Presentation
Sudden onset right-sided abdominal pain, tender all over the right side. ? cholecystitis, ? appendicitis
Patient Data
There is an obstructing right-sided calculus at the vesicoureteric junction, causing hydronephrosis of the right kidney and a dilated ureter. Right perinephric fat stranding is noted, as well as a small quanity of free fluid arond the right ureter in the retroperitoneum. This may represent change due to inflammation, but a contained urine leak is also possible. There is delayed enhancement of the right kidney when compared to the left.
The standard local protocol following diagnosis of an obstructing ureteric stone is to acquire an abdominal x-ray, in order to determine whether or not the stone can be seen on AXR and therefore AXR used as the modality for follow-up.
The abdominal x-ray shows a contrast filled bladder, obstructing the view of the ureteric calculus. The study has effectively produced an intravenous urogram image, with contrast filling an obstructed right-sided collecting system. There is normal handling and excretion of contrast from the left kidney.
Case Discussion
Ordinarily, in cases of suspected ureteric calculi, a non-contrast CT of the kidneys, ureters and bladder is performed. However, in this case, the clinical presentation was thought to be suggestive of cholecystitis or appendicitis, so a contrast CT was requested. The reduced enhancement of the right kidney compared to the left is indicative of obstructive uropathy. A delayed phase study may have helped to confirm whether the retroperitoneal fluid is due to a contained urine leak or just as a consequence of inflammation. The abdominal x-ray was performed soon after the contrast CT, at which time a large portion of the contrast had been excreted by the left kidney and into the bladder, with contrast also filling the obstructed right collecting system and ureter, obstructing any possible view of the right VUJ calculus. This presents an important learning point. It is important to use clinical reasoning to decide on the next step or investigation, rather than rigidly following a set protocol.
Case uploaded with the assistance of Dr Vikas Shah.
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