Kidney stone differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Differentiating Nephrolithiasis from other Diseases

Nephrolithiasis should be differentiated from other conditions presenting with acute flank or upper abdominal pain, hematuria, nausea and vomiting. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]

Category Disease History Signs and Symptoms Physical Examination Laboratory abnormalities
Nausea/vomiting Hematuria Location of pain Fever Tachycardia Hypotension Hypertension Anorexia Constipation Rebound abdominal tenderness Urinary frequency/Urgency/Dysuria Costovetebral angle tenderness Pelvic Examination Rectal Examination Complete Blood Count (CBC) Urinalysis BUN Creatinine Stone analysis Urine Beta- hCG Abnormal Liver Function Tests (LFTs) Serum Amylase/Lipase Abdominal/Pelvic CT scan Serum Parathyroid hormone levels (PTH)

Renal Pathology

 Nephrolithiasis + +
  • Flank/back pain radiating to groin
 - + - - +/- - - + - - - - - - -
  • Non-contrast CT scan may show stone as radiolucency
 +/-
Pyelonephritis
  • Urinary tract infection
  • Immunocompromised state (Diabetes, immunosuppressive medications)
  • Urinary tract obstruction
  • History of pyelonephritis
  • Pregnancy
  • Presence of urinary catheter, stent, nephrostomy tube
 + + (microscopic)
  • Costovertebral angle
  • Positive renal punch sign
 + + + - +/- - + + +
  • Uretheritis
  • Vaginitis
 -
  • Leukocytosis
  • Pyuria
  • Positive leukocyte esterase
 - - - -
  • Globaly decreased contrast uptake
  •  Foci from abscess pockets
 -
Renal infarct
  • Sickle cell disease or trait
  • Thrombosis
  • Trauma
  • Hypertension
  • Cardiac arrhythmia
  • Coagulopathy
  • Atherosclerosis
 + +
  • Flank pain
 + + - + - - - - - - -
  • Leukocytosis
  • Red blood cells
  • Proteinuria
 - - -
Renal papillary necrosis
  • Analgesic use (Phenacetin, acetaminophen, NSAIDs)
  • Pyelonephritis
  • Urinary tract obstruction
  • Sickle cell disease
  • Tuberculosis
  • Cirrhosis
  • Diabetes
  • Vasculitis
  • Renal vein thrombosis
 - + (microscopic)
  • Flank pain
 + +/- - + - - - + - - -
  • Bacteriuria
  • Pyuria
  • Microscopic hematuria
 - - - -
  • Blunted renal calyces
  • Contrast material–filled clefts in the renal medulla
  • Non-enhanced lesions surrounded by rings of excreted contrast material
  • Hyperattenuated medullary calcifications
 -
Renal cell carcinoma
  • Weight loss
  • History of smoking
  • Obesity
  • Von-Hippel Lindau disease
  • Night sweats
  • Malaise
  • Flank mass
 + + (microscopic)
  • Flank pain
 - - - + + +/- - - - - -
  • Anemia
  • Microscopic hemeturia
  • Renal cell casts
  • Urinary aquaporin-1 (AQP1) and adipophilin (ADFP)- proximal renal tubular cancer
 - - - -
  • Non-contrast CT:
    • Lesions are soft tissue attenuation 
    • Areas of calcification and necrosis
  • Contrast-enhanced:
    • Homogenous (small lesions) to irregular (large lesions) contrast enhancement
 -
Uretral stricture
  • Prior urinary tract surgery
  • Congenital
  • Urinary catheterization
  • Direct penile trauma
 - +/- - - - - - - - - + - - - - - - - - - - -

Gynecological Pathology

 Pelvic inflammatory disease
  • Endometritis
  • Saplingitis
  • Cesarian section
  • Septic abortion
  • Urinary tract infection
  • Tuberculosis
  • Actinomycosis
 - -
  • Right/left upper quadrant
 + + + - + - - + -
  • Cervical motion tenderness
  • Adnexal tenderness
  • Foul smelling vaginal/urtetheral discharge
 -
  • Leukocytosis
  • Bacteriuria (Neisseria gonorrhoeae or Chlamydia trachomatis, polymicrobial)
  • Pyuria
 - - - -
  • Thickening of the uterosacral ligaments
  • Haziness of the pelvic fat
  • Periovarian stranding
  • Enhancement of the adjacent peritoneum
  • Thick-walled, complex fluid collection with septa formation (abscess pockets)
 -
Ovarian torsion
  • Sudden acute pain
  • Sharp pain aggravated by walking
  • Intermittent/colicky pain
 + -
  • Unilateral poorly localized lower abdominal
 - + - - - - - - -
  • Adnexal tenderness
  • Adnexal mass
 - - - - - - - - -
  • Twisted ovarian pedicle
  • Enlarged ovary (>4.0 cm)
  • Distended pedicle
  • Possible underlying ovarian lesion
 -
Ectopic pregnancy
  • History of previous ectopic pregnancy
  • Tubal surgery
  • Intrauterine device usage
  • History of pelvic surgery
  • History of pelvic inflammatory disease
  • Sub-fertility
  • Sternous excercise
  • Increased maternal age
  • Cigarette smoking
 + -
  • Lower abdominal
  • Unilateral shoulder or neck pain (referred)
 - + - - + - + (if ruptured) + -
  • Vaginal bleeding
 -
  • Low platelet distribution width (decreased platelet activation)
  • Monocytosis
 - - - - + +/- - N/A -

Prostate Pathology

 Prostatitis
  • Bacterial infection by:
    • Ureaplasma urealyticum
    • Proteus
    • Chlamydia
    • Gonorrhea
    • E.Coli
    • Pseudomonas
    • Mycoplasma
  • Prior history of prostatitis
  • Urinary tract infection
  • Urinary catheterization
 - +
  • Perineal pain
  • Lower back pain
  • Suprapubic pain
 + + - - - - - + - -
  • Enlarged prostate
  • Rectal pain
  • Leukocytosis
  • Bacteriuria
  • Pyuria
  • Microscopic hematuria
 - - - - - - -
Prostatic cancer
  • Family history of prostate cancer (1st degree relatives)
  • Germline mutation of HOXB13 (G84E variant)
  • Black ethnicity
  • Age > 50 years
 - + - - - - - + - - + - -
  • Enlarged prostate
  • Firm and hard
 -
  • Positive prostate specific antigen (PSA)
  • High levels of TMPRSS2:ERG and PCA3
 - - - -
  • Focal areas of mass-like enhancement in the peripheral prostate
  • Calcifications
 -

Testicular Pathology

 Testicular torsion
  • Age 12 - 16 years
  • Previous history of testicular torsion
  • Family history of testicular torsion
  • Prematurity
  • Undescended testes
  • Low birth weight
 + -
  • Sudden onset unilateral testicular pain
 - + - - +/- - - +/- -
  • Absent cremasteric reflex
  • Testicle may be swollen, tender, and high-riding, with an abnormal transverse lie.
 - - - - - - - - -
  • Doppler ultrasound > CT scan for diagnosis (abscence of blood flow in the affected testis)
 -
Orchitis
  • Unprotected sexual intercourse
  • Mumps, coxsackie virus infection
  • Concurrent epididymitis
  • Congenital abnornmalities
  • Prostatitis
  • Prostatic hypertrophy or calculi
 + -
  • Abrupt onset of testicular pain
 + + - - - - - +/- -
  • Testicular swelling and tenderness
  • Normal cremasteric reflex
 -
  • Leukocytosis
 - - - - - - -
  • Ultrasound > CT scan for diagnosis (Testicular masses or swollen testicles with hypoechoic and hypervascular areas)
 -

Abdominal Pathology

 Cholecystitis
  • Female gender
  • Obesity
  • Pregnancy (increased progesterone promotes biliary stasis)
  • Rapid weight loss
  • Oral contraceptive use
  • Increasing age
  • Total parenteral nutrition
 + -
  • Right upper abdominal quadrant pain
  • Flank pain
 + + - - + - - - - - -
  • Leukocytosis
 - - -
  • Bilirubin (pigment) stones
  • Cholesterol stones
 - + +/-
  • Gallbladder distention
  • Wall thickening
  • Mucosal hyperenhancement,
  • Pericholecystic fat stranding or fluid
  • Gallstones
 -
Appendicitis
  • Male gender
  • Adolescents
  • Diet low in fiber and high in refined carbohydrates
  • History of appendicitis in first degree relatives
 + -
  • Pain in umblical area
  • Radiating to right lower abdominal quadrant
 + + - - + - + +/- - - -
  • Leukocytosis
 - - - - - - + (if perforation)
  • Larger than 6 mm in diameter,
  • Appendiceal wall thickening
  • Wall enhancement after contrast media infusion
  • Inflammatory fat stranding
  • Phlegmon
  • Free fluid
  • Free air bubbles
  • Abscess
  • Adenopathy
 -
Diverticulitis
  • Diverticulosis
  • Low fiber diet
  • Old age
 + -
  • Left lower abdominal quadrant
 + + - - + + - - - -
  • Bleeding
  • Rectal mass
  • Rectal tenderness
  • Leukocytosis
 - - - - - - + (if perforation)
  • Colonic wall thickening (wall thickness is greater than 3 mm on the short axis of the lumen)
  • Pericolic fat stranding
 -
Abdominal aortic aneurysm
  • Hypertension
  • Cigarette smoking
  • Pulsatile abdominal mass
 - -
  • Epigastric pain
  • Deep boring pain in the back
  • May radiate to flank
 - + + - - - + (if rupture) - - - - - - - - - - - -
  • Ultrasound more sensitive than CT scan
  • CT scan may accurately predict the aneurysmal size
  • Helical CT has faster scanning time (30 to 60 seconds) and the ability to obtain all images in one breath hold
 -
Portal vein thrombosis
  • Mutated JAK2 V617F
  • Anti-phospholipid syndrome
  • Paroxysmal nocturnal hemoglobinuria
  • Homocysteinuria
  • Factor V Leiden
  • Prothrombin mutation G20210A
  • Protein C or S deficiency
  • Oral contraceptive use
  • Cirrhosis
  • Pregnancy and post-partum
 + -
  • Abdominal or lumbar pain
 + + + - + - + (if bowel ischemia or infarction-secondary to extension of thrombus to superior mesenteric artery) - - -
  • Hematochezia
  • Anemia
  • Thrombocytopenia
 - - - - - + + (if bowel infarction, perforation)
  • On non-contrast CT:
    • Hyperdense thrombus
  • On contrast CT
    • Non-enhancing defect of bland thrombus
    • Tumor thrombus exhibits enhancement
Duodenal ulcer
  • Pain relieved by intake of food
  • Helicobacter pylori infection
  • Tobacco smoking
  • NSAID use
  • EtOH use
  • Older age
  • Female gender
  • Family history of duodenal ulcers
 + -
  • Epigastric pain
 + + + - - - + (if perforation) - - -
  • Melena
  • Anemia
 - - - - + (if bowel perforation)
  • Endoscopy > CT scan for diagnosis
 -
Ischemic colitis
  • Age > 60 years
  • Hemodialysis
  • Hypertension
  • Hypoalbuminemia
  • Diabetes mellitus
 + -
  • Acute-onset abdominal cramping 
 + + + (if necrosis and sepsis) + + + + (if transmural necrosis) - - -
  • Hematochezia
  • Leukocytois (if necrosis)
  • Anemia (if perforation and bleeding)
 - - - - + (if bowel perforation)
  • Bowel wall thickening
  • Thumbprinting
  • Pericolonic stranding with or without ascites.
  • Double halo or target sign 
  • Submucosal edema or hemorrhage
  • Pneumatosis coli (if infarction)
 -

References

  1. ↑ Worcester EM, Coe FL (June 2008). "Nephrolithiasis". Prim. Care. 35 (2): 369–91, vii. doi:10.1016/j.pop.2008.01.005. PMC 2518455. PMID 18486720.
  2. ↑ Semins MJ, Matlaga BR (February 2010). "Medical evaluation and management of urolithiasis". Ther Adv Urol. 2 (1): 3–9. doi:10.1177/1756287210369121. PMC 3126068. PMID 21789078.
  3. ↑ Venkatesh L, Hanumegowda RK (June 2017). "Acute Pyelonephritis - Correlation of Clinical Parameter with Radiological Imaging Abnormalities". J Clin Diagn Res. 11 (6): TC15–TC18. doi:10.7860/JCDR/2017/27247.10033. PMC 5535453. PMID 28764263.
  4. ↑ Garin EH, Olavarria F, Araya C, Broussain M, Barrera C, Young L (July 2007). "Diagnostic significance of clinical and laboratory findings to localize site of urinary infection". Pediatr. Nephrol. 22 (7): 1002–6. doi:10.1007/s00467-007-0465-7. PMID 17375337.
  5. ↑ Lee DG, Jeon SH, Lee CH, Lee SJ, Kim JI, Chang SG (April 2009). "Acute pyelonephritis: clinical characteristics and the role of the surgical treatment". J. Korean Med. Sci. 24 (2): 296–301. doi:10.3346/jkms.2009.24.2.296. PMC 2672131. PMID 19399273.
  6. ↑ Saeed K (2012). "Renal infarction". Int J Nephrol Renovasc Dis. 5: 119–23. doi:10.2147/IJNRD.S33768. PMC 3437809. PMID 22969301.
  7. ↑ Mahamid M, Francis A, Abid A, Awawde M, Abu-Elhija O (2014). "Embolic renal infarction mimicking renal colic". Int J Nephrol Renovasc Dis. 7: 157–9. doi:10.2147/IJNRD.S59745. PMC 4011809. PMID 24812524.
  8. ↑ Korzets Z, Plotkin E, Bernheim J, Zissin R (October 2002). "The clinical spectrum of acute renal infarction". Isr. Med. Assoc. J. 4 (10): 781–4. PMID 12389340.
  9. ↑ Brix AE (2002). "Renal papillary necrosis". Toxicol Pathol. 30 (6): 672–4. doi:10.1080/01926230290166760. PMID 12512867.
  10. ↑ Eknoyan G, Qunibi WY, Grissom RT, Tuma SN, Ayus JC (March 1982). "Renal papillary necrosis: an update". Medicine (Baltimore). 61 (2): 55–73. PMID 7038374.
  11. ↑ Ng CS, Wood CG, Silverman PM, Tannir NM, Tamboli P, Sandler CM (October 2008). "Renal cell carcinoma: diagnosis, staging, and surveillance". AJR Am J Roentgenol. 191 (4): 1220–32. doi:10.2214/AJR.07.3568. PMID 18806169.
  12. ↑ Ares Valdés Y, Amador Sandoval B, Morales JC, Alonso Domínguez F, Carballo Velásquez L, Fragas Valdés R, Shou Rodríguez A (September 2004). "[The role of CT scan in the diagnosis of renal cell carcinoma]". Arch. Esp. Urol. (in Spanish; Castilian). 57 (7): 737–42. PMID 15536955.
  13. ↑ Leveridge MJ, Bostrom PJ, Koulouris G, Finelli A, Lawrentschuk N (June 2010). "Imaging renal cell carcinoma with ultrasonography, CT and MRI". Nat Rev Urol. 7 (6): 311–25. doi:10.1038/nrurol.2010.63. PMID 20479778.
  14. ↑ Tritschler S, Roosen A, Füllhase C, Stief CG, Rübben H (March 2013). "Urethral stricture: etiology, investigation and treatments". Dtsch Arztebl Int. 110 (13): 220–6. doi:10.3238/arztebl.2013.0220. PMC 3627163. PMID 23596502.
  15. ↑ Mundy AR, Andrich DE (January 2011). "Urethral strictures". BJU Int. 107 (1): 6–26. doi:10.1111/j.1464-410X.2010.09800.x. PMID 21176068.
  16. ↑ Maciejewski C, Rourke K (February 2015). "Imaging of urethral stricture disease". Transl Androl Urol. 4 (1): 2–9. doi:10.3978/j.issn.2223-4683.2015.02.03. PMC 4708283. PMID 26816803.
  17. ↑ Soper DE (August 2010). "Pelvic inflammatory disease". Obstet Gynecol. 116 (2 Pt 1): 419–28. doi:10.1097/AOG.0b013e3181e92c54. PMID 20664404.
  18. ↑ Paavonen J (October 1998). "Pelvic inflammatory disease. From diagnosis to prevention". Dermatol Clin. 16 (4): 747–56, xii. PMID 9891675.
  19. ↑ Lee MH, Moon MH, Sung CK, Woo H, Oh S (December 2014). "CT findings of acute pelvic inflammatory disease". Abdom Imaging. 39 (6): 1350–5. doi:10.1007/s00261-014-0158-1. PMID 24802548.
  20. ↑ Eggert J, Sundquist K, van Vuuren C, Fianu-Jonasson A (October 2006). "The clinical diagnosis of pelvic inflammatory disease--reuse of electronic medical record data from 189 patients visiting a Swedish university hospital emergency department". BMC Womens Health. 6: 16. doi:10.1186/1472-6874-6-16. PMC 1624808. PMID 17054801.
  21. ↑ Washington C, Carmichael JC (December 2012). "Management of ischemic colitis". Clin Colon Rectal Surg. 25 (4): 228–35. doi:10.1055/s-0032-1329534. PMC 3577613. PMID 24294125.
  22. ↑ Chawla YK, Bodh V (March 2015). "Portal vein thrombosis". J Clin Exp Hepatol. 5 (1): 22–40. doi:10.1016/j.jceh.2014.12.008. PMC 4415192. PMID 25941431.
  23. ↑ "Imaging of Abdominal Aortic Aneurysms - - American Family Physician".
  24. ↑ Aggarwal S, Qamar A, Sharma V, Sharma A (2011). "Abdominal aortic aneurysm: A comprehensive review". Exp Clin Cardiol. 16 (1): 11–5. PMC 3076160. PMID 21523201.
  25. ↑ Destigter KK, Keating DP (August 2009). "Imaging update: acute colonic diverticulitis". Clin Colon Rectal Surg. 22 (3): 147–55. doi:10.1055/s-0029-1236158. PMC 2780264. PMID 20676257.
  26. ↑ Hameed AM, Lam VW, Pleass HC (February 2015). "Significant elevations of serum lipase not caused by pancreatitis: a systematic review". HPB (Oxford). 17 (2): 99–112. doi:10.1111/hpb.12277. PMC 4299384. PMID 24888393.
  27. ↑ "Imaging for Suspected Appendicitis - - American Family Physician".
  28. ↑ "CT Findings of Acute Cholecystitis and Its Complications : American Journal of Roentgenology : Vol. 194, No. 6 (AJR)".
  29. ↑ "Epididymitis and Orchitis: An Overview - - American Family Physician".
  30. ↑ Jia JB, Houshyar R, Verma S, Uchio E, Lall C (January 2016). "Prostate cancer on computed tomography: A direct comparison with multi-parametric magnetic resonance imaging and tissue pathology". Eur J Radiol. 85 (1): 261–267. doi:10.1016/j.ejrad.2015.10.013. PMID 26526901.
  31. ↑ Bratt O, Lilja H (January 2015). "Serum markers in prostate cancer detection". Curr Opin Urol. 25 (1): 59–64. doi:10.1097/MOU.0000000000000128. PMC 4315142. PMID 25393274.
  32. ↑ "Prostate Cancer (Prostate Carcinoma): Symptoms - National Library of Medicine - PubMed Health".
  33. ↑ Eskicioğlu F, Özdemir AT, Turan GA, Gür EB, Kasap E, Genç M (November 2014). "The efficacy of complete blood count parameters in the diagnosis of tubal ectopic pregnancy". Ginekol. Pol. 85 (11): 823–7. PMID 25675798.
  34. ↑ Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW (October 2011). "Diagnosis and management of ectopic pregnancy". J Fam Plann Reprod Health Care. 37 (4): 231–40. doi:10.1136/jfprhc-2011-0073. PMC 3213855. PMID 21727242.

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