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Imaging of flank pain: readdressing state-of-the-art

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Abstract

Pain resulting from renal and ureteral stones is a common cause for patients presenting in the acute setting. Since the late 1990s, computed tomography (CT) has been the initial imaging method of choice to evaluate patients with suspected ureteral stones; however, concerns regarding both radiation dose and cost-effectiveness have prompted investigations into a different imaging algorithm. Studies utilizing ultrasound have provided evidence indicating that it may be a more appropriate first step, with selective use of CT in selected cases, in the diagnostic work-up. Techniques have evolved with low-dose CT, dual-energy CT, and magnetic resonance urography emerging as useful in imaging of renal colic patients. This manuscript reviews the current literature on state-of-the-art imaging for acute flank pain and proposes a new imaging algorithm in the evaluation of patients with acute flank pain and suspected ureteral stones.

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References

  1. Pearle MS, Calhoun EA, Curhan GC, Urologic Diseases of America Project (2005) Urologic diseases in America project: urolithiasis. J Urol 173(3):848–857

    Article  PubMed  Google Scholar 

  2. Fwu CW, Eggers PW, Kimmel PL, Kusek JW, Kirkali Z (2013) Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States. Kidney Int 83(3):479–486

    Article  PubMed  PubMed Central  Google Scholar 

  3. Foster G, Stocks C, Brorofsky MS (2012) Emergency Department visits and hospital admissions for kidney stone disease, 2009: statistical brief #139. In: Healthcase Cose and Utilization Project (HCUP) Statistical Breids (Internet). Rockville (MD): Agency for Health Care Policy and Research (US); 2006 Feb-. 2009 [cited 2016 February 29th]; Available from: http://www.ncbi.nih.gov/books/NBK100827/

  4. Moore CL, Bomann S, Daniels B et al (2014) Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone—the STONE score: retrospective and prospective observational cohort studies. BMJ 348:g2191

    Article  PubMed  PubMed Central  Google Scholar 

  5. Wang RC, Rodriguez RM, Moghadassi M et al (2016) External validation of the STONE score, a clinical prediction rule for ureteral stone: an observational multi-institutional study. Ann Emerg Med 67(4):423–432.e2

    Article  PubMed  Google Scholar 

  6. Coursey CA, Casalino DD, Remer EM et al (2012) ACR Appropriateness Criteria® acute onset flank pain—suspicion of stone disease. Ultrasound Q 28(3):227–233

    Article  PubMed  Google Scholar 

  7. Teichman JM (2004) Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med 350(7):684–693

    Article  CAS  PubMed  Google Scholar 

  8. Niemann T, Kollmann T, Bongartz G (2008) Diagnostic performance of low-dose CT for the detection of urolithiasis: a meta-analysis. AJR Am J Roentgenol 191(2):396–401

    Article  PubMed  Google Scholar 

  9. Moore CL, Daniels B, Singh D, Luty S, Molinaro A (2013) Prevalence and clinical importance of alternative causes of symptoms using a renal colic computed tomography protocol in patients with flank or back pain and absence of pyuria. Acad Emerg Med Off J Soc Acad Emerg Med 20(5):470–478

    Article  Google Scholar 

  10. Ather MH, Faizullah K, Achakzai I, Siwani R, Irani F (2009) Alternate and incidental diagnoses on noncontrast-enhanced spiral computed tomography for acute flank pain. Urol J 6(1):14–18

    PubMed  Google Scholar 

  11. Fulgham PF, Assimos DG, Pearle MS, Preminger GM (2013) Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment. J Urol 189(4):1203–1213

    Article  PubMed  Google Scholar 

  12. Katz DS, Scheer M, Lumerman JH, Mellinger BC, Stillman CA, Lane MJ (2000) Alternative or additional diagnoses on unenhanced helical computed tomography for suspected renal colic: experience with 1000 consecutive examinations. Urology 56(1):53–57

    Article  CAS  PubMed  Google Scholar 

  13. Schoenfeld EM, Poronsky KE, Elia TR, Budhram GR, Garb JL, Mader TJ (2015) Young patients with suspected uncomplicated renal colic are unlikely to have dangerous alternative diagnoses or need emergent intervention. West J Emerg Med 16(2):269–275

    Article  PubMed  PubMed Central  Google Scholar 

  14. Coursey CA, Nelson RC, Boll DT et al (2010) Dual-energy multidetector CT: how does it work, what can it tell us, and when can we use it in abdominopelvic imaging? Radiographics 30(4):1037–1055

    Article  PubMed  Google Scholar 

  15. Hidas G, Eliahou R, Duvdevani M et al (2010) Determination of renal stone composition with dual-energy CT: in vivo analysis and comparison with x-ray diffraction. Radiology 257(2):394–401

    Article  PubMed  Google Scholar 

  16. Manglaviti G, Tresoldi S, Guerrer CS et al (2011) In vivo evaluation of the chemical composition of urinary stones using dual-energy CT. AJR Am J Roentgenol 197(1):W76–W83

    Article  PubMed  Google Scholar 

  17. Tiselius HG, Ackermann D, Alken P et al (2001) Guidelines on urolithiasis. Eur Urol 40(4):362–371

    Article  CAS  PubMed  Google Scholar 

  18. Wilhelm K, Schoenthaler M, Hein S et al (2015) Focused dual-energy CT maintains diagnostic and compositional accuracy for urolithiasis using ultralow-dose noncontrast CT. Urology 86(6):1097–1102

    Article  PubMed  Google Scholar 

  19. Chen CY, Hsu JS, Jaw TS et al (2015) Split-bolus portal venous phase dual-energy CT urography: protocol design, image quality, and dose reduction. AJR Am J Roentgenol 205(5):W492–W501

    Article  PubMed  Google Scholar 

  20. Chen CY, Tsai TH, Jaw TS et al (2016) Diagnostic performance of split-bolus portal venous phase dual-energy CT urography in patients with hematuria. AJR Am J Roentgenol 206(5):1013–1022

    Article  PubMed  Google Scholar 

  21. Lukasiewicz A, Bhargavan-Chatfield M, Coombs L et al (2014) Radiation dose index of renal colic protocol CT studies in the United States: a report from the American College of Radiology National Radiology Data Registry. Radiology 271(2):445–451

    Article  PubMed  Google Scholar 

  22. Hara AK, Wellnitz CV, Paden RG, Pavlicek W, Sahani DV (2013) Reducing body CT radiation dose: beyond just changing the numbers. AJR Am J Roentgenol 201(1):33–40

    Article  PubMed  Google Scholar 

  23. Poletti PA, Platon A, Rutschmann OT, Schmidlin FR, Iselin CE, Becker CD (2007) Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol 188(4):927–933

    Article  PubMed  Google Scholar 

  24. Brenner DJ, Elliston CD (2004) Estimated radiation risks potentially associated with full-body CT screening. Radiology 232(3):735–738

    Article  PubMed  Google Scholar 

  25. Westphalen AC, Hsia RY, Maselli JH, Wang R, Gonzales R (2011) Radiological imaging of patients with suspected urinary tract stones: national trends, diagnoses, and predictors. Acad Emerg Med Off J Soc Acad Emerg Med 18(7):699–707

    Article  Google Scholar 

  26. Smith-Bindman R, Aubin C, Bailitz J et al (2014) Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med 371(12):1100–1110

    Article  CAS  PubMed  Google Scholar 

  27. Luyckx F (2015) Who wants to go further has to know the past: A comment upon: Ultrasonography versus computed tomography for suspected nephrolithiasis-R. Smith-Bindman et al. N Engl J Med. 2014 Sep 18;371(12):1100-1110. World J Urol 33(10):1371–1372

    Article  PubMed  Google Scholar 

  28. Song Y, Hernandez N, Gee MS, Noble VE, Eisner BH (2015) Can ureteral stones cause pain without causing hydronephrosis? World J Urol

  29. Fowler KA, Locken JA, Duchesne JH, Williamson MR (2002) US for detecting renal calculi with nonenhanced CT as a reference standard. Radiology 222(1):109–113

    Article  PubMed  Google Scholar 

  30. Patlas M, Farkas A, Fisher D, Zaghal I, Hadas-Halpern I (2001) Ultrasound vs CT for the detection of ureteric stones in patients with renal colic. Br J Radiol 74(886):901–904

    Article  CAS  PubMed  Google Scholar 

  31. Ripolles T, Errando J, Agramunt M, Martinez MJ (2004) Ureteral colic: US versus CT. Abdom Imaging 29(2):263–266

    Article  CAS  PubMed  Google Scholar 

  32. Sheafor DH, Hertzberg BS, Freed KS et al (2000) Nonenhanced helical CT and US in the emergency evaluation of patients with renal colic: prospective comparison. Radiology 217(3):792–797

    Article  CAS  PubMed  Google Scholar 

  33. Coll DM, Varanelli MJ, Smith RC (2002) Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol 178(1):101–103

    Article  PubMed  Google Scholar 

  34. Johri N, Cooper B, Robertson W, Choong S, Rickards D, Unwin R (2010) An update and practical guide to renal stone management. Nephron Clin Pract 116(3):c159–c171

    Article  PubMed  Google Scholar 

  35. Moore CL, Scoutt L (2012) Sonography first for acute flank pain? J Ultrasound Med Off J Am Inst Ultrasound Med 31(11):1703–1711

    Google Scholar 

  36. European Association of Urology. Guidelines on urolithiasis. http://uroweb.org/guideline/urolithiasis/. Accessed 8 Sept 2016

  37. Dalziel PJ, Noble VE (2013) Bedside ultrasound and the assessment of renal colic: a review. Emerg Med J EMJ 30(1):3–8

    Article  PubMed  Google Scholar 

  38. Manthey DE, Teichman J (2001) Nephrolithiasis. Emerg Med Clin North Am 19(3):633–654, viii

    Article  CAS  PubMed  Google Scholar 

  39. Masselli G, Weston M, Spencer J (2015) The role of imaging in the diagnosis and management of renal stone disease in pregnancy. Clin Radiol 70(12):1462–1471

    Article  CAS  PubMed  Google Scholar 

  40. Wallace GW, Davis MA, Semelka RC, Fielding JR (2012) Imaging the pregnant patient with abdominal pain. Abdom Imaging 37(5):849–860

    Article  PubMed  Google Scholar 

  41. Regan F, Kuszyk B, Bohlman ME, Jackman S (2005) Acute ureteric calculus obstruction: unenhanced spiral CT versus HASTE MR urography and abdominal radiograph. Br J Radiol 78(930):506–511

    Article  CAS  PubMed  Google Scholar 

  42. Lubarsky M, Kalb B, Sharma P, Keim SM, Martin DR (2013) MR imaging for acute nontraumatic abdominopelvic pain: rationale and practical considerations. Radiographics 33(2):313–337

    Article  PubMed  Google Scholar 

  43. Bannas P, Pickhardt PJ (2015) MR evaluation of the nontraumatic acute abdomen with CT correlation. Radiol Clin N Am 53(6):1327–1339

    Article  PubMed  Google Scholar 

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Correspondence to Priyanka Jha.

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Jha, P., Bentley, B., Behr, S. et al. Imaging of flank pain: readdressing state-of-the-art. Emerg Radiol 24, 81–86 (2017). https://doi.org/10.1007/s10140-016-1443-9

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  • DOI: https://doi.org/10.1007/s10140-016-1443-9

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