International Journal of Surgery 32 (2016) 179e182

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.journal-surgery.net

Original research

Management of alternative pathology detected using CT KUB in

suspected ureteric colic
Mina Sarofim a, *, Adrian Teo b, Robert Wilson c
a
Bankstown Hospital, University of New South Wales, Australia
b
Bankstown Hospital Sydney, Australia
c
Bankstown and Liverpool Hospitals Sydney, Australia

h i g h l i g h t s

Two hundred and fifteen consecutive CT KUB examinations ordered in the emergency department of a tertiary-care centre for clinically suspected
ureteric colic were retrospectively reviewed.

The positive detection rate for ureteric calculi in males was 43.3% compared to a lower rate for females of 29.6% (p < 0.05). Alternative radiological
findings occurred in 72 patients (33.5%), including 15 patients (7.0%) who had clinically important alternative pathology requiring acute management.
The rate of clinically important alternative findings was significantly higher in males than females, 9.7% versus 2.5% respectively (p ¼ 0.04).

Surgical intervention was more common in patients with alternative radiological findings classified as gastrointestinal (18.2%) compared to non-
gastrointestinal (3.6%), however this did not reach statistical significance (p ¼ 0.07).

a r t i c l e i n f o a b s t r a c t

Article history: Acute flank pain is a common presentation to the emergency department (ED), and imaging studies play
Received 31 March 2016 an important role in establishing an accurate diagnosis. Computed Tomography of Kidneys, Ureters,
Received in revised form Bladder (CT KUB) has surpassed all other imaging modalities to become the gold standard in detection of
15 June 2016
ureteric calculi. The purpose of this study is to identify the range and management of alternative di-
Accepted 26 June 2016
Available online 30 June 2016
agnoses established by CT KUB in patients with suspected ureteric colic. Two hundred and fifteen
consecutive CT KUB examinations ordered in the ED of a tertiary-care centre for suspected ureteric colic
were retrospectively reviewed. This comprised of 134 male (62.3%) and 81 female (37.7%) patients with a
Keywords:
Abdominal pain
mean age of 53 years old. The positive detection rate for ureteric calculi in males was 43.3% compared to
Urolithiasis a lower rate for females of 29.6% (p < 0.05). Almost two-thirds of patients were discharged following CT
CT KUB KUB imaging, and admission rates were significantly higher in those with alternative radiological find-
Diagnosis ings (p < 0.04) Alternative radiological findings occurred in 72 patients (33.5%), including 15 patients
Emergency department (7.0%) who had clinically important alternative pathology. The rate of clinically important alternative
findings was significantly higher in males than females, 9.7% versus 2.5% respectively (p ¼ 0.04). Surgical
intervention was more common in patients with alternative radiological findings classified as gastro-
intestinal (18.2%) compared to non-gastrointestinal (3.6%), however this did not reach statistical sig-
nificance (p ¼ 0.07). In conclusion, significant alternative pathology was identified using CT KUB in 7% of
patients with suspected ureteric colic. The low rates of detection of ureteric calculi and significant
alternative pathology in female patients suggests a more thorough clinical assessment is warranted to
improve their management, prior to ordering investigations with exposure to radiation.
© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Acute flank pain is a common presentation to the emergency

department. Renal colic, or more accurately ureteric colic, is a
* Corresponding author. common cause of severe flank pain which may radiate to the groin.
E-mail address: drsarofim@gmail.com (M. Sarofim). It has a lifetime incidence of 12% and occurs three times more

http://dx.doi.org/10.1016/j.ijsu.2016.06.047
1743-9191/© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
180 M. Sarofim et al. / International Journal of Surgery 32 (2016) 179e182

frequently in males [1]. A definitive diagnosis of ureteric colic based
on clinical examination and laboratory findings is challenging, as it
may share similar presentations to other abdominal pathologies.
Imaging studies play an important role in establishing an accurate
diagnosis.
Computed Tomography of Kidneys, Ureter and Bladder (CT KUB)
was first proposed as a valuable method of evaluating ureteric colic
by Smith et al., in 1995 [2]. Since then it has surpassed other im-
aging modalities, namely intravenous urography and ultrasonog-
raphy, to become the gold standard in detection of renal and
ureteric calculi [3]. Advantages include high sensitivity and speci-
ficity, availability, test rapidity, operator independence, low radia-
tion dose, no contrast requirement and the ability to detect
alternative abdominal pathology [4e9]. The purpose of this study is
to identify the range of alternative diagnoses established by CT KUB
in patients with suspected ureteric colic, and evaluate the impact
on patient management such as disposition, further imaging and
surgical intervention.
2. Method
CT KUB cases were identified using the radiology information
system. Between March and June 2015, 215 consecutive CT KUB
examinations were ordered in the emergency department of a
tertiary-care centre. The referring doctors for these scans were
emergency department physicians in cases where ureteric colic
was suspected. Examinations were excluded if they were repeat
scans for re-evaluation of calculi. The CT KUB images were obtained
on a 64-Slice CT Scanner (General Electrical medical systems, Mil-
waukee, Wisconsin, USA) using 3 mm collimation without oral or
intravenous contrast.
Radiology department CT reports were each retrospectively
reviewed by at least one specialist radiologist for evidence of uri-
nary tract calculi, as well as alternative radiological findings. Pa-
tients with alternative radiological findings were subdivided into
clinically important or incidental. Clinically important findings
were defined as those which required acute management or
directly accounted for the patient's symptoms. Incidental findings
were those of no clinical significance or may require deferred
treatment but were unlikely to account for the presenting symp-
toms. Alternative findings were also classified as gastrointestinal or
non-gastrointestinal. Electronic medical records for all patients
were reviewed to determine management following CT KUB im-
aging, specifically discharge disposition, subsequent imaging and
surgical intervention.
The data were analysed using SPSS version 22 (SPSS Inc, Chi-
cago, IL, USA). The chi-square test was used to compare the rate of
findings between categorical groups. Ethics approval was obtained.
3. Results
Two hundred and fifteen consecutive CT KUB reports were ob-
tained between March and June 2015. A total of 134 male (62.3%)
and 81 female (37.7%) patients underwent CT KUB for suspected
ureteric colic in the emergency department during the data
collection period. The mean age was 53 years old (range 17e101
years).
Of the total, 82/215 patients (38.1%) were positive for ureteric
calculi. The positive detection rate in males was 43.3% (58/134)
compared to a lower rate for females of 29.6% (24/81), which was a
statistically significant difference (p < 0.05). A total of 82 alternative
radiological findings were found in 72/215 patients (33.5%), as eight
patients each had two alternative findings and one patient had
three. 57/215 patients (26.5%) had incidental findings, and 15/215
patients (7.0%) had clinically important findings requiring acute
management as listed in Table 1. Alternative findings in almost two-
thirds of patients (44/72) were classified as gastrointestinal (Fig. 1).
There were three patients (1.4%) who had both ureteric calculi and
clinically important alternative findings. The rate of clinically
important alternative findings was significantly higher in males
(13/134) than females (2/81), 9.7% versus 2.5% respectively
(p ¼ 0.04).
Almost two-thirds of patients (n ¼ 137, 63.7%) were discharged
from the emergency department following CT KUB imaging. Those
with ureteric calculi had a significantly higher discharge rate
compared to those without (72.0% versus 58.6% respectively,
p < 0.05). Admission rates were significantly higher in those with
alternative radiological findings (45.8% versus 31.5%, p < 0.04). Of
the 78 patients (36.3%) who required admission, 24 (30.8%) un-
derwent further imaging and 25 (32.1%) required surgical inter-
vention (urological and non-urological) as described in Table 2 and
Table 3 respectively.
The rate of subsequent imaging between the gastrointestinal (6/
44) and non-gastrointestinal (6/28) groups was not statistically
different (13.6% versus 21.4%, p ¼ 0.39). In patients with gastroin-
testinal alternative findings, four received abdominal ultrasound
for cholelithiasis and two received renal ultrasounds with CT KUB
findings of no calculi but cholelithiasis and diverticulosis

Table 1
Alternative radiological findings on CT KUB imaging for suspected ureteric colic. Note: Cumulative percentage exceeds 100% as nine patients had two or more alternative
radiological findings. ~n ¼ 15 patients with 16 findings as one patient had both inguinal hernia and acute cholecystitis.

Alternative radiological findings Frequency (%)

Requiring acute management (n ¼ 15/72~, 20.8%) Ventral hernia 3 (4.2)

Acute vertebral fracture 3 (4.2)
Inguinal hernia 2 (2.8)
Abdominal aortic aneurysm 2 (2.8)
Disseminated abdominal malignancy 2 (2.8)
Acute appendicitis 1 (1.4)
Acute cholecystitis 1 (1.4)
Small bowel obstruction 1 (1.4)
Transitional cell carcinoma 1 (1.4)
Incidental (n ¼ 57/72, 79.2%) Hepatic steatosis 21 (29.2)
Cholelithiasis 14 (19.4)
Mesenteric lymphadenopathy 9 (12.5)
Diverticulosis 8 (11.1)
Pericardial effusion 3 (4.2)
Cystitis 3 (4.2)
Ovarian cysts 3 (4.2)
Adnexal mass 3 (4.2)
Uterine fibroids 2 (2.8)
 M. Sarofim et al. / International Journal of Surgery 32 (2016) 179e182
Fig. 1. Flow chart illustrating patients with alternative radiological findings on CT KUB.
Table 2
Further imaging studies in patients admitted after CT KUB.
Imaging study (n ¼ 24) Frequency (%)
Renal ultrasound 9 (37.5)
Abdominal ultrasound 4 (16.7)
CT abdomen/pelvis 3 (12.5)
Spine xray 3 (12.5)
CT intravenous pyelogram 1 (4.2)
CT aortogram 1 (4.2)
Unrelated CT 3 (12.5)
respectively. In the non-gastrointestinal group, two received CT
abdomen/pelvis for transitional cell carcinoma and pericardial
effusion respectively, two received spine xrays for acute vertebral
fracture and mesenteric lymphadenopathy, one received a CT aor-
togram for abdominal aortic aneurysm and one unrelated CT (CT
brain) for vertebral fracture.
Although rate of surgical intervention was more common in
patients with alternative radiological findings classified as gastro-
intestinal (8/44) compared to non-gastrointestinal (1/28), this did
not reach statistical significance (18.2% versus 3.6%, p ¼ 0.07). Eight
patients with alternative findings classified as gastrointestinal un-
derwent a surgical intervention; five ureteric stents for calculi, two
laparotomies for small bowel obstruction and ventral hernia
respectively, and one laparoscopic appendicectomy for appendi-
citis. By comparison in the non-gastrointestinal group, only one
patient required a ureteric stent for calculi. In addition, one patient
with no alternative findings on CT KUB underwent a diagnostic
laparoscopy.
4. Discussion
Acute flank pain due to ureteric colic is a common presentation
to the emergency department. It has a lifetime incidence of 12%, the
typical patient a male aged between 30 and 60 years. Ureteric
lithiasis is a recurrent disease, as over half of these patients will
experience further episodes [10]. A provisional diagnosis of ureteric
colic is suspected after a thorough history and examination
including urinalysis, and confirmed by imaging. In the Emergency
department setting, CT KUB has overtaken all other imaging mo-
dalities in the investigation of ureteric colic, replacing intravenous
urography and ultrasonography. It is the gold standard method of
detection of renal tract calculi with both sensitivity and specificity
of 96e100%. It is rapid and readily available, which may
181
Table 3
Surgical interventions in patients admitted after CT KUB.
Surgical intervention (n ¼ 25) Frequency (%)
Ureteric stent 19 (76.0)
Laparotomy 2 (8.0)
Laparoscopy 2 (8.0)
Nephrostomy 1 (4.0)
Laser lithotripsy 1 (4.0)
significantly reduce time spent by patients in the emergency
department [11]. It does not require iodinated contrast or bowel
preparation, is operator independent, and has the ability to detect
unsuspected alternative findings as causes of flank pain [6,9,12].
Clinically important findings on CT KUB in this study was 7%.
Amongst similar previous studies, this figure ranges from 10 to 15%
with a comparable spectrum of pathology involving the genito-
urinary tract and abdominal organs such as the liver, gall bladder,
bowel and appendix [5e9,12]. In our study, based on radiological
features, cholecystitis was differentiated from cholelithiasis and
similarly diverticulitis from diverticulosis. Gynaecological findings
such as ovarian cysts, adnexal masses and fibroids were clinically
assessed in otherwise asymptomatic and pre-menopausal women
as requiring deferred management versus acute intervention.
The use of CT KUB beyond the specific evaluation of urinary tract
calculi, so called ‘indication creep’, has been demonstrated previ-
ously with alternative pathology detection rates as high as 45% [13].
To reduce indication creep, Nadeem et al. [12] have proposed an
algorithm for ordering CT KUB in patients presenting with flank
pain. A CT KUB is suggested if there is a history of ureteric calculi, or
in the presence of lower urinary tract symptoms, flank tenderness
or microscopic haematuria. In the remainder of patients with flank
pain, ultrasound and xray should be first line investigations, with a
CT KUB performed only if these produce equivocal findings. Whilst
a useful guide, the sensitivity and specificity of such an approach
are not prospectively validated. The modest rate of non-urological
emergencies in this study and the small number of general surgi-
cal procedures required, suggests low indication creep and appro-
priate use of CT KUB imaging at this facility.
The difference in detection rate across studies is partially
accounted for by the definition of ‘clinically relevant’ versus ‘truly
incidental’ pathology. A second, and perhaps more powerful vari-
able in the rate of alternative findings is the clinician's underlying
suspicion of correctly diagnosing ureteric calculi. One recent study
compared urolithiasis detection rates across different specialties,
182 M. Sarofim et al. / International Journal of Surgery 32 (2016) 179e182
which was significantly higher among urologists (67%) and ED
physicians (67%) compared to other specialists (43%). Conversely,
detection of alternative pathology was significantly lower among
urologists (12%) compared to ED physicians (18%) and other spe-
cialists (24%) [6]. More recent studies report a lower yield of
ureteric calculi and clinically important alternative findings in fe-
male patients [14,15]. This was also the case in the present study. A
more thorough clinical assessment is warranted in female patients
to avoid investigations involving potential radiation exposure.
This study revealed that patients with alternative radiological
findings were more likely to require admission from the emergency
department. The most common subsequent imaging request was a
renal tract ultrasound, followed by abdominal investigation with
ultrasound and CT. There was no statistical difference in rates of
imaging studies between gender groups, nor between gastroin-
testinal and non-gastrointestinal findings. In the non-
gastrointestinal group, it appears that CT KUB findings are used
to direct which form of subsequent imaging is required.
Other than urological procedures, surgical management of pa-
tients with alternative findings comprised either laparotomy or
laparoscopy and was not influenced by gender. Alternative findings
classified as gastrointestinal had a surgical intervention rate
(including urological and non-urological procedures) five times
higher than those with non-gastrointestinal findings. This was
clinically but not statistically different. No patients required both
further imaging and surgical intervention. This suggests CT KUB
imaging provided adequate information to proceed with surgery in
both urological and intra-abdominal pathology.
To date, there are no studies which evaluate the disposition and
management of patients with alternative pathology detected by CT
KUB imaging. The limitations of this study may be overcome in
future through analysis of a larger sample size to examine indica-
tion creep and provide statistical significance of trends observed in
our subgroup analysis. Additionally, radiological findings should be
confirmed clinically or histologically where possible.
5. Conclusion
CT KUB imaging is the gold standard investigation in suspected
ureteric colic. The incidence of clinically important alternative
findings in this study was 7%, with males demonstrating signifi-
cantly higher rates compared to females. Patients with alternative
radiological findings were more likely to require admission. Non-
urological surgical interventions were limited to laparotomy or
laparoscopy. The low yield of both ureteric calculi and clinically
important alternative findings in female patients suggests a more
thorough clinical assessment is warranted in this population.
Ethical approval
Ethics approval obtained from “South Western Sydney Local
Health District (SWSLHD) Research and Ethics Office”. HREC refer-
ence: LNR/15/LPOOL/466.
Sources of funding
None.
Author contribution
Dr Mina Sarofim MD.

Conception and clinical question formation.

Identification of suitable cases.

Data collection and entry.

Statistical analysis.

Presentation of findings (including drafting publications/
presentations).
Dr Adrian Teo MBBS FRACS.

Conception and clinical question formation.

Statistical analysis.

Editing of publications/presentations.
A/Prof Robert Wilson MBBS BSC FRACS.

Conception and clinical question formation.

Overall supervision of project and troubleshooting.

Statistical analysis.

Editing of publications/presentations.
Conflicts of interest
None.
Guarantor
Dr Mina Sarofim MD.
References
[1] A. Trinchieri, Epidemiology of urolithiasis: an update, Clin. Cases Miner. Bone
Metab. 5 (2) (2008) 101e106.
[2] R.C. Smith, A.T. Rosenfield, K.A. Choe, K.R. Essenmacher, M. Verga,
M.G. Glickman, et al., Acute flank pain: comparison of non-contrast-enhanced
CT and intravenous urography, Radiology 194 (3) (1995) 789e794.
[3] F. Ahmed, A.M. Zafar, N. Khan, Z. Haider, M.H. Ather, A paradigm shift in
imaging for renal colic e is it time to say good bye to an old trusted friend? Int.
J. Surg. 8 (3) (2010) 252e256.
[4] N.A. Ahmad, M.H. Ather, J. Rees, Unenhanced helical computed tomography in
the evaluation of acute flank pain, Int. J. Urol. Off. J. Jpn. Urol. Assoc. 10 (6)
(2003) 287e292.
[5] H. Hoppe, R. Studer, T.M. Kessler, P. Vock, U.E. Studer, H.C. Thoeny, Alternate
or additional findings to stone disease on unenhanced computerized tomog-
raphy for acute flank pain can impact management, J. Urol. 175 (5) (2006)
1725e1730 discussion 30.
[6] M. Nadeem, M.H. Ather, A. Jamshaid, S. Zaigham, R. Mirza, B. Salam, Rationale
use of unenhanced multi-detector CT (CT KUB) in evaluation of suspected
renal colic, Int. J. Surg. 10 (10) (2012) 634e637.
[7] F.U. Chowdhury, S. Kotwal, G. Raghunathan, T.M. Wah, A. Joyce, H.C. Irving,
Unenhanced multidetector CT (CT KUB) in the initial imaging of suspected
acute renal colic: evaluating a new service, Clin. Radiol. 62 (10) (2007)
970e977.
[8] D.S. Katz, M. Scheer, J.H. Lumerman, B.C. Mellinger, C.A. Stillman, M.J. Lane,
Alternative or additional diagnoses on unenhanced helical computed to-
mography for suspected renal colic: experience with 1000 consecutive ex-
aminations, Urology 56 (1) (2000) 53e57.
[9] M.H. Ather, K. Faizullah, I. Achakzai, R. Siwani, F. Irani, Alternate and incidental
diagnoses on noncontrast-enhanced spiral computed tomography for acute
flank pain, Urol. J. 6 (1) (2009) 14e18.
[10] A. Trinchieri, F. Ostini, R. Nespoli, F. Rovera, E. Montanari, G. Zanetti,
A prospective study of recurrence rate and risk factors for recurrence after a
first renal stone, J. Urol. 162 (1) (1999) 27e30.
[11] E.M. Rekant, C.L. Gibert, F.L. Counselman, Emergency department time for
evaluation of patients discharged with a diagnosis of renal colic: unenhanced
helical computed tomography versus intravenous urography, J. Emerg. Med.
21 (4) (2001) 371e374.
[12] N.A. Ahmad, M.H. Ather, J. Rees, Incidental diagnosis of diseases on un-
enhanced helical computed tomography performed for ureteric colic, BMC
Urol. 3 (2) (2003).
[13] M.Y. Chen, R.J. Zagoria, H.S. Saunders, R.B. Dyer, Trends in the use of unen-
hanced helical CT for acute urinary colic, AJR Am. J. Roentgenol. 173 (6) (1999)
1447e1450.
[14] T.C. Hall, J.A. Stephenson, A. Rangaraj, K. Mulcahy, A. Rajesh, Imaging protocol
for suspected ureteric calculi in patients presenting to the emergency
department, Clin. Radiol. 70 (3) (2015) 243e247.
[15] K. Patatas, Does the protocol for suspected renal colic lead to unnecessary
radiation exposure of young female patients? Emerg. Med. J. 27 (5) (2010)
389e390.