These entities warrant further imaging and/or consultation. Another complication of urolithiasis is renal calyx rupture, which secondary to extravasation of urine is suggested on ultrasound by an anechoic perinephric fluid collection. Severe hydronephrosis, especially if coupled with laboratory evidence of acute kidney injury, would raise concern for an obstructing stone. Moreover, the greater benefit of point-of-care ultrasound for this particular case is the evaluation for complicated urolithiasis. Though this patient had classic signs and symptoms of renal colic and may have been treated successfully without any imaging, the confirmatory findings with point-of-care ultrasound rapidly solidified the diagnosis for the physician and the definitive evidence was reassuring for the patient.
Thus, the absence of a ureteral jet does not define obstruction, but the presence of one helps to rule out a complete obstruction.Īs the patient’s pain was resolved after a few hours, she was discharged home, and continued to be asymptomatic at her urology clinic follow-up 10 days later. However, jets are not always visualized immediately even in healthy patients, as frequency of ureteral jets may range from seconds to minutes, and are influenced by the patient’s hydration status. A continuous low flow or absent jet may be associated with a high-grade obstruction. Ureteral jets typically flow in an anteromedial direction. To best visualize jets, the transducer is placed in a transverse position at the level of the trigone, which can be estimated by the landmarks of the seminal vesicles or mid-cervix. Ureteral jets represent urine flowing into the bladder from the ureters. The addition of color Doppler to gray-scale imaging may confirm the presence of a stone by revealing the twinkling artifact, which has been found to be more sensitive than shadowing in detecting stones. In addition they are not always associated with shadowing. These stones may be difficult to detect due to surrounding echogenic renal sinus fat, mesenteric fat, or bowel. The twinkling sign is a color Doppler artifact that appears as a rapidly alternating mixture of red and blue Doppler signals distal to strongly reflective granular surfaces, such as found on urinary stones. The addition of color Doppler revealed a twinkling sign posterior to the focus, as well as a ureteral jet from the right ureter (Fig.
The bladder was also examined, which revealed a non-shadowing, hyperechoic focus at the left ureterovesicular junction (UVJ) (Fig. A focused bedside ultrasound was performed by the emergency physician using a 5–2 MHz curvilinear array transducer (Model HD11XE, Philips, Andover, MA), which revealed mild left hydronephrosis (Fig.
The patient’s urine beta-hCG was negative and urinalysis showed no pyuria but was positive for blood. The patient had normal vital signs, and physical examination was remarkable only for mild left costovertebral angle tenderness. She denied any recent lifting or trauma, dysuria, hematuria, frequency, urgency, vaginal bleeding, or vaginal discharge. The patient had no significant past medical, surgical, or family history, and no history of similar pains in the past. The pain was described as sharp and intermittent, radiating to the left-lower quadrant of the abdomen, and was associated with nausea and vomiting. A 43-year-old female presented to the emergency department (ED) complaining of acute left flank pain for 1 day.
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