Two striking cases of urinary tract calculi were recently examined in the Radiologic Clinic of The Hospital of the University of Pennsylvania. In each patient a survey film of the abdomen showed multiple smooth, round shadows arranged in groups, but in neither the position nor of the configuration usually attributable to urinary tract calculi. In one instance intravenous urography was sufficient to establish the diagnosis; in the other, intravenous urography and retrograde pyelography were required. Case I: I. R., white male, aged 23, was first seen in the Gastro-intestinal Clinic for symptoms suggestive of gallbladder disease. For two years he had complained of epigastric fullness, belching, and pain across the upper abdomen occurring about one hour after meals and persisting for several hours. The pain was not relieved by food. There was no nausea or vomiting; no changes had been observed in the stools, and there were no complaints referable to the urinary tract, such as frequency, dysuria, or hematuria. Except for childhood diseases the patient had never been ill so far as he or his parents could recollect. Physical examination was completely negative, and the patient appeared to be in excellent health. Hemoglobin 90 per cent, white blood count 5,900, blood urea nitrogen 12 mg. per 100 c.c., normal P.S.P. test. Routine chemical and microscopic urinalysis showed normal findings. The patient was first referred to the Department of Radiology for cholecystography. This revealed a functioning gallbladder. On one of the roentgenograms, a 14 × 17-inch film, a large mass was observed occupying the left lower quadrant within which there were abnormal areas of density (Fig. 1). Roentgenograms in various positions demonstrated the mobile character of these densities. Because the symptoms were essentially gastro-intestinal and since no mass could be palpated in the left lower abdominal quadrant, a barium meal examination and subsequently a barium enema study were performed. These were negative for intrinsic disease but showed displacement of the small intestine and descending and sigmoid colon to the right and anteriorly (Fig. 2). Intravenous urography demonstrated absence of kidney function on the left side (Fig. 3A). A retrograde study finally revealed a huge hydronephrotic sac in this region containing multiple calculi (Fig. 3B). At operation the roentgen diagnosis was confirmed and following nephrectomy and a transient bronchopneumonia the patient has been symptomless and well. Examination of the gross surgical specimen revealed hydronephrosis, nephrolithiasis, and a congenital polar vessel causing constriction of the pelvis at the ureteropelvic junction. The stones were composed of calcium oxalate. The pathological process had evidently been present for a long time in this case, which serves to emphasize how relatively silently a urinary tract lesion may develop to considerable proportions before giving rise to symptoms.
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Dec 1, 1987
Jorn Thiede 
Open Access