A Large Calcified Kidney Stone
Radiology Cases in Pediatric Emergency Medicine
Volume 7, Case 6
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 14 year old female who presents to the
emergency department with severe pain in her lower
back for the past two hours. She describes the pain as
sharp and worse than being stabbed by a knife. She
has also had some abdominal pain along with
menstrual cramps for the past two days. She took
some acetaminophen before coming to the ED and she
states that the pain is slightly better. There is no
history of fever or chills. There is some suggestion of
urgency, but no dysuria. She feels nauseated and she
has vomited twice. Her LMP was four weeks ago and
she denies any possibility of pregnancy.
Her past medical history is unremarkable. There is
no family history of kidney stones.
Exam: VS T36.7 (oral), P89, R 20, BP 90/60,
oxygen saturation in room air 99%. She is alert and
cooperative. She is uncomfortable, but she does not
appear to be in severe pain. HEENT unremarkable.
Neck supple. Heart regular without murmur. Lungs
clear. No chest tenderness. Her abdomen is soft and
non-tender on palpation. Bowel sounds are
normoactive. There is no rebound tenderness. Her
back is very tender over her mid lumbar spine and this
is somewhat worse over her right flank. Her distal
pulse are good. She is able to move all her extremities
well and she speaks well.
A urine dipstick is positive for blood. Blood studies
are drawn and an IV is started. She is given morphine
for pain. Her urine pregnancy test is negative and she
is sent to radiology for an abdominal series.
View abdominal series.
Supine view (below)
Upright view (below)
Any abnormalities here? What diagnostic
procedure would you order next?
There is a calcified density in the right lower
quadrant visible on both views of the abdominal series.
This is suspected to be a ureteral stone since her
symptoms are consistent with this.
View a close-up of this stone.
She is given additional doses of morphine to control
her pain. Her laboratory studies show a normal CBC
(WBC 6,700) and chemistry (normal BUN, creatinine,
SGPT and lipase). Her urinalysis shows 5-10 WBCs
and 50-100 RBCs.
An abdominal ultrasound is performed but she is too
uncomfortable to cooperate well and this study is
non-diagnostic except for the presence of mild
hydronephrosis of her right kidney.
An intravenous pyelogram (IVP) is ordered. A 20
minute and a delayed abdominal flat plate are shown
View 20-minute IVP flat plate (below).
View delayed IVP (below).
An earlier IVP flat plate demonstrates prompt
excretion of contrast from the left kidney. The
20-minute IVP shows contrast excretion from the left
kidney and a contrast enhanced right kidney without
contrast excretion. The delayed IVP (a slightly oblique
view) shows delayed contrast excretion from the right
kidney confirming an obstruction on the right.
Is the calcified density in the right lower quadrant
causing the obstruction?
The IVP demonstrates an obstruction in the right
ureter, along with a clinical presentation consistent with
ureteral colic. This makes it very likely that she has a
ureteral stone. However, the calcified density is very
large for a ureteral stone. Additionally, the location of
the calcified density is not exactly in the expected path
of the ureter. An appendicolith is suspected.
Her pain has subsided following the administration
of analgesics. Interestingly, she did not have much
abdominal pain on initial presentation, since she was
mostly complaining of back pain. Now that her back
pain is under better control, she is complaining of some
abdominal pain, but it is not severe. The severity of her
nausea has been fluctuating. She is given some
promethazine and her nausea has now subsided.
A urologist is consulted for her ureteral obstruction
and a pediatric surgeon is consulted for the possibility
of appendicitis. An abdominal CT scan is ordered;
however, the radiologist is reluctant to give her a
second dose of IV contrast for the CT scan. She is
followed clinically and she passes a small amount of
tissue in her urine which contains a tiny stone. Her
abdominal pain persists and she eventually undergoes
an appendectomy which shows an early appendicitis
with an appendicolith.
This is an interesting case in that the patient
actually has two different acute conditions
simultaneously. Although the calcified density on her
abdominal series appeared to be too large for a
ureteral stone, this was assumed to be a large ureteral
stone because of her clinical presentation. In fact, the
stone was felt to be too large to pass spontaneously, so
the possibility of lithotripsy or surgical retrieval of the
stone were discussed. Calcifications in the right lower
quadrant should always raise the possibility of an
appendicolith and acute appendicitis. As a pitfall,
clinicians may attribute this finding to other causes
such as vascular calcification, gynecological
calcification, intestinal contents (ingested sand or
gravel), or as in this case, a ureteral stone. A CT scan
without and then with contrast may have been a more
optimal study which would have identified the ureteral
stone and the appendicolith.
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Web Page Author:
Loren Yamamoto, MD, MPH
Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine