Spontaneous rupture of the renal pelvis due to an obstructing ureteral calculus diagnosed by point-of-care ultrasound
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A 37-year-old man presented to the emergency department with left flank pain and vomiting. Bedside ultrasound performed by the treating emergency physician revealed left-sided hydronephrosis and perinephric fluid, suggesting a rupture of the renal pelvis. Urinary sonography revealed an absent left ureteral jet, suggesting left ureteral obstruction. Treatment was initiated and a non-contrast computed tomography scan confirmed the initial ultrasound findings.
KeywordsEmergency ultrasound Critical ultrasound Calyceal rupture Urinoma Hydronephrosis
A 37-year-old man with no prior medical history presented to the emergency department (ED) 4 h after the onset of acute left flank pain and vomiting. He denied fever, diarrhea, dysuria, or trauma. His temperature was 98.2°F, pulse 104/min, respirations 18/min, blood pressure 142/78 mm Hg, and his room air oxygen saturation was 98%. His physical examination was remarkable for left costovertebral angle tenderness. His abdomen was soft and non-tender without rebound or guarding. A mid-stream urinalysis showed 0–2 red blood cells/high powered field.
Results and discussion
Rupture of the renal pelvis with extravasation of urine into the perinephric and/or retroperitoneal space is a rare condition most often resulting from trauma , but also associated with obstructing ureteral calculi, or compression of the ureter by pregnancy , tumor or retroperitoneal fibrosis . Flank and abdominal pain are the most common presenting symptoms, and ultrasonography and computed tomography (CT) are the initial diagnostic modalities of choice. Serial ultrasound exams may demonstrate enlargement of the perinephric fluid collection  that may prompt urologic intervention. Symptoms can also be relatively mild, however, and as in our case, resolve without the need for urgent urologic intervention.
Patients with flank and upper abdominal pain have a broad differential diagnosis, including many life-threatening entities, such as acute cholecystitis, pancreatitis, intestinal obstruction, mesenteric ischemia, aortic dissection, and aortic aneurysm. The ability to rapidly diagnose a rupture of the renal collecting system using point-of-care sonography can be of great assistance in the evaluation of these patients, and can affect the choice of subsequent diagnostic and therapeutic strategies.
Conflict of interest
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