urinary calculi imaging in english.docx

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Urinary Calculi Imaging http://emedicine.medscape.com/article/381993-overview#show

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Urinary Calculi Imaging Author: J Kevin Smith, MD, PhD; Chief Editor: Eugene C Lin, MD more...

OverviewPreferred examination

The goals of imaging of urinary calculi are to determine the presence ofstones within the urinary tract, evaluate for complications, estimate thelikelihood of stone passage, confirm stone passage, assess the stoneburden, and evaluate disease activity.[1, 2, 3, 4, 5, 6, 7]

Images of stone disease are provided below:

Magnified scout intravenous urogram shows a large, relatively lucent calculus in thelower pole of the right kidney.
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Scout intravenous urogram shows a smooth, dense, round calculus in the leftkidney.

Renal sonogram demonstrates an echogenic shadowing calculus in the renalcollecting system with hydronephrosis.

Contrast-enhanced CT scan demonstrates an opaque staghorn calculus filling theleft renal collecting system
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Intravenous urogram (10-min delay) Magnified view of the left ureterocele with alarge stone in it.

Prone nonenhanced CT image shows that the stone in the left ureterovesicaljunction does not move to the dependent portion of the bladder. This findingindicates that it is still in the distal ureter at the ureterovesical junction and that it hasnot passed into the bladder.

Contrast-enhanced CT image of the right kidney shows a cluster of calyceal calculi

without hydronephrosis.

When acute flank pain suggests the passage of a urinary stone, manymethods of examination can be used.[8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19] Often,conventional radiography is initially used to screen for stones, bowelabnormalities, or free intra-abdominal air. Radiographs can also be used tomonitor the passage of visible stones.
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Intravenous urography (IVU) (excretory urography) provides importantphysiologic information regarding the degree of obstruction.Ultrasonography (US) is useful in young or pregnant patients [20, 21] and inpatients allergic to iodinated contrast material. US is also helpful in problemsolving.

All of these methods have become less useful with the advent of moresensitive and specific nonenhanced computed tomography (CT) scanning.When CT is available, it is now considered the examination of choice forthe detection and localization of urinary stones. Almost all studiesconducted to date show that IVU provides no additional clinically importantinformation after nonenhanced CT is performed. As a result of the higherradiation dose of CT, conventional or digital radiography should be used tomonitor the passage of stones if radiographic follow-up studies are

indicated and if the stone is visible on conventional radiographs.

[22]

Passage of aurinary stoneis the single most common cause ofacuteureteral obstructionand affects as many as 12% of the population.The pain may be some of the most severe pain that humans experience,and complications of stone disease may result in severe infection; renalfailure; or, in rare cases, death.[23]

Limitations of techniques

Because of the higher radiation dose with CT, conventional or digital

radiography should be used to monitor the passage of stones ifradiographic follow-up is believed to be indicated and if the stone is visibleon conventional radiographs. Pregnant or pediatric patients may be imagedwith US first to avoid radiation exposure. The rare false-negative finding isusually due to reader error or a protease-inhibitor CT-lucent stone. False-positive results are usually due to phleboliths adjacent to the ureter. Insome cases, intravenous contrast material may be needed to opacify theureter.

Ultrasonography (US) has limited sensitivity for smaller stones, and does

not depict the ureters well. It should be used mainly in patients who areyoung, those who are pregnant, or those undergoing multiple examinations(eg, patients with spine injury).

IVU is the traditional examination for the assessment of urinary stonedisease, and it does provide physiologic information related to the degreeof obstruction. The radiation dose is generally smaller than that of CT, but itis of the same order of magnitude. Intravenous contrast is required, with
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resultant risks of an allergic reaction or nephrotoxicity. IVU is less sensitivethan CT, especially for small or nonobstructing stones.

Radiography

Conventional radiographyConventional radiography, as shown in the image below, is often performedas a preliminary examination in patients with abdominal pain possiblyresulting from urinary calculi. These images should be obtained beforecontrast material is administered to prevent obscuring calcifications withinthe collecting system or calyceal diverticula. Conventional radiographsshould include the entire urinary tract, and, often, 2 images are required.[24,25, 26, 27, 28, 29, 30]

Abdominal radiograph shows calcification filling the left collecting system. Thisfinding is consistent with a staghorn calculus. For its size, the stone is relativelylucent.

Stones are often found at key points of narrowing such as the ureteropelvicjunction (UPJ), the ureterovesical junction (UVJ), and the point at which theureter crossing the iliac vessels. An addition site is on the right side wherethe ureter passes through the root of the mesentery. Calcium stones assmall as 1-2 mm can be seen. Cystine stones as small as 3-4 mm may bedepicted, but uric acid stones are usually not seen unless they havebecome calcified.

Typically, phleboliths are round or oval, and they may demonstrate acentral lucency. However, they are often difficult to distinguish from ureteralcalculi. Phleboliths in the pelvis are usually located lower than and lateral tothe ureter, but they overlap with the ureter. Because gonadal veins parallel
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the upper ureters, contrast enhancement may be needed to opacify theureter and demonstrate the extraurinary location of phleboliths in thegonadal veins.

An erect or posterior oblique radiograph obtained on the side of the

calcification may help in distinguishing urinary stones from extraurinarycalcifications. This view can also depict calcifications that are projectedover the sacrum or transverse processes on the frontal view.

Preinjection renal tomography may depict additional stones, and it can beused to confirm the relationship of stones to the kidneys.

Because stones are more visible with a lower peak kilovoltage (kVp),maintaining a maximum of 60-80 kVp is best, if possible. Larger patientsmay require a higher peak kilovoltage for acceptable exposure and scatter.

In this situation, compression of the abdomen and collimation is critical.Mild bowel preparation may be helpful for increasing the sensitivity ofconventional radiography for small stones in patients undergoing screeningor follow-up observation for stones.

Intravenous urography

Intravenous urography, as shown in the images below, is useful forconfirming the exact location of a stone within the urinary tract. IVU depictsanatomic abnormalities such as dilated calyces, calyceal diverticula,

duplication, UPJ obstruction, retrocaval ureter, and others that maypredispose patients to stone formation or alter therapy. Because contrastagents can obscure stones in the collecting system, scouting the entireurinary tract prior to their administration is critical.


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Magnified scout intravenous urogram shows a large, relatively lucent calculus in thelower pole of the right kidney.

Intravenous urogram. After the intravenous injection, contrast material in thecollecting system obscures the calculus.

Scout intravenous urogram shows a smooth stone in the right kidney.


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Intravenous urogram obtained 5 minutes after the intravenous injection. Contrastmaterial in the collecting system obscures the stone.

When an acute urinary stone is the primary consideration, compressionmay not be used to increase sensitivity for detection of low-grade

obstruction. A caveat is that the contralateral kidney may have anabnormality that requires ureteric compression for adequate examination.In rare cases, the use of compression has been associated with fornicealrupture.

When a stone causes acute obstruction, an obstructive nephrogram maybe present. This may be prolonged and hyperopaque, with increasingopacity over time. The nephrogram of acute obstruction is usuallyhomogeneous, but may also be striated or occasionally not visible onradiographs.[31]

Other signs include delayed excretion, dilatation to the point of obstruction,or blunting of the calyceal fornices. Immediately after the passage of astone, residual mild obstruction or edema can be detected at the UVJ.Delayed images may be needed to opacify to the point of the obstruction,but using gravity to position the more opaque and more distal contrastmaterialladen-urine is also possible by placing the patient in a prone orerect position.

Extravasation of urine at the fornices may result in pyelosinus or

pyelolymphatic extravasation, which is often first indicated by blurring of thecalyceal fornices. Greater extravasation may outline the collecting system,and the contrast may dissect into the perinephric space; however, if theurine is not infected, this is usually clinically insignificant.

Degree of confidence

Although 90% of urinary calculi are opaque on abdominal radiographs, thesensitivity for the prospective identification of individual stones is only 50-60%, and the specificity is only approximately 70%. Approximately 10% ofstones are radiolucent on conventional radiographs.

False positives/negatives

Occasionally, false-positive findings result from extrarenal calcification, butthese are usually correctly identified with IVU. Lucent stones appear asfilling defects on IVU, but they are not distinguished from nonstone-fillingdefects such as transitional cell carcinomas or blood clots. US and CT are


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effective tools in making this distinction; however, much of the uretercannot be visualized with US.

Computed Tomography

With a sensitivity of 94-97% and a specificity of 96-100%, helical CT is themost sensitive radiologic examination for the detection, localization, andcharacterization of urinary calcifications; therefore, helical CT isconsiderably more effective than IVU.[32, 33, 34, 35, 36, 37, 38, 39] Helical CT scansfrequently depict non-obstructing stones that are missed on intravenousurography (IVU). CT is faster and no contrast agent is needed in mostpatients.

CT easily differentiates between non-opaque stones and blood clots ortumors (compared with IVU, which may depict only a filling defect). In

addition, helical CT is better than US or IVU in detecting other causes ofabdominal pain. In fact, in most studies, IVU added little or noinformation.[40, 41]

Rarely, pure matrix stones may demonstrate soft-tissue opacity on CTscans, and indinavir stones appear lucent.[42] However, all other stonesappear opaque on CT scans.[43]

Technique

Because stones in the collecting system may be obscured by contrastmaterial, nonenhanced CT, as shown in the images below, is usuallyperformed.[44, 45, 46, 41, 47, 48, 49, 50, 51, 52] Helical CT is important to avoid missingstones because of section misregistration. A 5-mm helical technique with apitch of 1.5:1 or less is preferred, although some radiologists choose to usea pitch of as much as 2:1.[53, 54, 55] The kidneys and, if possible, the entireabdomen should be scanned during a single breath hold to prevent sectionmisregistration.[56, 57, 58]


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Axial nonenhanced CT section at the level of the kidney demonstrates anattenuating proximal ureteral calculus (arrow). No significant hydronephrosis isidentified. CT can be performed much more rapidly than urography and without theuse of intravenous contrast material.

Axial nonenhanced CT image at the level of the kidneys shows bilateral renal calculi,right hydronephrosis, and moderate perinephric fluid.

Axial nonenhanced CT image of the urinary bladder demonstrates an attenuatingcalculus at the right ureteropelvic junction.


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Nonenhanced CT image of the pelvis shows dilatation of the distal left ureter andmild periureteral fluid near the left ureterovesical junction.

Nonenhanced CT image of the pelvis shows a small attenuating stone at the leftureterovesical junction.

Because patients with stones are often young and because stone diseasemay recur, minimizing the radiation dose is critical.[59]A fairly high level ofnoise as a result of the inherently high contrast levels is tolerable in mostpatients. Reported radiation doses for CT are 2.8-4.5 mSv compared with1.3-1.5 mSv for a 3-image IVU. However, the uterine dose is approximately0.006 Gy for 4-image IVU compared with 0.0046 Gy for nonenhancedCT.[60]

At the authors' institution, approximately 12% (10-20%) of patients whoundergo nonenhanced CT for possible urinary stones receive intravenouscontrast material for further evaluation. To discern between phleboliths and


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urinary stones, 50 mL of low-osmolar contrast agent should beadministered. After 3-5 minutes, a 5-mm helical scan is obtained throughthe area of concern.

Fewer contrast-enhanced studies are needed with increasing experience.

Soft tissue around the rim of a calculus can differentiate it from a phlebolith.A phlebolith may have a comet tail of soft tissue extending from it; thisfinding differentiates it from a calculus.[61] On CT scans, phleboliths do nothave radiolucent centers, as often seen on plain radiographs.[43, 62]

When contrast-enhanced scans, as shown in the images below, arerequired to evaluate pain not related to stones, routine abdominal and/orpelvic CT should be performed.[63] In this situation, 100-150 mL of a low-osmolar oral and rectal contrast agent is used, and a 5-mm helical CT scanis obtained with a pitch of 1.5:1. Patient selection determines the number of

examinations needed.

Contrast-enhanced CT section reveals a dense calculus in the right kidney, but thehydronephrosis has resolved.

Axial contrast-enhanced CT scan. The excretory phase image through the kidneysshows extravasation of contrast material in and near the renal pelvis andsurrounding the proximal ureter, which is opacified. The finding is consistent withfornix rupture.


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Axial contrast-enhanced CT image through the ureterovesical junction confirms thestone within a left ureterocele. A Foley catheter balloon is visible in the bladder.

Contrast-enhanced CT image of the lower abdomen shows a tiny, obstructing, leftureteral calculus.


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Contrast-enhanced CT image shows a patchy area of hypo-opacity consistent with

pyelonephritis.

Stones at the UVJ may be difficult to distinguish from stones that havealready passed into the bladder. If the distinction changes therapy, a repeatscan through the UVJ in the prone position may be helpful. Stones thathave already passed into the bladder will drop into a dependent location.[64]

CT findings

CT may depict the following:

Stones in the ureter Enlarged kidneys Hydronephrosis (83% sensitive, 94% specific) Perinephric fluid (82% sensitive, 93% specific) Ureteral dilatation (90% sensitive, 93% specific) Soft-tissue rim sign (good positive predictive value with a positive odds

ratio of 31:1); see the image below.[65, 66]


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Nonenhanced CT image shows an obstructing left proximal ureteral calculus with a

slight soft-tissue rim around the stone (ie, rim sign).

The amount of perinephric fluid is correlated with the degree of obstructionseen on IVU, and as with the obstruction, the amount of fluid is correlatedwith the likelihood of stone passage. Normal hyperattenuating renalpyramids sometimes are seen. These indicate that significant obstruction isnot present. However, this finding has been seen with proven ureteralcalculi and is often absent in patients without stones. For this reason, theusefulness of IVU is limited. If contrast material is administered, a delayedor hyperattenuating nephrogram may also be visible on CT scans if theureter has an obstruction.

Conventional radiography may be helpful in visualizing larger stones, oncethey are identified on CT scans, to provide a baseline to follow passage ofthe stone. If kidney, ureter, and bladder radiographs fail to depict the stone,CT may be needed to follow its passage.

Approximately 40-55% of stones are not visible on abdominal radiographs.Almost no stones with attenuation values of less than 200 HU are visible,and repeat CT scans are usually required if passage of the stone is to be

followed. Cystine and urate stones have an attenuation of 100-500 HU;calcium stones usually demonstrate attenuation higher than 700 HU.Considerable overlap exists in the CT attenuation values of calcium stones.


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Special concerns

In the diagnosis and treatment of kidney stones, special concerns exist inpatients who are pregnant, in those who have contraindications to the useof contrast media, and in those with renal insufficiency.

Pregnancy does not predispose patients to stone formation; however,stone formation is a complication in as many as 0.05% of pregnancies, andthe diagnosis may be difficult to establish with imaging because of thedisplacement and obscuration of organs by the enlarged uterus andfetus.[20] Consider using US first in a pregnant patient, especially in the firsttrimester. IVU can be used, but the views should be limited to scout and10- to 30-minute images if possible.[67]

CT can also be useful, and the radiation dose may be justified (especially if

the clinical picture is confusing), because any fetal damage is unlikely atthe typical radiation doses. Minimize the dose by increasing the pitch anddecreasing the milliamperage. MRI may be a useful tool for problemsolving.

Nonenhanced CT results are usually diagnostic,[68] but if contrast material isneeded, actions can be taken to decrease the risk of an adverse reaction inpatients. The patient can be premedicated with steroids and histamineblockers. Use of low-osmolar contrast agent also helps. Use of iodinatedcontrast agents should be avoided in patients who have had previous life-

threatening reactions. Nonenhanced CT is usually sufficient with the aid ofUS and MRI as problem-solving tools. Nuclear scintigraphy may also behelpful in confirming obstruction.[69]

Usually, in patients with renal insufficiency, nonenhanced CT is sufficient.Very poor renal function results in a failure to opacify the collecting system.

As in pregnant patients, US, MRI, and scintigraphy can be useful asproblem-solving tools.

If contrast material is used for IVU or for problem solving with CT,nephrotoxicity and allergy-like reactions are possible. Patients may

potentially sue for contrast material

related injuries if nonenhanced CT wasavailable but not used.

Radiation exposure should be minimized in pregnant women, and femalepatients should be questioned carefully. If needed, a pregnancy test shouldbe performed prior to CT scanning or radiography. US may be used initiallyin pregnant or pediatric patients, but CT may be indicated to confirm or


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diagnose urinary stone disease and exclude other pelvic pathology inpregnant women.[70]


Individual CT signs are associated with varying degrees of confidence, asnoted in CT findings above. False-positive results are almost exclusivelythe result of a phlebolith adjacent to the ureter. False-negative results areprimarily due to indinavir radiolucent stones and error. CT scans oftensuggest an alternative or additional diagnosis when renal stone disease isclinically suspected.[71, 72]

Magnetic Resonance Imaging

Stones are not directly visible on MRIs because they produce no signal.However, they may be indirectly visualized as a filling defect in the ureter or

collecting system on heavily T2-weighted images or on gadolinium-enhanced T1-weighted images.[73, 74, 75, 76] MRI can be useful as a problem-solving tool if the use of iodinated contrast material or radiation iscontraindicated (eg, during pregnancy).

Gadolinium-based contrast agents have been linked to the development ofnephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy(NFD). The disease has occurred in patients with moderate to end-stagerenal disease after being given a gadolinium-based contrast agent toenhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes

fatal disease. Characteristics include red or dark patches on the skin;burning, itching, swelling, hardening, and tightening of the skin; yellowspots on the whites of the eyes; joint stiffness with trouble moving orstraightening the arms, hands, legs, or feet; pain deep in the hip bones orribs; and muscle weakness.

Ultrasonography

On sonograms, stones are demonstrated as bright echogenic foci withposterior acoustic shadowing. Stones are visualized fairly well with US in

the kidneys and the distal ureter at or near the UVJ, especially if dilatationis present. US is good for the visualization of complications such ashydronephrosis (or other signs of obstruction); however, some patients withacute obstruction have little or no dilation.[77, 78, 79, 80, 81]

In particular, US is helpful in evaluating those with renal insufficiency orcontraindications for the use of contrast media; however, US is oftenskipped in favor of nonenhanced CT.[82]


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In addition, US is good for characterizing lucent filling defects that arevisualized as stones on IVU. However, US does not provide directphysiologic information regarding the degree of obstruction. Dopplerimaging may demonstrate a high resistive index in acute obstruction, butthis may not occur immediately or after forniceal rupture. Absence of theureteral jet, as visualized with color Doppler on the symptomatic side, ispresumptive evidence for a high-grade obstruction in a well-hydratedpatient.[83, 84, 85, 86, 87]


US is very insensitive for stones, especially stones smaller than 2 mm,stones at the UPJ, or stones in the mid ureter. Fowler et al suggest that UShas a sensitivity as low as 24%, compared with nonenhanced CT.Furthermore, estimations of stone size may not be accurate. Compared

with nonenhanced CT, US is more dependent on the operator's ability andmore time consuming.

False positives/negatives

US is fairly specific when stones are seen, with a specificity as high as90%. With US, matrix or indinavir stones may have soft tissue echogenicitywithout shadowing. False-positive findings may result from renal vascularcalcifications. False-positive diagnoses of hydronephrosis also result fromdilated vascular structures in the renal hilum. Doppler imaging is helpful indistinguishing dilated vascular structures from hydronephrosis.

Nuclear Imaging

Nuclear medicine studies may demonstrate the retention of activity in thecortex or collecting system when the obstruction is ongoing. Nuclearmedicine tests are useful in determining differential renal function fortreatment planning and for assessing how much renal function might returnafter the obstruction is relieved.[88, 69] For example, a kidney with very littlefunction might be removed if very little function persists after a trial ofdrainage. Occasionally, confirming the obstruction with nuclear medicine

studies is useful if the administration of iodinated contrast material iscontraindicated.

Renal function evaluation is not reliable in the presence of ongoingobstruction. Conversely, imaging findings may be normal with low-gradeobstruction.


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Contributor Information and DisclosuresAuthor

J Kevin Smith, MD, PhD Professor of Abdominal Imaging, Vice Chair forVeterans Affairs, Department of Radiology, University of Alabama at

Birmingham School of Medicine; Chief of Service, Department ofRadiology, Birmingham Veterans Affairs Medical Center

J Kevin Smith, MD, PhD is a member of the following medicalsocieties:Alpha Omega Alpha,American College of Radiology,AmericanRoentgen Ray Society,International Society for Magnetic Resonance inMedicine,Radiological Society of North America, andSociety ofRadiologists in Ultrasound

Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Lockhart, MD, MPH Professor of Radiology, Associate Director ofRadiology Medical Student Education, Chief of Abdominal Imaging,University of Alabama at Birmingham School of Medicine

Mark E Lockhart, MD, MPH is a member of the following medicalsocieties:American Institute of Ultrasound in Medicine,American RoentgenRay Society,Association of University Radiologists,Radiological Society ofNorth America,Society of Radiologists in Ultrasound, andSociety ofUroradiology


Nicole W Berland Outreach Support for Hurricane Relief, Collat JewishFamily Service


Philip Kenney, MD Professor of Radiology and Chairman, Department ofRadiology, University of Arkansas for Medical Sciences
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Philip Kenney, MD is a member of the following medical societies:AlphaOmega Alpha,American College of Radiology,American Roentgen RaySociety,Association of University Radiologists,Radiological Society ofNorth America,andSociety of Uroradiology


Specialty Editor Board

Steven Perlmutter, MD, FACR Associate Professor of Clinical Radiology,The School of Medicine at Stony Brook University; Medical Director ofRadiology, Peconic Bay Medical Center

Steven Perlmutter, MD, FACR is a member of the following medical

societies:American College of Radiology,American Institute of Ultrasoundin Medicine,American Medical Association,American Roentgen RaySociety,Association of Program Directors in Radiology,Association ofUniversity Radiologists,Medical Society of the State of NewYork,Radiological Society of North America,Society of BreastImaging,Society of Nuclear Medicine,andSociety of Uroradiology


Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department ofSpecialist Rehabilitation Services, Hutt Valley District Health Board, NewZealand


Robert M Krasny, MD Resolution Imaging Medical Corporation

Robert M Krasny, MD is a member of the following medicalsocieties:American Roentgen Ray SocietyandRadiological Society of

North America


Chief Editor

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator forCardiac Imaging, Radiology Residency Program, Virginia Mason Medical
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Center; Clinical Assistant Professor of Radiology, University of WashingtonSchool of Medicine

Eugene C Lin, MD is a member of the following medical

societies:American College of Nuclear Medicine,American College ofRadiology,Radiological Society of North America, andSociety of NuclearMedicine


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