Avoiding CT by Using US to Evaluate Pediatric Renal Colic
Avoiding CT by Using US to Evaluate Pediatric Renal Colic
An 18-year-old male patient with a history of renal colic diagnosed by a previous POCUS presented to the pediatric ED with acute right flank pain and dysuria. He reported that the pain was sharp and stabbing and was worse with activity, which was similar to his past renal colic. The patient had taken oral analgesics with no relief. He denied any fever, nausea, or vomiting and the remainder of his review of systems was also negative. In the ED, his vital signs were temperature, 36.8°C; blood pressure, 131/80 mm Hg; pulse rate, 82 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 99% on room air. His examination was unremarkable except for right costovertebral angle tenderness.
POCUS showed right hydronephrosis with a 6.6-mm stone identified in the right ureterovesical junction with "twinkling artifact" described in the US technique section (Figure 1 and Video 1 http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/vTyiofq-UsI). The patient was given analgesics and intravenous fluids. His pain resolved with passing of the stone and the patient was discharged home.
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Figure 1.
Case 1: 18-year-old male with right hydroureteronephrosis and ureteropelvic junction stone with "twinkle artifact." (A) Right hydroureteronephrosis. (B) Normal left kidney. (C) Twinkling artifact (arrow). (D) Twinkling artifact and normal left ureteral jet (asterisk). (E) Visible stone measuring 6.6 mm at right ureterovesical junction.
A 19-year-old female patient with a medical history of pyelonephritis and nephrolithiasis diagnosed by a CT 5 months earlier presented to the pediatric ED with a 1-day history of right flank pain. She endorsed chills, nausea, and increased urinary frequency but, otherwise, the remainder of her review of systems was negative. She reported that her pain was similar to her previous episode of renal colic. In the ED, her vital signs were temperature, 37.2°C; blood pressure, 156/82 mm Hg; heart rate, 62 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 96% on room air. Her examination was notable for right costovertebral angle tenderness and right lower quadrant tenderness to deep palpation with no rebound or guarding.
POCUS showed moderate right hydroureteronephrosis, which persisted post void. There was no sonographically identified calculus or perinephric fluid collection. The left kidney was within normal limits. Bilateral ureteral jets were visualized, with the right jet less than the left jet, consistent with a partially obstructing ureteral stone (Figure 2 and Video 2: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/YqYPEv8Jigo). Her urine pregnancy test was negative and her urinalysis showed moderate blood with small leukocyte esterase. She received analgesics and was discharged home with antibiotics because there was concern for pyelonephritis. Her urine culture was positive so she completed a course of antibiotics. She passed the stone without complication and has not had recurrence of renal colic as of the writing of this report.
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Figure 2.
Case 2: 19-year-old female with right hydronephrosis and decreased right ureteral jet. (A) Right hydronephrosis. (B) Normal left kidney. Diminished right ureteral jet (C) compared to normal left ureteral jet (D).
A 19-year-old girl with a history of recurrent renal colic diagnosed by two previous CTs and left ureteral stent placement 2 months prior presented to the pediatric ED with fever and left flank pain for 3 days. Of note, her ureteral stents were planned for removal 1 month earlier, but this was postponed for nonmedical reasons. Her pain was not relieved by analgesics and had been gradually worsening. She also noted hematuria with malodorous urine. The remainder of her review of systems was negative.
In the ED, her vital signs were temperature, 37.7°C; blood pressure, 110/57 mm Hg; pulse rate, 111 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 99% on room air. On examination, she had significant left flank and costovertebral angle tenderness. She was treated for her pain and nausea. Her complete blood count was normal. Her urinalysis was notable for large blood and large leukocyte esterase and a urine culture was sent. POCUS showed migration of her left ureteral stent into her bladder with hydronephrosis of the left kidney and intrarenal stones (Figure 3 and Video 3: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/Yt8OLMOOaWk). An abdominal x-ray confirmed the displacement of her ureteral stent. She was started on antibiotics due to concern for pyelonephritis and she was admitted to the urology service for removal of her displaced ureteral stent. Lithotripsy was also performed. She completed a course of antibiotic therapy for a positive urine culture.
(Enlarge Image)
Figure 3.
Case 3: 19-year-old female with left ureteral stent migration into bladder, left hydronephrosis, and intrarenal stone with "twinkling artifact." (A) Left kidney with intrarenal stone and twinkling artifact (arrow). (B) Left kidney with second intrarenal stone and twinkling artifact (arrowhead). (C) Transverse view of bladder with coiling migrated left ureteral stent. (D) Twinkling artifact at tip of ureteral stent and normal right ureteral jet visualized on color Doppler.
A 3-year-old Hispanic boy with a recent history of urinary tract infection treated with oral antibiotics presented to the ED with persistent fever and dysuria. The patient's mother reported that 5 days before, the patient presented to another ED with similar symptoms and was diagnosed with a urinary tract infection. He was sent home with a prescription for cefixime, which mom reported compliance. However, the fever and dysuria had persisted, so he was brought to the ED.
His vital signs in the ED were temperature, 38.3°C; blood pressure 86/65 mm Hg; pulse rate, 130 beats/min; respiratory rate, 18 breaths/min; and O2 saturation, 99% on room air. On physical examination, he was uncircumcised but otherwise had unremarkable findings. His urinalysis showed moderate leukocyte esterase and moderate blood. POCUS showed a 10-mm stone in the right ureterovesical junction (Figure 4 and Video 4: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/_hxhi9i-dmE). He was admitted for intravenous antibiotics given concern for an infected urolith. His hospital course was uncomplicated and the patient was discharged home with resolution of his symptoms.
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Figure 4.
Case 4: 3-year-old male with bladder stone. Large bladder stone measuring 1 cm on top of right ureterovesical junction with posterior acoustic shadowing (arrows) in transverse (A) and sagittal (B) views.
A 21-year-old female patient with a history of polycystic kidney disease and multiple bilateral stones diagnosed by two previous CTs in the last 2 years presented to the pediatric ED with lower back pain and left flank pain. She denied any nausea or vomiting and her review of systems was otherwise negative. In the ED, her vital signs were temperature, 36.2°C; blood pressure, 135/63 mm Hg; pulse rate, 64 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 99% on room air. Her examination was unremarkable except for left flank tenderness.
POCUS showed an enlarged left polycystic kidney compared to a right polycystic kidney, with a diminished left ureteral jet visualized compared to a normal right ureteral jet, consistent with partial obstruction (Figure 5 and Video 5: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/v33w8oyVFRs). She was subsequently discharged home with analgesics and was given close follow-up with her primary care physician. She passed the stone without complications.
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Figure 5.
Case 5: A 21-year-old female with polycystic kidney disease and multiple bilateral stones. Right (A) and left (B) polycystic kidneys. Normal right ureteral jet (C). Diminished left (D) ureteral jet compared to right jet (C) suggestive of partial obstruction.
Case Report
Case 1
An 18-year-old male patient with a history of renal colic diagnosed by a previous POCUS presented to the pediatric ED with acute right flank pain and dysuria. He reported that the pain was sharp and stabbing and was worse with activity, which was similar to his past renal colic. The patient had taken oral analgesics with no relief. He denied any fever, nausea, or vomiting and the remainder of his review of systems was also negative. In the ED, his vital signs were temperature, 36.8°C; blood pressure, 131/80 mm Hg; pulse rate, 82 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 99% on room air. His examination was unremarkable except for right costovertebral angle tenderness.
POCUS showed right hydronephrosis with a 6.6-mm stone identified in the right ureterovesical junction with "twinkling artifact" described in the US technique section (Figure 1 and Video 1 http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/vTyiofq-UsI). The patient was given analgesics and intravenous fluids. His pain resolved with passing of the stone and the patient was discharged home.
(Enlarge Image)
Figure 1.
Case 1: 18-year-old male with right hydroureteronephrosis and ureteropelvic junction stone with "twinkle artifact." (A) Right hydroureteronephrosis. (B) Normal left kidney. (C) Twinkling artifact (arrow). (D) Twinkling artifact and normal left ureteral jet (asterisk). (E) Visible stone measuring 6.6 mm at right ureterovesical junction.
Case 2
A 19-year-old female patient with a medical history of pyelonephritis and nephrolithiasis diagnosed by a CT 5 months earlier presented to the pediatric ED with a 1-day history of right flank pain. She endorsed chills, nausea, and increased urinary frequency but, otherwise, the remainder of her review of systems was negative. She reported that her pain was similar to her previous episode of renal colic. In the ED, her vital signs were temperature, 37.2°C; blood pressure, 156/82 mm Hg; heart rate, 62 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 96% on room air. Her examination was notable for right costovertebral angle tenderness and right lower quadrant tenderness to deep palpation with no rebound or guarding.
POCUS showed moderate right hydroureteronephrosis, which persisted post void. There was no sonographically identified calculus or perinephric fluid collection. The left kidney was within normal limits. Bilateral ureteral jets were visualized, with the right jet less than the left jet, consistent with a partially obstructing ureteral stone (Figure 2 and Video 2: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/YqYPEv8Jigo). Her urine pregnancy test was negative and her urinalysis showed moderate blood with small leukocyte esterase. She received analgesics and was discharged home with antibiotics because there was concern for pyelonephritis. Her urine culture was positive so she completed a course of antibiotics. She passed the stone without complication and has not had recurrence of renal colic as of the writing of this report.
(Enlarge Image)
Figure 2.
Case 2: 19-year-old female with right hydronephrosis and decreased right ureteral jet. (A) Right hydronephrosis. (B) Normal left kidney. Diminished right ureteral jet (C) compared to normal left ureteral jet (D).
Case 3
A 19-year-old girl with a history of recurrent renal colic diagnosed by two previous CTs and left ureteral stent placement 2 months prior presented to the pediatric ED with fever and left flank pain for 3 days. Of note, her ureteral stents were planned for removal 1 month earlier, but this was postponed for nonmedical reasons. Her pain was not relieved by analgesics and had been gradually worsening. She also noted hematuria with malodorous urine. The remainder of her review of systems was negative.
In the ED, her vital signs were temperature, 37.7°C; blood pressure, 110/57 mm Hg; pulse rate, 111 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 99% on room air. On examination, she had significant left flank and costovertebral angle tenderness. She was treated for her pain and nausea. Her complete blood count was normal. Her urinalysis was notable for large blood and large leukocyte esterase and a urine culture was sent. POCUS showed migration of her left ureteral stent into her bladder with hydronephrosis of the left kidney and intrarenal stones (Figure 3 and Video 3: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/Yt8OLMOOaWk). An abdominal x-ray confirmed the displacement of her ureteral stent. She was started on antibiotics due to concern for pyelonephritis and she was admitted to the urology service for removal of her displaced ureteral stent. Lithotripsy was also performed. She completed a course of antibiotic therapy for a positive urine culture.
(Enlarge Image)
Figure 3.
Case 3: 19-year-old female with left ureteral stent migration into bladder, left hydronephrosis, and intrarenal stone with "twinkling artifact." (A) Left kidney with intrarenal stone and twinkling artifact (arrow). (B) Left kidney with second intrarenal stone and twinkling artifact (arrowhead). (C) Transverse view of bladder with coiling migrated left ureteral stent. (D) Twinkling artifact at tip of ureteral stent and normal right ureteral jet visualized on color Doppler.
Case 4
A 3-year-old Hispanic boy with a recent history of urinary tract infection treated with oral antibiotics presented to the ED with persistent fever and dysuria. The patient's mother reported that 5 days before, the patient presented to another ED with similar symptoms and was diagnosed with a urinary tract infection. He was sent home with a prescription for cefixime, which mom reported compliance. However, the fever and dysuria had persisted, so he was brought to the ED.
His vital signs in the ED were temperature, 38.3°C; blood pressure 86/65 mm Hg; pulse rate, 130 beats/min; respiratory rate, 18 breaths/min; and O2 saturation, 99% on room air. On physical examination, he was uncircumcised but otherwise had unremarkable findings. His urinalysis showed moderate leukocyte esterase and moderate blood. POCUS showed a 10-mm stone in the right ureterovesical junction (Figure 4 and Video 4: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/_hxhi9i-dmE). He was admitted for intravenous antibiotics given concern for an infected urolith. His hospital course was uncomplicated and the patient was discharged home with resolution of his symptoms.
(Enlarge Image)
Figure 4.
Case 4: 3-year-old male with bladder stone. Large bladder stone measuring 1 cm on top of right ureterovesical junction with posterior acoustic shadowing (arrows) in transverse (A) and sagittal (B) views.
Case 5
A 21-year-old female patient with a history of polycystic kidney disease and multiple bilateral stones diagnosed by two previous CTs in the last 2 years presented to the pediatric ED with lower back pain and left flank pain. She denied any nausea or vomiting and her review of systems was otherwise negative. In the ED, her vital signs were temperature, 36.2°C; blood pressure, 135/63 mm Hg; pulse rate, 64 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 99% on room air. Her examination was unremarkable except for left flank tenderness.
POCUS showed an enlarged left polycystic kidney compared to a right polycystic kidney, with a diminished left ureteral jet visualized compared to a normal right ureteral jet, consistent with partial obstruction (Figure 5 and Video 5: http://www.jem-journal.com/article/S0736-4679%2815%2900029-3/addonshttp://youtu.be/v33w8oyVFRs). She was subsequently discharged home with analgesics and was given close follow-up with her primary care physician. She passed the stone without complications.
(Enlarge Image)
Figure 5.
Case 5: A 21-year-old female with polycystic kidney disease and multiple bilateral stones. Right (A) and left (B) polycystic kidneys. Normal right ureteral jet (C). Diminished left (D) ureteral jet compared to right jet (C) suggestive of partial obstruction.