Tritschler S, Roosen A, Füllhase C, Stief CG, Rübben H (March 2013). "Urethral stricture: etiology, investigation and treatments". Dtsch Arztebl Int. 110 (13): 220–6. doi:10.3238/arztebl.2013.0220. PMC 3627163. PMID 23596502.
  15. ↑ Mundy AR, Andrich DE (January 2011). "Urethral strictures". BJU Int. 107 (1): 6–26. doi:10.1111/j.1464-410X.2010.09800.x. PMID 21176068.
  16. ↑ Maciejewski C, Rourke K (February 2015). "Imaging of urethral stricture disease". Transl Androl Urol. 4 (1): 2–9. doi:10.3978/j.issn.2223-4683.2015.02.03. PMC 4708283. PMID 26816803.
  17. ↑ Soper DE (August 2010). "Pelvic inflammatory disease". Obstet Gynecol. 116 (2 Pt 1): 419–28. doi:10.1097/AOG.0b013e3181e92c54. PMID 20664404.
  18. ↑ Paavonen J (October 1998). "Pelvic inflammatory disease. From diagnosis to prevention". Dermatol Clin. 16 (4): 747–56, xii. PMID 9891675.
  19. ↑ Lee MH, Moon MH, Sung CK, Woo H, Oh S (December 2014). "CT findings of acute pelvic inflammatory disease". Abdom Imaging. 39 (6): 1350–5. doi:10.1007/s00261-014-0158-1. PMID 24802548.
  20. ↑ Eggert J, Sundquist K, van Vuuren C, Fianu-Jonasson A (October 2006). "The clinical diagnosis of pelvic inflammatory disease--reuse of electronic medical record data from 189 patients visiting a Swedish university hospital emergency department". BMC Womens Health. 6: 16. doi:10.1186/1472-6874-6-16. PMC 1624808. PMID 17054801.
  21. ↑ Washington C, Carmichael JC (December 2012). "Management of ischemic colitis". Clin Colon Rectal Surg. 25 (4): 228–35. doi:10.1055/s-0032-1329534. PMC 3577613. PMID 24294125.
  22. ↑ Chawla YK, Bodh V (March 2015). "Portal vein thrombosis". J Clin Exp Hepatol. 5 (1): 22–40. doi:10.1016/j.jceh.2014.12.008. PMC 4415192. PMID 25941431.
  23. ↑ "Imaging of Abdominal Aortic Aneurysms - - American Family Physician".
  24. ↑ Aggarwal S, Qamar A, Sharma V, Sharma A (2011). "Abdominal aortic aneurysm: A comprehensive review". Exp Clin Cardiol. 16 (1): 11–5. PMC 3076160. PMID 21523201.
  25. ↑ Destigter KK, Keating DP (August 2009). "Imaging update: acute colonic diverticulitis". Clin Colon Rectal Surg. 22 (3): 147–55. doi:10.1055/s-0029-1236158. PMC 2780264. PMID 20676257.
  26. ↑ Hameed AM, Lam VW, Pleass HC (February 2015). "Significant elevations of serum lipase not caused by pancreatitis: a systematic review". HPB (Oxford). 17 (2): 99–112. doi:10.1111/hpb.12277. PMC 4299384. PMID 24888393.
  27. ↑ "Imaging for Suspected Appendicitis - - American Family Physician".
  28. ↑ "CT Findings of Acute Cholecystitis and Its Complications : American Journal of Roentgenology : Vol. 194, No. 6 (AJR)".
  29. ↑ "Epididymitis and Orchitis: An Overview - - American Family Physician".
  30. ↑ Jia JB, Houshyar R, Verma S, Uchio E, Lall C (January 2016). "Prostate cancer on computed tomography: A direct comparison with multi-parametric magnetic resonance imaging and tissue pathology". Eur J Radiol. 85 (1): 261–267. doi:10.1016/j.ejrad.2015.10.013. PMID 26526901.
  31. ↑ Bratt O, Lilja H (January 2015). "Serum markers in prostate cancer detection". Curr Opin Urol. 25 (1): 59–64. doi:10.1097/MOU.0000000000000128. PMC 4315142. PMID 25393274.
  32. ↑ "Prostate Cancer (Prostate Carcinoma): Symptoms - National Library of Medicine - PubMed Health".
  33. ↑ Eskicioğlu F, Özdemir AT, Turan GA, Gür EB, Kasap E, Genç M (November 2014). "The efficacy of complete blood count parameters in the diagnosis of tubal ectopic pregnancy". Ginekol. Pol. 85 (11): 823–7. PMID 25675798.
  34. ↑ Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW (October 2011). "Diagnosis and management of ectopic pregnancy". J Fam Plann Reprod Health Care. 37 (4): 231–40. doi:10.1136/jfprhc-2011-0073. PMC 3213855. PMID 21727242.

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