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Mimics of Renal Colic: Alternative Diagnoses at Unenhanced Helical CT¹

¹ From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110. Presented as an education exhibit at the 2003 RSNA scientific assembly. Received February 9, 2004; revision requested March 4 and received April 5; accepted April 14. All authors have no financial relationships to disclose. Address correspondence to S.B. (e-mail: bhallas@mir.wustl.edu).

View larger version (177K): [in a new window]   Figure 1.  Medullary nephrocalcinosis in a 34-year-old woman with medullary sponge kidney, renal colic, and hematuria. Unenhanced helical CT scan shows several calcifications centered in the region of the medullary pyramids (arrows). No ureteral stone was found.

View larger version (149K): [in a new window]   Figure 2a.  Obstructing stone at the right ureterovesical junction in a 26-year-old woman with right flank pain. Unenhanced helical CT scans show a tiny stone located at the right ureterovesical junction (arrow in b) and secondary right hydronephrosis and perinephric stranding (arrow in a).

View larger version (153K): [in a new window]   Figure 2b.  Obstructing stone at the right ureterovesical junction in a 26-year-old woman with right flank pain. Unenhanced helical CT scans show a tiny stone located at the right ureterovesical junction (arrow in b) and secondary right hydronephrosis and perinephric stranding (arrow in a).

View larger version (149K): [in a new window]   Figure 3a.  Bilateral obstructing ureteral stones in a 36-year-old man who presented with flank pain and hematuria. (a) Unenhanced helical CT scan shows bilateral enlarged kidneys with perinephric stranding. (b, c) CT scans show distal left ureteral stones (b) and a tiny obstruction in the right ureterovesical junction (arrow in c). Note the soft-tissue rim sign (arrow in b).

View larger version (147K): [in a new window]   Figure 3b.  Bilateral obstructing ureteral stones in a 36-year-old man who presented with flank pain and hematuria. (a) Unenhanced helical CT scan shows bilateral enlarged kidneys with perinephric stranding. (b, c) CT scans show distal left ureteral stones (b) and a tiny obstruction in the right ureterovesical junction (arrow in c). Note the soft-tissue rim sign (arrow in b).

View larger version (149K): [in a new window]   Figure 3c.  Bilateral obstructing ureteral stones in a 36-year-old man who presented with flank pain and hematuria. (a) Unenhanced helical CT scan shows bilateral enlarged kidneys with perinephric stranding. (b, c) CT scans show distal left ureteral stones (b) and a tiny obstruction in the right ureterovesical junction (arrow in c). Note the soft-tissue rim sign (arrow in b).

View larger version (119K): [in a new window]   Figure 4a.  Acute pyelonephritis in a 19-year-old woman with acute left flank pain. (a) Initial unenhanced helical CT scan shows an enlarged left kidney with perinephric stranding and urothelial thickening, but no obstructing stone. (b) Contrast-enhanced CT scan shows striated enhancement of the kidney (arrow). Results of urinalysis helped confirm the presence of urinary tract infection.

View larger version (127K): [in a new window]   Figure 4b.  Acute pyelonephritis in a 19-year-old woman with acute left flank pain. (a) Initial unenhanced helical CT scan shows an enlarged left kidney with perinephric stranding and urothelial thickening, but no obstructing stone. (b) Contrast-enhanced CT scan shows striated enhancement of the kidney (arrow). Results of urinalysis helped confirm the presence of urinary tract infection.

View larger version (123K): [in a new window]   Figure 5a.  Renal abscess in a 26-year-old man with acquired immunodeficiency syndrome who presented with right flank pain. (a) Initial unenhanced helical CT scan shows no obstructing stone but demonstrates a hypoattenuating mass in the right upper pole. (b) Delayed contrast-enhanced CT scan helps confirm the presence of a cystic lesion with adjacent renal parenchymal edema (arrows). Staphylococcus aureus was seen in cultures of the aspirated specimen.

View larger version (133K): [in a new window]   Figure 5b.  Renal abscess in a 26-year-old man with acquired immunodeficiency syndrome who presented with right flank pain. (a) Initial unenhanced helical CT scan shows no obstructing stone but demonstrates a hypoattenuating mass in the right upper pole. (b) Delayed contrast-enhanced CT scan helps confirm the presence of a cystic lesion with adjacent renal parenchymal edema (arrows). Staphylococcus aureus was seen in cultures of the aspirated specimen.

View larger version (140K): [in a new window]   Figure 6a.  Complicated renal arteriovenous malformation in a 66-year-old man who presented with acute right flank pain and hematuria. (a, b) Initial unenhanced helical CT scans show a complex cystic mass of the right kidney with peripheral calcification (arrows in a) and blood within the bladder and right collecting system (b). No obstructing stone was found. Air within the bladder was secondary to Foley catheter placement. (c) Angiogram helps confirm the presence of a large arteriovenous malformation (arrows), as did the results of pathologic examination.

View larger version (141K): [in a new window]   Figure 6b.  Complicated renal arteriovenous malformation in a 66-year-old man who presented with acute right flank pain and hematuria. (a, b) Initial unenhanced helical CT scans show a complex cystic mass of the right kidney with peripheral calcification (arrows in a) and blood within the bladder and right collecting system (b). No obstructing stone was found. Air within the bladder was secondary to Foley catheter placement. (c) Angiogram helps confirm the presence of a large arteriovenous malformation (arrows), as did the results of pathologic examination.

View larger version (138K): [in a new window]   Figure 6c.  Complicated renal arteriovenous malformation in a 66-year-old man who presented with acute right flank pain and hematuria. (a, b) Initial unenhanced helical CT scans show a complex cystic mass of the right kidney with peripheral calcification (arrows in a) and blood within the bladder and right collecting system (b). No obstructing stone was found. Air within the bladder was secondary to Foley catheter placement. (c) Angiogram helps confirm the presence of a large arteriovenous malformation (arrows), as did the results of pathologic examination.

View larger version (136K): [in a new window]   Figure 7a.  Transitional cell carcinoma in a 56-year-old man who presented with gross hematuria. (a) Unenhanced helical CT scan shows a vague soft-tissue mass within the urinary bladder (arrow). (b) Delayed contrast-enhanced CT scan enables better characterization of the mass. Results of biopsy helped confirm the presence of transitional cell carcinoma.

View larger version (136K): [in a new window]   Figure 7b.  Transitional cell carcinoma in a 56-year-old man who presented with gross hematuria. (a) Unenhanced helical CT scan shows a vague soft-tissue mass within the urinary bladder (arrow). (b) Delayed contrast-enhanced CT scan enables better characterization of the mass. Results of biopsy helped confirm the presence of transitional cell carcinoma.

View larger version (160K): [in a new window]   Figure 8.  Hemorrhagic renal cell carcinoma in a 58-year-old man who presented with acute flank pain and hematuria. Unenhanced helical CT scan shows a large hemorrhagic mass within the left kidney (arrows). No obstructing stone was seen. Surgical findings helped confirm the presence of hemorrhagic renal cell carcinoma.

View larger version (154K): [in a new window]   Figure 9.  Spontaneous subcapsular hematoma in a patient with left renal colic who was receiving anticoagulants. Unenhanced helical CT scan shows a subcapsular collection with high attenuation (arrows). Contrast-enhanced CT scans (not shown) helped confirm the presence of subcapsular hematoma without a distinct underlying mass.

View larger version (155K): [in a new window]   Figure 10a.  Renal lymphoma in a 75-year-old woman who presented with left renal colic. (a) Initial unenhanced helical CT scan shows an enlarged left kidney with subcapsular soft-tissue attenuation (arrows) and an ill-defined lesion posteriorly. No obstructing stone was seen. (b) Contrast-enhanced CT scan helps confirm the presence of both subcapsular and parenchymal masses (arrows). Results of biopsy helped confirm the diagnosis of non-Hodgkin lymphoma.

View larger version (163K): [in a new window]   Figure 10b.  Renal lymphoma in a 75-year-old woman who presented with left renal colic. (a) Initial unenhanced helical CT scan shows an enlarged left kidney with subcapsular soft-tissue attenuation (arrows) and an ill-defined lesion posteriorly. No obstructing stone was seen. (b) Contrast-enhanced CT scan helps confirm the presence of both subcapsular and parenchymal masses (arrows). Results of biopsy helped confirm the diagnosis of non-Hodgkin lymphoma.

View larger version (130K): [in a new window]   Figure 11.  Emphysematous cystitis in a 62-year-old diabetic man who presented with groin pain and hematuria. Unenhanced helical CT scan shows a thick-walled urinary bladder with intraluminal and intramural air, a finding that is consistent with emphysematous cystitis. Escherichia coli was seen in a culture of the urine specimen.

View larger version (140K): [in a new window]   Figure 12.  Hemorrhagic cyst in a 24-year-old woman who presented with right-sided groin pain. Unenhanced helical CT scan shows a right adnexal cyst with high attenuation and a hematocrit level (arrow). No obstructing stone was seen. The presence of a hemorrhagic ovarian cyst was later confirmed with transvaginal US.

View larger version (147K): [in a new window]   Figure 13.  Complex ovarian mass in a 38-year-old woman who presented with right-sided groin pain. Unenhanced helical CT scan shows a cystic adnexal mass with internal septa (arrow). Analysis of the surgical specimen confirmed the diagnosis of cystadenofibroma.

View larger version (131K): [in a new window]   Figure 14.  Ruptured ectopic pregnancy in a 42-year-old woman who presented with acute right flank pain. Unenhanced helical CT scan shows a hemorrhagic mass in the right adnexa (arrow), a finding that is associated with hemoperitoneum. No obstructing stone was seen. Imaging was performed before results of a urine pregnancy test were known. The beta subunit of human chorionic gonadotropin was later found to be positive. Surgical findings helped confirm the diagnosis of ruptured ectopic pregnancy.

View larger version (136K): [in a new window]   Figure 15.  Acute appendicitis in a 30-year-old woman who presented with right flank pain. Unenhanced helical CT scan shows an enlarged thick-walled appendix with periappendiceal stranding (arrow). No obstructing stone was seen. Surgical findings helped confirm the diagnosis of acute appendicitis.

View larger version (145K): [in a new window]   Figure 16.  Acute appendicitis in a 32-year-old woman who presented with right flank pain. Unenhanced helical CT scan shows a dilated appendix, with periappendiceal stranding and appendicolith (arrows). Surgical findings helped confirm appendicitis.

View larger version (138K): [in a new window]   Figure 17.  Diverticulitis in a 42-year-old man who presented with left flank pain. Unenhanced helical CT scan shows a thick-walled colonic diverticulum associated with mesocolic fluid and inflammation (arrow). No obstructing stone was seen. The diverticulitis resolved with antibiotic therapy.

View larger version (148K): [in a new window]   Figure 18.  Cecal diverticulitis in a 40-year-old woman who presented with right flank pain. Unenhanced helical CT scan shows cecal diverticula with adjacent mesocolic fluid and inflammatory changes (arrow), findings consistent with diverticulitis.

View larger version (148K): [in a new window]   Figure 19.  Closed-loop bowel obstruction in a 70-year-old man with left flank pain. Initial unenhanced helical CT scan shows a U-shaped bowel orientation of dilated ileal loops, a finding that represents obstruction, and associated fluid in the small bowel mesentery (arrows). At exploratory surgery, necrotic bowel secondary to a closed-loop bowel obstruction was found.

View larger version (138K): [in a new window]   Figure 20.  Enteroenteric intussusception in a 38-year-old man who presented with acute left flank pain. Unenhanced helical CT scan demonstrates an intussusception in the left lower quadrant with telescoping of mesenteric vessels and fat (arrow). No obstructing stone was seen. Surgical findings helped confirm lymphoma as the lead point.

View larger version (129K): [in a new window]   Figure 21a.  Initial manifestation of Crohn disease in a 26-year-old woman who presented with right-sided groin pain. (a) Unenhanced helical CT scan shows several tethered small intestinal loops in the right lower quadrant, with findings suggestive of enteroenteric fistulas (arrow). No obstructing stone was found. (b) CT scan obtained after oral and intravenous administration of contrast material enables better delineation of the enteroenteric fistulas (arrow).

View larger version (137K): [in a new window]   Figure 21b.  Initial manifestation of Crohn disease in a 26-year-old woman who presented with right-sided groin pain. (a) Unenhanced helical CT scan shows several tethered small intestinal loops in the right lower quadrant, with findings suggestive of enteroenteric fistulas (arrow). No obstructing stone was found. (b) CT scan obtained after oral and intravenous administration of contrast material enables better delineation of the enteroenteric fistulas (arrow).

View larger version (136K): [in a new window]   Figure 22a.  Acute cholecystitis in a 36-year-old woman with right renal colic. Unenhanced helical CT scans obtained after the inadvertent administration of oral contrast material show a distended gallbladder with pericholecystic inflammation (arrows in a) and stones within the neck of the gallbladder (arrow in b). Surgical findings helped confirm the presence of acute cholecystitis.

View larger version (135K): [in a new window]   Figure 22b.  Acute cholecystitis in a 36-year-old woman with right renal colic. Unenhanced helical CT scans obtained after the inadvertent administration of oral contrast material show a distended gallbladder with pericholecystic inflammation (arrows in a) and stones within the neck of the gallbladder (arrow in b). Surgical findings helped confirm the presence of acute cholecystitis.

View larger version (147K): [in a new window]   Figure 23a.  Choledocholithiasis in a 46-year-old man who presented with right flank pain. (a) Initial unenhanced helical CT scan shows mild intrahepatic biliary ductal dilatation (arrow). No obstructing ureteral stone was found. (b) Unenhanced CT scan obtained slightly caudad to a shows high attenuation within the duct (arrow). Findings at endoscopic retrograde cholangiopancreatography helped confirm the presence of choledocholithiasis.

View larger version (149K): [in a new window]   Figure 23b.  Choledocholithiasis in a 46-year-old man who presented with right flank pain. (a) Initial unenhanced helical CT scan shows mild intrahepatic biliary ductal dilatation (arrow). No obstructing ureteral stone was found. (b) Unenhanced CT scan obtained slightly caudad to a shows high attenuation within the duct (arrow). Findings at endoscopic retrograde cholangiopancreatography helped confirm the presence of choledocholithiasis.

View larger version (138K): [in a new window]   Figure 24.  Acute alcoholic pancreatitis in a 46-year-old man with known renal stones who presented with left flank pain. Unenhanced helical CT scan shows bilateral renal calculi as well as an edematous pancreas with peripancreatic inflammation and fluid collections (arrowheads), findings that are consistent with acute pancreatitis.

View larger version (142K): [in a new window]   Figure 25.  Ruptured abdominal aortic aneurysm in a 66-year-old man who presented with acute left flank pain. Unenhanced helical CT scan shows a ruptured 8-cm abdominal aortic aneurysm with an associated large retroperitoneal hematoma (arrows).

View larger version (144K): [in a new window]   Figure 26a.  Ruptured common iliac artery aneurysm in a 68-year-old man with acute left flank pain. Unenhanced helical CT scans show a ruptured left common iliac artery aneurysm with disruption of intimal calcification (arrow in b) and a large left retroperitoneal hematoma (arrow in a).

View larger version (139K): [in a new window]   Figure 26b.  Ruptured common iliac artery aneurysm in a 68-year-old man with acute left flank pain. Unenhanced helical CT scans show a ruptured left common iliac artery aneurysm with disruption of intimal calcification (arrow in b) and a large left retroperitoneal hematoma (arrow in a).

View larger version (131K): [in a new window]   Figure 27a.  Acute type B aortic dissection in a 44-year-old man who presented with acute left flank pain. (a) Initial unenhanced helical CT scan demonstrates displaced intimal calcification within the abdominal aorta (arrow), a finding that is suggestive of aortic dissection. (b) Contrast-enhanced CT scan obtained at follow-up helps confirm the diagnosis of aortic dissection. Note the intimal flap (arrow).

View larger version (111K): [in a new window]   Figure 27b.  Acute type B aortic dissection in a 44-year-old man who presented with acute left flank pain. (a) Initial unenhanced helical CT scan demonstrates displaced intimal calcification within the abdominal aorta (arrow), a finding that is suggestive of aortic dissection. (b) Contrast-enhanced CT scan obtained at follow-up helps confirm the diagnosis of aortic dissection. Note the intimal flap (arrow).

View larger version (145K): [in a new window]   Figure 28.  Acute thrombosis of the left external iliac vein in a 40-year-old woman who presented with left-sided groin pain. Unenhanced helical CT scan shows high attenuation within an enlarged left external iliac vein (arrow) and adjacent inflammatory stranding consistent with acute venous thrombosis.

View larger version (136K): [in a new window]   Figure 29.  Acute splenic rupture in a 40-year-old woman with polycythemia vera who presented with left flank pain. Unenhanced helical CT scan shows marked splenomegaly with hemoperitoneum, a finding that is consistent with splenic rupture.

View larger version (129K): [in a new window]   Figure 30a.  Initial images of multiple myeloma in a 60-year-old man who presented with left flank pain. Unenhanced helical CT scans obtained at the level of the kidneys show a destructive lytic lesion within a lumbar vertebral body (arrow in a) and several lytic lesions within the pelvis (b), findings that are consistent with biopsy-proved multiple myeloma.

View larger version (134K): [in a new window]   Figure 30b.  Initial images of multiple myeloma in a 60-year-old man who presented with left flank pain. Unenhanced helical CT scans obtained at the level of the kidneys show a destructive lytic lesion within a lumbar vertebral body (arrow in a) and several lytic lesions within the pelvis (b), findings that are consistent with biopsy-proved multiple myeloma.