Hydronephrosis and free fluid identified by point-of-care ultrasound leads to diagnosis.

Abstract

A 64-year-old man with a history of hypertension presented for evaluation of sudden-onset, right lower quadrant abdominal pain radiating to the right flank with associated non-bloody, non-bilious emesis. He denied dysuria, hematuria, fevers, chills, history of similar symptoms, or previous abdominal surgeries. On physical examination, he was afebrile and hypertensive to 189/113, with vitals otherwise within normal limits. He appeared uncomfortable, with moderate right upper and right lower quadrant tenderness with mild guarding but no costovertebral angle tenderness. Point-of-care ultrasound was performed, which identified moderate hydronephrosis with associated free fluid surrounding the right kidney, concerning for obstruction and collecting system rupture (Figure 1). A contrasted computed tomography of the abdomen and pelvis confirmed high-grade obstruction attributed to 5-mm calculus within the proximal ureter causing dilatation of the ureter with hydronephrosis and perinephric fluid (Figure 2). Findings were consistent with calyceal rupture, resulting in urology consult. The urology team took the patient to the operating room for ureteral stenting, antibiotics, and staged ureteroscopy and lithotripsy. Spontaneous rupture of the renal pelvis is a rare but critical diagnosis in patients with acute abdomen.1 A retrospective review found that 74% of cases were attributed to ureteric stones; less common causes included benign or malignant extrinsic ureteric compression, pelvic–ureteric junction and vesico–ureteric junction obstruction, bladder outlet obstruction, and iatrogenic disease.2 Treatment is tailored to the cause and is often managed conservatively with antibiotics but may require urologic intervention.3 Ultrasound is a helpful tool in identifying abnormalities consistent with calyceal rupture, which include hydronephrosis and perinephric free fluid.