Kidney stone differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

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].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

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 History Signs and Symptoms Physical Examination Laboratory abnormalities
Nausea/vomiting Hematuria Location of pain Fever Tachycardia Hypotension Hypertension Anorexia Constipation Rebound 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
  • Primary hyper parathyroidism
  • Inadequate dietary calcium intake
  • Hypercalciuria
  • Hyperoxaluria
  • Cystinuria
  • Renal tubular acidosis
  • Infection with urease producing bacteria (Ureaplasma urealyticum, Klebsiella, Protues)
+ +
  • 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
Appendicitis
  • Male gender
  • Adolescents
  • Diet low in fiber and high in refined carbohydrates
  • History of appendicitis in first degree relatives
Diverticulitis
  • Diverticulosis
  • Low fiber diet
  • Old age
Abdominal aortic aneurysm
  • Hypertension
  • Cigarette smoking
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
Duodenal ulcer
  • Helicobacter pylori infection
  • Tobacco smoking
  • NSAID use
  • EtOH use
  • Older age
  • Female gender
  • Family history of duodenal ulcers
Ischemic colitis
  • Age > 60 years
  • Hemodialysis
  • Hypertension
  • Hypoalbuminemia
  • Diabetes mellitus

References

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