Emerg Radiol (2017) 24:81–86

DOI 10.1007/s10140-016-1443-9

REVIEW ARTICLE

Imaging of flank pain: readdressing state-of-the-art

Priyanka Jha 1 & Brian Bentley 1 & Spencer Behr 1 & Judy Yee 1,2 & Ronald Zagoria 1

Received: 5 August 2016 / Accepted: 5 September 2016 / Published online: 10 September 2016
# American Society of Emergency Radiology 2016

Abstract Pain resulting from renal and ureteral stones is a staggering 1 million Americans visit the emergency depart-
common cause for patients presenting in the acute setting. ment for flank pain resulting from obstructive
Since the late 1990s, computed tomography (CT) has been nephrourolithiasis [1]. Approximately, half a million of these
the initial imaging method of choice to evaluate patients with will undergo imaging with non-contrast computed tomogra-
suspected ureteral stones; however, concerns regarding both phy (CT) [2]. Estimated lifetime prevalence for kidney stone
radiation dose and cost-effectiveness have prompted investi- disease is approximately 7 % for women and 13 % for men [1]
gations into a different imaging algorithm. Studies utilizing and appears to be continuously increasing with lifestyle
ultrasound have provided evidence indicating that it may be changes and better diagnostic tools [2, 3].
a more appropriate first step, with selective use of CT in se- Patients presenting with severe acute onset flank pain usually
lected cases, in the diagnostic work-up. Techniques have undergo additional evaluation with imaging to determine the pre-
evolved with low-dose CT, dual-energy CT, and magnetic cise etiology. The optimal imaging work-up should be dependent
resonance urography emerging as useful in imaging of renal on the clinical context and the specifics of each patient. Multiple
colic patients. This manuscript reviews the current literature factors play a role in the most appropriate imaging when evalu-
on state-of-the-art imaging for acute flank pain and proposes a ating suspected urolithiasis. A clinical scoring scheme has been
new imaging algorithm in the evaluation of patients with acute developed in the emergency medicine literature, acronymed
flank pain and suspected ureteral stones. STONE [4]: sex, timing, origin (race), nausea/vomiting, and
erythrocytes (urine red blood cells). This calculates a risk quotient
Keywords Renal stone . Low-dose CT . Ultrasound . MRI . for obstructive nephroureterolithiasis and the need for further
Pregnancy . Imaging protocol . STONE score imaging in these patients. While initial data from applying
STONE criteria suggested that imaging could be deferred in
lower-risk patients, recent data has questioned whether CT imag-
ing can be avoided in the current practice setting [5]. This man-
Clinical background uscript provides an analysis of available imaging techniques to
evaluate the patients presenting with acute flank pain in the emer-
Ureteral stones are a frequent cause for emergency room gency department, and an imaging algorithm is proposed (Fig. 1).
visits, which results in substantial health care costs. A

* Priyanka Jha Conventional imaging with non-contrast CT

[email protected]
CT remains the most commonly ordered modality to image
1
Department of Radiology and Biomedical Imaging, University of
suspected nephrolithiasis in the acute setting [6, 7]. This offers
California, San Francisco, 4150 Clement Street, Building 200, Rm several advantages such as high sensitivity and diagnostic ac-
2A-166, San Francisco, CA 94121, USA curacy as well as the potential to evaluate for non-urinary tract
2
San Francisco Veterans Administration Medical Center, San causes of acute flank pain and hence, provide alternate diagno-
Francisco, CA, USA ses. Large-scale meta-analysis has suggested a sensitivity of
82 Emerg Radiol (2017) 24:81–86

Fig. 1 Proposed algorithm for

imaging work-up for suspected
ureteral stone in the emergency
setting

97 % and a specificity of 95 % for the detection of obstructive Role of dual-energy CT

nephroureterolithiasis, even with low-dose computed tomogra-
phy (CT) [8]. Up to 10 % of patients being evaluated with non- Dual-energy CT (DECT) functions by scanning at two separate
contrast CT for acute flank pain will have alternative etiologies energy levels, typically 80 and 140 kV, and then utilizes the
for their symptoms [9, 10]. About half of these will have find- resulting differential photoelectric absorption to calculate an
ings requiring acute detection and management [9, 10]. attenuation ratio [14]. This technique has been shown to accu-
rately classify in vivo stone composition as verified with crys-
Alternative diagnosis tallography [15, 16]. Patients whose renal stone may not rea-
sonably be expected to pass spontaneously may benefit from
One significant advantage of performing CT in an acute set- dual-energy CT in an acute setting to guide therapy as the
ting is detecting alternative diagnosis. CT has been recom- preferred treatment may depend on the chemical composition
mended as the standard of care in evaluation of patients with of the stone. Both the decision to use shockwave lithotripsy
acute onset flank pain both by the American Urological versus percutaneous neprholithotomy for active stone removal,
Association and the Agency for Healthcare Research and as well as the optimization of a recurrence prevention regimen,
Quality [6, 11]. This recommendation is based not only on can benefit from understanding stone composition [17].
the high sensitivity of CT but also its sensitivity for detection While the role of dual-energy contrast-enhanced CT in the
of surgical emergencies. Katz et al. demonstrated that alterna- non-acute setting to analyze the composition of urinary tract
tive diagnoses for flank pain are encountered with non- stones has been well studied [18], authors have also recently
contrast CT at a rate of about 10 % [12]. These included both evaluated the use of dual-energy CT in the acute setting [19,
genitourinary as well as non-genitourinary findings, such as 20]. They proposed calculation of virtual non-contrast images
adnexal masses, pyelonephritis, genitourinary obstruction at to evaluate for stone disease, while the contrast-enhanced portion
multiple locations, perinephric hemorrhage, renal cell carcino- of the study will adequately evaluate alternative intra-abdominal
ma, colonic pathology, appendicitis, small bowel disease, cho- pathology. Chen et al. demonstrated that split bolus DECT could
lecystitis, pancreatitis, amongst others [12]. However, due to be used to calculate virtual non-contrast images for renal stones.
the methodological concerns of this study, it has been claimed Using this method, they reported overall sensitivity of stone
that the authors may have possibly overestimated the preva- detection to be 87.5 % in virtual unenhanced images, compared
lence of alternative diagnosis. Moore et al. performed a similar to non-contrast images. Omitting the unenhanced scan as a part
study in patients with flank or back pain in the absence of of this protocol reduced the mean radiation dose from 15.6 to
pyuria and again demonstrated 10 % incidence of alternative 6.7 mSv [19, 20]. While radiation dose has been a concern with
diagnosis, although only about 3 % of these were truly emer- dual-energy CT, recent studies have demonstrated that a reduced
gent findings [9]. Recent studies have indeed demonstrated radiation dosage can be achieved by lowering the tube current by
that in otherwise healthy, young patients (less than 50 years as much as 38 % without compromising diagnosis [18].
of age) without urinary tract infection or trauma, the risk of
dangerous alternative diagnoses is likely quite low [13]. This Radiation dose from computed tomography
is also the population most vulnerable to radiation given their
young age and the possibility of repeated imaging in the fu- In recent years, the debate over dose issues and the public
ture. Even with repeat visits, symptomatic relief and medical awareness of radiation exposure has become more prevalent.
expulsive therapy was felt to be sufficient and not requiring Despite its increased sensitivity for diagnosing urolithiasis,
inpatient treatment. Authors have also suggested that non- CT delivers ionizing radiation to the patient. A recent report
resolution of pain in the ER after supportive therapy can be from the American College of Radiology National Radiology
used as a possible criterion to guide CT imaging [13]. Data Registry examined over 49,000 renal colic protocol CT
Emerg Radiol (2017) 24:81–86 83

examinations [21]. This large review of the Dose Index performed by Westphalen et al. evaluating the National
Registry found the overall mean institutional dose-length Hospital Ambulatory Medical Care Survey (NHAMCS) data-
product (DLP) was 746 mGycm (effective dose, 11.2 mSv), base reflected a tenfold increase in the incidence of CT utili-
with a range of 307–1497 mGycm (effective dose, 4.6– zation without an associated increase in incidence of
22.5 mSv) for mean DLPs. Only 10 % of institutions reviewed nephroureterolithiasis, diagnosis of significant alternative di-
kept the DLP to 400 mGycm (effective dose, 6 mSv) or less in agnoses, or hospital admissions [25]. In the face of such in-
at least 50 % of their patients. formation, the role of CT in actually changing patient man-
As federal and state regulators continue to scrutinize the use agement and the overutilization of CT in the emergent setting
of medical radiation, practices have adapted their protocols and has been questioned. Hence, other modalities have been stud-
upgraded their CT scanners to implement reduced-dose tech- ied as an alternative to CT in the acute setting.
niques. Protocols for renal colic and suspected urolithiasis have
been targeted as an area for significant dose savings [22]. In
general, CT scans with an effective dose of 3 mSv or less have Ultrasound
been considered low dose [22]. Comparative evaluation of stan-
dard versus low-dose techniques for patients with renal colic Studies have evaluated the role for ultrasound for the initial
has yielded encouraging results. A study utilizing low-dose CT assessment of acute flank pain. One recent article published in
in patients with body mass index (BMI) <30 demonstrated a the New England Journal of Medicine [26] supports using
sensitivity of 95 % and a specificity of 97 % for detecting ultrasound as an initial imaging modality for acute onset flank
ureteral calculi, and was 86 % sensitive for detecting calculi pain. The data comes from a multicenter comparative effec-
<3 mm [23]. The modified protocol in this study applied a tube tiveness trial performed by Bindman et al. evaluating point-of-
current ≤30 mAs for these non-obese patients. Despite this and care ultrasonography in the emergency department, ultraso-
multiple other publications, which have similar results for low- nography performed by a radiologist, and abdominal CT.
dose scans, reduced-dose renal protocol CT is used infrequently The randomized trial, composed of 2759 patients, compared
in the USA, and institutional variation is substantial [22]. each group’s cumulative radiation exposure, number of seri-
Risks of ionizing radiation for the doses typically adminis- ous adverse events, return emergency department visits, hos-
tered are difficult to quantify. Extrapolation of the linear no- pitalizations, and diagnostic accuracy [26]. The number of
threshold model has been used to help evaluate the biologic serious adverse events amongst the three groups ranged
impact of these exposures. Radiation-associated cancer risk 10.8–12.4 % and was not significantly different (p value =
for effective doses in the ranges described for renal stone 0.50). Secondary outcomes of pain scores, hospital admis-
protocols has been estimated to be approximately one addi- sions, and emergency department readmissions also did not
tional cancer per 1000 CT examinations over a lifetime, when significantly differ among the groups. Some of the patients
averaging patient age and sex [22, 24]. It has been estimated initially evaluated by ultrasound (40.7 % of patient’s in the
that the risk of fatal cancer is 0.05 % (1 in 2000) for 10 mSv of point-of-care ultrasonography group and 27.0 % of the pa-
ionizing radiation [24]. The risks for each individual patient tient’s in the radiology ultrasound group) did eventually un-
can vary significantly depending on factors such as habitus, dergo additional imaging with a CT scan, and therefore, their
age, and frequency of repeat scans. cumulative radiation dose was not zero yet still significantly
Patients with urinary tract stone disease are likely candidates less than the CT group. This supports the idea that ultrasound
for repeat imaging, hence raising concerns for increased risk of should be performed as a screening study in the acute setting
cancer induction. Radiation dose reduction with iterative recon- eliminating radiation exposure for the majority of patients,
struction (IR) techniques has been evaluated by Andrabi et al. without changing patient outcomes and morbidity. However,
[11]. Three vendor techniques, namely, ASIR, iDOSE, and there have been some concerns regarding the reference stan-
SAFIRE, were compared with conventional filtered back pro- dard utilized by the study. The reference standard used was
jection (FBP), and significantly higher subjective and objective reported passage or surgical removal of a stone, which is an
measurements of image noise were found in FBP examinations imperfect standard [27]. Additionally, the study was not de-
compared with dose-modified iterative reconstruction exami- signed or powered to compare sensitivity or specificity of
nations. Compared to FBP, radiation dose was lower for all the ultrasonography versus CT [26]. Also, ultrasound may not
three IR techniques but within similar range to each other [11]. depict the stone itself, which may lead to management issues,
While aggressively dose-reduced studies performed with radi- where in the stone size plays a major role [28].
ation doses in the range of 1 mSv detect stones larger than The sensitivity for ultrasound detection of urolithiasis is
3 mm, these scans underperform in the detection of stones operator-dependent and has been reported to range between
smaller than this size [12]. 12 and 98 % [29–32]. The wide range may reflect varying
The rationale for non-contrast CT in the acute setting is still levels of experience for sonographers and whether the studies
actively debated. In addition to radiation concerns, a study are performed by radiologists or sonographers.
84 Emerg Radiol (2017) 24:81–86

colic, is argued to be definitive for urolithiasis [35].

Ultrasound also requires a longer time to perform compared
to CT.
Ultrasonography as a first test for suspected urolithiasis gen-
erating renal colic has been widely supported in Europe. The
2015 European Association of Urology Urolithiasis Guideline
Panel published guidelines recommending ultrasound be the pri-
mary diagnostic imaging tool partly due to factors of radiation
and cost [36]. A proposed clinical algorithm for suspected renal
colic, which begins with bedside ultrasound and stratifies patients
on degree of hydronephrosis, allowed for discharge of up to 50 %
of patients with no further imaging in the emergency department.
After 2 months, these patients demonstrated no serious adverse
effects [37]. In Europe, radiologists themselves perform ultra-
sounds whereas in North America, the sonographers perform
ultrasounds under a radiologist’s supervision. Allowing for dif-
ferences in practice patterns, the European experience should be
translatable to a North American setting as well.
There is indeed a subset of patients with small renal stones
that do not develop hydronephrosis. This subset may remain
undiagnosed with the ultrasound only approach, and hence,
ultrasound is an imperfect imaging modality in this situation
[28]. However, a review of urology literature indicates that
Fig. 2 15-year-old girl presenting with right flank pain and history of even patients with severe hydronephrosis may not suffer per-
recurrent nephrolithiasis. T2-weighted coronal MR image demonstrates manent damage to the kidneys until 2–4 weeks after initial
right hydronepehrosis. A 1.2-cm hypointensity is seen in distal right
ureter representing an obstructing UVJ calculus
insult and therefore, may not require further emergent imaging
or inpatient management [37, 38]. This data suggest that ul-
trasonography is a better imaging alternative than CT in the
Ultrasonography has limited ability to visualize stones less acute setting for appropriately selected patients suspected to
than 3 mm; however, it can reliably detect stones greater than have urolithiasis.
5 mm [29]. Fortunately, approximately 70 % of stones equal to
or less than 5 mm are expected to pass spontaneously [33, 34].
The location of stones can affect sonographic detection.
Stones in the mid ureter are more difficult to identify often Magnetic resonance imaging
due to the presence of overlying bowel gas. Larger body hab-
itus may also limit detection of stones. A secondary finding of While ultrasound and CT are expected to remain the mainstays
hydronephrosis, which can be effectively diagnosed with ul- for renal colic imaging, magnetic resonance imaging (MRI)
trasound, in a patient with classic signs and symptoms of renal may serve a role in select patients. Primarily, MRI is usually

Fig. 3 33-year-old pregnant woman presenting with left flank pain. a hydronephrosis of pregnancy. b Axial T1-weighted image demonstrates
Coronal T2-weighted images demonstrate bilateral hydronephrosis. No edematous pancreatic head and body with ductal dilation (arrow) sugges-
obstructing stone or lesions were identified, consistent with physiologic tive of pancreatitis
Emerg Radiol (2017) 24:81–86 85

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