0100 3984 RB 51 06 0VII PDF

Editorial
Ureterolithiasis and the quest for rational use of diagnostic

imaging methods
Ureterolitíase e a busca pelo uso racional dos métodos de diagnóstico por imagem
Jorge Elias Jr.1
Over the past 30 years, there has been an increase in the protocols for this common clinical entity, allowing more rational
number of cases of urolithiasis at health care facilities in the allocation of resources and more rapid decision-making regard-
United States, that number doubling between 1990 and 2010; ing the most appropriate treatment for such patients.
consequently, urolithiasis now ranks among the ten most com- Obviously, decisions regarding the initial imaging method
mon complaints in emergency rooms(1).That growth was five for the investigation of lumbar pain suspected to be caused by
times greater than was that in the overall number of emer- urolithiasis should take into consideration variables and param-
gency room visits, in general, which shows the importance of eters other than BMI, such as age, gender, the imaging methods
this condition in the emergency setting(1). Although there are available, and the expertise of the medical staff at the facility
differences among countries in terms of ethnicities, dietary in question. One question that arises in this context is whether
habits, and climate, there seems to be a trend toward a global room exists for ultrasound as an exclusive method for the evalu-
increase in the incidence of urolithiasis, with a proportional in- ation of ureteral calculi in symptomatic patients. In other words,
crease among females, although that incidence continues to is the information provided by a positive ultrasound result in the
be higher in white men between 45 and 64 years of age(1). detection of the calculus sufficient? In that context, the funda-
The three major risk factors for urolithiasis in the general mental findings are the position of the calculus, its size, and
population are obesity, diabetes mellitus, and the use of dietary the presence or absence of other calculi. The position and size
calcium supplementation(1). Obesity has a direct negative impact of the calculus have an influence on the immediate treatment,
on the accuracy of abdominal ultrasound, as has been shown whereas the presence or absence of other calculi has an influ-
in studies of conditions such as appendicitis(2,3). Sauvain et al.(3) ence on decisions regarding systemic treatment for the preven-
found that ultrasound findings were inconclusive for the diagnosis tion of additional calculi, given that urolithiasis recurs in only
of appendicitis in 42% of patients with a body mass index (BMI) approximately 22% of clinically treated cases, compared with
≥ 25 kg/m2, compared with 6% of those with a BMI < 25 kg/m2, more than 90% of untreated cases. The indication for conser-
suggesting that computed tomography should be the method of vative clinical treatment, using drugs that facilitate the expul-
choice for patients who are overweight or obese. Keller et al.(2) sion of ureteral stones, is still a controversial issue. However,
also demonstrated a high (49%) rate of nondiagnostic ultrasound after the publication of the first randomized studies, more than
examinations for appendicitis in overweight patients. ten years ago, it has become relatively well established and is
In an article published in the previous issue of Radiologia routinely used when the calculus is > 0.5 cm in diameter and
Brasileira, Nery et al.(4) showed that the use of ultrasound can there is no indication for emergency intervention, such as pyelo-
delay the diagnosis and treatment of suspected ureteral calculi nephritis, obstruction of a single kidney, and intractable pain(5).
for patients with a BMI > 27 kg/m2, because such patients will It is of note that ultrasound can overestimate the size of a ure-
subsequently need to be evaluated by multidetector computed teral calculus, especially for calculi with a diameter ≤ 0.5 cm, al-
tomography (MDCT). The authors also demonstrated that for though it is expected that such stones are likely to be eliminated
each unit increase in BMI there was a 16% increase in the rate spontaneously, without the need for pharmacological therapy(5).
of false-positive ultrasound results. Although there have long It is also noteworthy that there have been refinements to the
been indications that ultrasound has low accuracy in the ab- ultrasound technique that facilitate the evaluation of urolithia-
dominal evaluation of overweight individuals, the Nery et al. sis, such as the evaluation of the twinkling artifact(6,7), ureteral
article(4) is the first to provide such solid evidence regarding ul- jet examination using Doppler ultrasound(8,9), and detection/
trasound evaluation in suspected cases of ureterolithiasis. This characterization of hydronephrosis caused by a ureteral calcu-
is a valuable information for the construction of clinical care lus(10), findings that can have an impact on diagnostic accuracy
and can facilitate case-by-case treatment. Therefore, there is
1. Associate Professor in the Division of Imaging Sciences and Medical Phys- the possibility that the performance of ultrasound, which is an
ics, Head of the Department of Internal Medicine, Ribeirao Preto Medical School innocuous and effective method in comparison with MDCT, will
of University of Sao Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil. E-mail: jejunior@
fmrp.usp.br.. improve. Although MDCT is a more accurate method(11), it car-
https://orcid.org/0000-0002-1158-1045. ries the risks inherent to the use of ionizing radiation. To our
Radiol Bras. 2018 Nov/Dez;51(6):VII–VIII VII

0100-3984 © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem http://dx.doi.org/10.1590/0100-3984.2018.51.6e2
knowledge, there have been no randomized studies comparing morbid obesity to have an ultrasound window that allows the
ultrasound and MDCT in the evaluation of ureterolithiasis. How- diagnostic examination to be performed. In that context, it is
ever, in 2014, Smith-Bindman et al.(12) conducted a randomized important that the diagnostic impression be given after the ex-
multicenter study involving 2759 patients for nephrolithiasis amination and not as a prejudgment. That is certainly one of the
evaluation. The authors showed that, for nephrolithiasis, there factors that explains the great variability across studies evaluat-
were no differences among the ultrasound performed by radiolo- ing the accuracy of ultrasound.
gists, the point-of-care ultrasound performed by the emergency It should be borne in mind that, for the pediatric popula-
room physician, and MDCT, in terms of high-risk diagnoses tion and for pregnant women, ultrasound is the main method
with complications, serious adverse events, pain scores, return for the investigation of urolithiasis, being followed by magnetic
emergency room visits, or hospitalization rates, the levels of ra- resonance imaging if necessary(15–17). Finally, when MDCT is in-
diation exposure being lower in the patients in whom the inves- dicated, there is evidence that strongly supports a recommen-
tigation began with ultrasound. A concern that should always be dation for the use of a protocol with an up to 85% reduction in
present is the unnecessary use of MDCT in general, but more the radiation dose(13,18).
specifically when the number of exams per patient is large, as REFERENCES
can occur in cases of chronic pain and multiple episodes of ure- 1. Fwu CW, Eggers PW, Kimmel PL, et al. Emergency department visits, use of im-
teral stone passage(13). aging, and drugs for urolithiasis have increased in the United States. Kidney Int.
2013;83:479–86.
It is important to note that there is a validated clinical pre-
2. Keller C, Wang NE, Imler DL, et al. Predictors of nondiagnostic ultrasound for
diction system, known as the Sex, Timing, Origin, Nausea, Eryth- appendicitis. J Emerg Med. 2017;52:318–23.
rocytes (STONE) score, that can identify patients with a high 3. Sauvain MO, Tschirky S, Patak MA, et al. Acute appendicitis in overweight pa-
tients: the role of preoperative imaging. Patient Saf Surg. 2016;10:13.
probability of uncomplicated ureteral calculi, who could benefit
4. Nery DR, Costa YB, Mussi TC, et al. Epidemiological and imaging features
from the institution of treatment without undergoing MDCT(14). that can affect the detection of ureterolithiasis on ultrasound. Radiol Bras.
However, the evaluation of patients on a case-by-case basis, 2018;51:287–92.
5. Dahm P, Hollingsworth JM. Medical expulsive therapy for ureteral stones-stone
considering the daily clinical routine, together with patient ex- age medicine. JAMA Intern Med. 2018;178:1058–9.
pectations and perceptions of the quality of medical care (in- 6. Abdel-Gawad M, Kadasne RD, Elsobky E, et al. A prospective comparative study
cluding whether or not a medical test is requested), adds im- of color Doppler ultrasound with twinkling and noncontrast computerized to-
mography for the evaluation of acute renal colic. J Urol. 2016;196:757–62.
portant variables to the equation of care for suspected cases of 7. Mitterberger M, Aigner F, Pallwein L, et al. Sonographic detection of renal and
urolithiasis. In addition, the confidence provided by visualization ureteral stones. Value of the twinkling sign. Int Braz J Urol. 2009;35:532–9;
discussion 540–1.
of the calculus by the requesting physician, compared with the
8. de Bessa J Jr, Dénes FT, Chammas MC, et al. Diagnostic accuracy of color Dop-
blind confidence in the outcome of an ultrasound examination, pler sonographic study of the ureteric jets in evaluation of hydronephrosis. J
also affects individualized care in patient-centered medicine. In Pediatr Urol. 2008;4:113–7.
9. Heidenreich A, Desgrandschamps F, Terrier F. Modern approach of diagnosis
that sense, the study conducted by Nery et al.(4) provides impor-
and management of acute flank pain: review of all imaging modalities. Eur Urol.
tant information regarding current clinical practice; that is, what 2002;41:351–62.
occurs in patients who undergo MDCT, which was used as a 10. Daniels B, Gross CP, Molinaro A, et al. STONE PLUS: evaluation of emergency
department patients with suspected renal colic, using a clinical prediction
reference standard for determining the accuracy of ultrasound. tool combined with point-of-care limited ultrasonography. Ann Emerg Med.
It is of note that the ultrasound and MDCT results were both 2016;67:439–48.
negative in 31.2% of the cases; that is, one third of the patients 11. de Souza LR, Goldman SM, Faintuch S, et al. Comparison between ultrasound
and noncontrast helical computed tomography for identification of acute ure-
probably did not need to undergo MDCT after ultrasound. There- terolithiasis in a teaching hospital setting. Sao Paulo Med J. 2007;125:102–7.
fore, when the ultrasound results are negative, the BMI is < 27 12. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed
tomography for suspected nephrolithiasis. N Engl J Med. 2014;371:1100–10.
kg/m2, and there are no signs of hydronephrosis, clinical follow-
13. Elkoushy MA, Andonian S. Lifetime radiation exposure in patients with recurrent
up is probably the best course of action. nephrolithiasis. Curr Urol Rep. 2017;18:85.
The abovementioned considerations indicate only the 14. Moore CL, Bomann S, Daniels B, et al. Derivation and validation of a clinical pre-
diction rule for uncomplicated ureteral stone—the STONE score: retrospective
complexity of this theme, in which the consensus regarding the and prospective observational cohort studies. BMJ. 2014;348:g2191.
use of imaging methods in population-based health care has 15. Cheng PM, Moin P, Dunn MD, et al. What the radiologist needs to know about
room to evolve. One major counterpoint is the fact that when urolithiasis: part 1—pathogenesis, types, assessment, and variant anatomy. AJR
Am J Roentgenol. 2012;198:W540–7.
we receive a request for ultrasound to investigate urolithiasis 16. Ellison JS, Merguerian PA, Fu BC, et al. Follow-up imaging after acute evalua-
in a non-hospital setting, a situation that is very common, the tions for pediatric nephrolithiasis: trends from a national database. J Pediatr
Urol. 2018. pii: S1477-5131(18)302017-9. [Epub ahead of print].
examination should usually be performed following best prac-
17. Jha P, Bentley B, Behr S, et al. Imaging of flank pain: readdressing state-of-the-
tices, with the expectation that we will be able to resolve the art. Emerg Radiol. 2017;24:81–6.
case, regardless of the BMI of the patient in question. Although 18. Moore CL, Daniels B, Singh D, et al. Ureteral stones: implementation of a re-
duced-dose CT protocol in patients in the emergency department with mod-
patient BMI has a direct effect on the diagnostic accuracy of erate to high likelihood of calculi on the basis of STONE score. Radiology.
abdominal ultrasound, it is not uncommon for patients with 2016;280:743–51.
VIII Radiol Bras. 2018 Nov/Dez;51(6):VII–VIII

0100 3984 RB 51 06 0VII PDF

Uploaded by

Copyright:

Available Formats

0100 3984 RB 51 06 0VII PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

0100 3984 RB 51 06 0VII PDF

Uploaded by

Copyright:

Available Formats

Editorial

Ureterolithiasis and the quest for rational use of diagnostic

Jorge Elias Jr.1

Radiol Bras. 2018 Nov/Dez;51(6):VII–VIII VII

VIII Radiol Bras. 2018 Nov/Dez;51(6):VII–VIII

You might also like