cirus
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In nephrolithiasis:
CT is best. if pregnant, do an U/S (No Xray or CT)
1st Step Should be urine analysis, or Xray , or CT???? which to start with
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| liliaeliz
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fertil femal do U/A then pregnant test if is positive do ultrasound, if is negative do CT scan .
male or no fertil famale do U/A then CTscan
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| liliaeliz
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fertil female do U/A then pregnant test if is positive do ultrasound, if is negative do CT scan .
male or no fertil female do U/A then CTscan
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| Drtweetie
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if we already know that she's pregnant, what do we need to check U/A to confirm? I'd say in a pregnant lady with suspicion of nephrolithiasis, do U/S!
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| cirus
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U didn understand my qs
The first steo=p in a normal individual should be:
1. Urine Analysis
2. U/S
3. CT.
For what i know, it should be :
1-->U/A ( for hematuria & urine pict)
2. If a female pt & pregnancy test is in the choices, then it is the 2nd step, if not then CT unless it was mentioned that she is pregnant.
is this correct
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| doyoudig
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yes that what I rememebr as well
1. UA should always be the initial step to get an idea what u are dealing with and possible type of stone
2. US is the Dx Test of Choice in Preg Pts but X rays are safe to do as well and should be next before US is it gives u hints on type of stone (such as Ca Stones)
US has less sensitivity to detect ureteric stones, but good for Renal Stones
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| Justice
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In many circumstances Pts with suspected renal calculus get UA and than KUB, not CT...
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| dr_arc
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pt with clinical picture suspicious of nephrolithiasis
first step = u/a
next step = ctscan.
if pt is a female in the reproductive age grp= u/a foll by preg test.
if nonpreg= ctscan.
if preg= us---stone undetected then do a transvaginal us to see if the stone is somewhere in the lower part of ureter.-----still undetected-single shot IVP i.e limited exposure.
ref-uworld.
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| Drtweetie
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sorry cirus, I was half-asleep...
of course: initial test in all suspicious nephrolithiasis is UA, XR is for recurrent stones, CT is more sensitive; if pregnant, then do U/S
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| zeloc
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dr arc, I thought after UA, the next step in the nonpregnant patient is KUB, not CT?
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| dr_arc
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zeloc wrote:
dr arc, I thought after UA, the next step in the nonpregnant patient is KUB, not CT?
i think it is ct, it says so in uworld and i think that is what kaplan says too, but ct is def better than anything. KUB used to be the gold std for evrything renal for long but now we have better alternatives. maybe someone else can add something here?
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| Justice
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dr_arc wrote:
maybe someone else can add something here
Here is the citation from lovely eMedicine: http://www.emedicine.com/EMERG/topic499.htm
Imaging Studies:
Most authors recommend diagnostic imaging to confirm the diagnosis in first-time episodes of ureterolithiasis, when the diagnosis is unclear, or if associated proximal UTI is suspected.
Kidney, ureter, and bladder (KUB) radiograph
Multiple studies show that the KUB has low sensitivity and specificity for the presence of ureterolithiasis and adds nothing to the emergent clinical impression. At follow-up, the urologist may find the KUB to be helpful in determining the exact size and shape of the stone, in establishing a baseline for follow-up studies, and for visualization of the surgical orientation.
KUB can be used to monitor passage of a previously documented opaque stone.
Computed tomography (CT): CT scan has been thought historically to play no role in diagnosis of ureterolithiasis because of the need for many cuts to define stones as small as 1-2 mm in diameter. Since 1996, helical CT scanners have been able to acquire images with greatly reduced examination time and with little motion artifact. Noncontrast helical CT has become the criterion standard imaging study in the ED diagnosis of ureterolithiasis (see Image 1).
Numerous studies have demonstrated that CT has a sensitivity of 95-100% and superior specificity and accuracy compared with the historic criterion standard, intravenous pyelogram (IVP).
Other advantages of helical CT include rapid (<5 min) acquisition time, avoidance of intravenous (IV) contrast, and potential for diagnosis of other pathology including AAA, pancreatitis, appendicitis, ovarian disorders, diverticular disease, and biliary tract disorders. The cost of the study varies among institutions and averages approximately $619.
Principal disadvantages are that helical CT gives no information on renal function or degree of urinary obstruction.
Indinavir stones are not visualized well by helical CT scan.
Intravenous pyelogram: Prior to the advent of helical CT, IVP was the test of choice in diagnosing ureterolithiasis. IVP is widely available and fairly inexpensive ($486, varies among institutions) but less sensitive than noncontrast helical CT. IVP remains the test of choice in patients with suspected indinavir stones.
Contrast is administered intravenously at a dose of 1 mL/kg, and KUB films are taken immediately and at 1, 5, 10, and 15 minutes until contrast fills both distal ureters (see Image 2). Look for direct visualization of stone within the ureter, unilateral ureteral dilation, delayed appearance of the nephrogram phase, lack of normal peristalsis pattern of the ureter, or perirenal contrast extravasation. Degree of obstruction is graded based on delay in appearance of the nephrogram.
Anaphylaxis to ionic contrast agents (eg, Renografin, Conray) occurs in 1-2 patients per 1000 IVP studies. Risk of recurrence is approximately 15% if reexposed to ionic agents but falls to 5% when nonionic agents are used. Risk of anaphylaxis can be reduced further by pretreatment with a combination of H1- and H2-blockers and steroids, but studies showing the benefit of pretreatment began pretreatment more than 12 hours prior to study. Risk of nephrotoxicity is not clearly reduced with use of nonionic agents. Indications for use of nonionic contrast agents vary among institutions but consistently include history of prior mild to moderately severe reaction to ionic contrast, asthma, multiple allergies, or severe cardiac disease.
Disadvantages of IVP include radiation exposure and risk of nephrotoxicity or anaphylactoid reaction to contrast agent. IVP is relatively contraindicated in pregnant or dehydrated patients or if serum creatinine level exceeds 2 mg/dL. IVP is absolutely contraindicated in patients with a history of severe contrast-induced anaphylaxis. False-negative results usually occur with stones located at the ureterovesical junction.
Ultrasonography: This is a good imaging modality in patients who are pregnant or to rule out the presence of an AAA in patients older than 60 years with a first or atypical presentation of nephrolithiasis.
A handful of small studies have found sensitivities of 65-100% (see Images 3-4). Ultrasonography has been found to be less accurate in diagnosis of ureteral stones than IVP or helical CT. Diagnostic criteria include direct visualization of the stone, hydroureter more than 6 mm in diameter, and perirenal urinoma suggesting calyceal rupture. The cost is approximately $440.
Advantages include lack of radiation exposure and ability to complete the study at the bedside in patients who are potentially in unstable condition.
Disadvantages include inferior sensitivity, lack of universal availability, dependence on operator expertise, and inability to accurately estimate the degree of urinary obstruction.
A urine-filled bladder provides an excellent acoustic window for ultrasound imaging; sonograms occasionally may demonstrate a stone at the ureterovesical junction that is not seen on helical CT or IVP.
Future studies may utilize 2-dimensional ultrasonography in combination with color Doppler analysis of the ureteral jets to enhance sensitivity of ultrasonography in patients with ureteral colic.
Magnetic resonance imaging: MRI can be used to detect ureteral stones. One study of 40 consecutive patients with acute flank pain found sensitivity of 54-58% and specificity of 100% using breath-hold heavily T2-weighted sequences (Sudah, 2001). Sensitivity and specificity increased to 96.2-100% and 100%, respectively, using gadolinium-enhanced 3-D FLASH MR urography. Although MRI does not play a major role in the diagnosis of ureteral stones, lack of radiation makes MRI a good choice in pregnant women who have nondiagnostic findings from a sonogram.
However, I personally had KUB in my family clinic (Wisconsin, USA), 2 years ago, and did not have any CT... It seems that the choice depends on the size of the clinic, and most of primary HMO just do not have CT equipment...
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| MAGY17
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