Old-Fashioned Image

Contributed by readers • Edited by Sheldon Jacobson, MD

A 32-year-old woman entered the emergency department (ED) with a chief complaint of sudden onset of severe abdominal pain. The patient had been awakened by the pain, which she described as diffuse, mid-abdominal, and in the right lower quadrant. There was a dull quality to the pain interspersed with colicky episodes. Although nauseated, the patient had not vomited. She also reported feeling "feverish." She had had a normal bowel movement earlier that day and denied any urinary symptoms.

The patient calculated that she was in the middle of her menstrual cycle, and denied vaginal bleeding or dyspareunia. She had had two pregnancies resulting in two live births, was sexually active, and was not using birth control. Four years prior to this visit she had been treated for breast cancer with lumpectomy, radiation, and chemotherapy. She was not taking any medications or herbal remedies and was following no special dietary regimen.

On physical examination, the patient was in acute distress. Her vital signs were as follows: temperature, 100.8° F; pulse, 110 and regular; and blood pressure 100/65 mm Hg. Pulse oximetry on room air showed 100% saturation. Cardiopulmonary findings were normal. Bowel sounds were present and her abdomen was nondistended but tender in the right lower quadrant and the periumbilical region. Rectal and pelvic examinations were negative.

The patient had a white blood count of 12,200; hemoglobin and platelet counts were normal. The urine pregnancy test was negative. Urine dip was positive for blood only. Microscopic examination of the urine showed 4 to 5 white blood cells and many red blood cells per high-power field. The obstruction series was interpreted as showing no active disease.

At this point, the leading diagnoses were appendicitis, right-sided diverticulitis, and nephrolithiasis. The patient was started on antibiotics and intravenous hydration. A "stone" computed tomography (CT) scan was obtained and was interpreted as "no stone seen." An ultrasound examination of the lower abdomen showed a small amount of fluid in the pelvis and numerous small ovarian cysts. The appendix was not visualized.

After a surgical consultant evaluated the patient, his impression was that she had appendicitis, with the inflamed retrocecal appendix "plastered" against the ureter. The patient was admitted and given small amounts of morphine. Laparoscopic abdominal exploration was scheduled for early the next afternoon. The following morning, the patient was still in distress. An abdominal CT scan with intravenous and oral contrast medium was performed. This study was equivocal, as one radiologist thought that there was fat stranding around the appendix, a positive sign of appendicitis. However, the senior radiologist on duty thought that the study appeared normal.

As a tie-breaker, the surgeon ordered an "old-fashioned" intravenous pyelogram (IVP). In the rapid-sequence early phase, there was some delay in the appearance of dye on the right side as well as a delay in emptying of the right ureter. A tiny stone was finally visualized at the ureterovesical junction. The patient was sent home on analgesics and did well without any further intervention.
 

DISCUSSION

This instructive case supports the old adage "all that glitters is not gold." The glitter in this instance came from an early paper lauding the sensitivity and specificity of the stone CT scan. Much hype ensued, calling for the new technique to replace the standard IVP. Note that this patient had not only a stone CT scan, but also an abdominal ultrasound, an obstruction series, and an enhanced abdominal CT—certainly not a productive use of resources. An IVP early in this case would have spared the patient radiation exposure and the discomfort of multiple studies.

As new diagnostic modalities are developed and introduced, one has to understand how to integrate them within the algorithms for evaluating patients with abdominal pain. I think the utility of the stone CT scan has been oversold because it is easier to perform than an IVP and it avoids the use of intravenous contrast material. It can visualize larger, especially calcified stones, as well as hydroureter and hydronephrosis. The IVP, on the other hand, can visualize the site of obstruction, often the stone itself, and tell us definitively whether the calcific density is in the retroperitoneum or the renal collecting system of the U-V junction. It can also help us determine whether there is complete obstruction of the ureter or an anatomic abnormality of the collecting system. In suspected nephrolithiasis, there is a distinct role for the IVP in the work-up and management of some patients who have a nondiagnostic stone CT scan or for whom it is critical to determine the degree of obstruction.