A 45 year old woman with past medical history of DM and nephrolithiasis s/p ureteral stent placement presents with right flank pain. Pain is progressive and associated with nausea and vomiting. She has had subjective fevers at home and dysuria. She denies polyuria or increased urinary frequency. Physical exam is significant for right CVA tenderness and right-sided abdominal pain radiating to the groin. Point of care bilateral renal ultrasound demonstrates the findings below. What’s the diagnosis?
Answer: Bilateral Staghorn Calculi
Patient had a hospital admission 2 weeks prior to this presentation and underwent cystoscopy and right retrograde pyelogram with ureteral stent placement. Urine cultures grew gram-negative rods, she was treated with ceftriaxone.
Learning Points
Staghorn calculi
– Large, complex stones filling the majority of the renal pelvis and calyces.
– Increased rates of infection, urosepsis, and kidney injury leading to increased morbidity and mortailty.
– Often struvite in composition and associated with Proteus mirabilis; a gram-negative rod. Other urease-producing bacteria are potential sources.
– Treatment can be conservative with antibiotics and percutaneous procedures. More often surgical intervention is necessary to prevent complications and mortality.
POCUS – is there hydronephrosis?
– Bedside ultrasound is useful in identifying and grading severity of hydronephrosis.
– Studies have demonstrated a sensitivity of 77-90% and specificity of 71-96% for detecting hydronephrosis for emergency physicians
Retrieved from: https://www.pocus101.com/renal-ultrasound-made-easy-step-by-step-guide/
References:
- Sharbaugh A, Morgan Nikonow T, Kunkel G, Semins MJ. Contemporary best practice in the management of staghorn calculi. Ther Adv Urol. 2019;11:1756287219847099. Published 2019 May 9. doi:10.1177/1756287219847099
- Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.
- Sibley S, Roth N, Scott C, et al. Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J 2020; 12(1):31.
- Riddell J, Case A, Wopat R, Beckham S, et al. Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 2014; 15(1).
- Watkins S, Bowra J, Sharma P, et al. Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic. Emerg Med Australasia 2007;19(3):188-95.
- Nixon G, Blattner K, Muirhead J & Kerse N. Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management. Journal of primary health care 2018; 10(4), 324–330.
