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Flank pain and fever
1. Flank pain and fever
A Case Discussion of Clinical Integration of POCUS
Free Open-Access Medical Education in Point of Care
Ultrasound
Produced by Pitt IM POCUS
2. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Case wrap-up
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
3. Case info
65 m w hx of BPH, kidney stones, in ED w fevers/chills/N/V/back pain. Dx acute pyelo,
possible stone
Prior dx of kidney stones on CT (6-8 mm, unknown type), managed medically. Has
intermittent L flank pain. Last 2 days - f/c/n/v/back pain.
T 38.6 HR 98 BP 154/88 SpO2 99% UA: 1+ blood, 3+ LE, WBC TNTC +L CVA and suprapubic
tenderness WBC 18 Cr 1.6 (baseline 1.3)
Pt admitted with a diagnosis of acute pyelonephritis and possible kidney stones and started
on ceftriaxone. Foley was placed with difficulty but has drained 200 cc in the few minutes
since placement
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
4. Group Poll
It is 8PM. What would be your approach to imaging?
-if POCUS unavailable
-we will assume radiology staff not in house overnight, but could be called in
No imaging needed now
Renal US in AM
CT A/P in AM
CT A/P stat
5. Results of Twitter Poll
It is 8PM. What would be your approach to imaging?
-if POCUS unavailable
-we will assume radiology staff not in house overnight, but could be called in
No imaging needed now
Renal US in AM
CT A/P in AM
CT A/P stat
6. Decision to Perform POCUS
Note the variation in approach to imaging (when POCUS unavailable) based on the poll
currently. Probably need imaging (CT) but varying opinions on urgency.
Prior to performing POCUS , is is important emphasize the idea of the "POCUS question" i.e
what are we asking on POCUS, and will the answer help us? Some considerations
• Is the exam literature-based as a point-of-care study
• How would each possible finding change mgmt More on this later
A decision should be made to perform POCUS when it can help answer a focused question
and guide management
7. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Case wrap-up
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
12. POCUS interpretation
Point-of-Care Ultrasound
Performed MM/DD/YY
L kidney: Mild to moderate left hydronephrosis. Distended L ureter w possible stone at PUJ.
R kidney: No hydronephrosis seen
Bladder: Foley in decompressed bladder. Small stones in bladder.
13. POCUS interpretation
L kidney: Mild to mod left hydro (absence of color flow helps confirm). Distended
L ureter w possible stone at PUJ.
15. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Case wrap-up
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
17. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
18. Hospital Course
These POCUS findings, in this clinical setting, led to a dx of obstructive
urolithiasis with infection.
CT A/P was performed, which confirmed ureter dilation and mild-mod left
hydronephrosis. Interestingly, no stones were seen on CT.
Urine cx grew E. coli (pan-sensitive)
Urology was consulted and performed cystoscopy/ureteroscopy, which did
reveal a stone in the mid-distal ureter. The stone was extracted and noted to be
~1 cm calcium oxalate stone. Infection subsequently resolved with abx
treatment
19. Learning Points
1) When to obtain imaging in a pt with acute pyelo?
2) How do we grade hydronephrosis on POCUS?
3) How sensitive and specific is POCUS for hydronephrosis?
4) Is POCUS useful to r/o stone?
5) How do we integrate POCUS findings to affect dx in mgmt in this case?
20. 1) When to obtain imaging in a pt with acute pyelo?
In general, imaging indicated if no response to therapy (>48-72 hrs) or
complicating factor present ex: history of stone disease,
immunocompromised (see tables from ACR appropriateness criteria)
https://acsearch.acr.org/docs/69489/Narrative
21. 1) When to obtain imaging in a pt with acute pyelo?
22. 1) When to obtain imaging in a pt with acute pyelo?
23. 2) How do we grade hydronephrosis on POCUS
http://www.thepocusatlas.com/hydro-and-obstruction
24. 3) How sensitive/specific is POCUS for hydronephrosis?
• POCUS for hydronephrosis performed by IM residents had sensitivity
of >90% and specificity of > 90%
(https://www.ncbi.nlm.nih.gov/pubmed/24154905 ).
• Another study in the ED found sensitivity 86% for any hydronephrosis
and 66% specificity (next slide)
• 95% specificity for moderate or greater hydronephrosis
• Tip: Note that hydronephrosis may not be seen on initial exam (CT or
US) due to low UOP. May be worth hydrating and reassessing on
POCUS several hours later if clinical concern for obstruction persists.
25.
26. 4) Is POCUS useful for ruling out a stone?
• The simple answer – No
• Review of ED POCUS for nephrolithiasis: sensitivity ~70%, specificity ~75%
https://journalfeed.org/article-a-day/2018/pocus-for-kidney-stone-be-
careful
• However, negative POCUS scans have been associated with low rates of
stone-related adverse events (0.4%) in ED patients
https://www.nejm.org/doi/full/10.1056/nejmoa1404446
27. 5) How do we integrate POCUS findings in this case?
28. 5) How do we integrate POCUS findings in this case?
See helpful algortithm from
UpToDate here on
approach to acute
complicated UTI in the
inpatient setting
29. Case wrap-up
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
30. Take home points
• In a patient with pyelonephritis and any concern for obstruction or stone
disease, POCUS can be useful to determine whether or not hydronephrosis
(and thus, obstruction) is present.
• Hydronephrosis may not be seen on initial exam (CT or US) due to low
UOP. May be worth hydrating and reassessing on POCUS several hours
later if clinical concern for obstruction persists.
• POCUS can look for stones, but has low sensitivity and specificity and
should not be used to rule out the present of a stone.
• Remember to be clear on what exactly you are asking on POCUS, and how
possible findings will impact your approach in the practical setting.
31. Want to dive deeper into this case, or see more cases?
This case was presented by Pitt IM POCUS on twitter in May 2019. Follow this
link to see the full thread, including comments and discussion from the POCUS
MedTwitter community. We thank the MedTwitter community for
contributions to this thread.
Please follow us at @PittIMPOCUS
Follow this link for other case presentations
Any questions, please contact
Michelle Fleshner – mfleshner301@gmail.com
Steve Fox – stevefox00@gmail.com
32. This is free, open access medical education. You may download, share, modify,
and use freely when used for medical education.
Patient confidentiality is the priority in these cases, so details may be left out
or modified to prevent identification. An effort is made to maintain the
educational quality.
33. References/Additional Reading
• American College of Radiology Appropriateness Criteria. Acute
Pyelonephritis (ACR)
• UpToDate – Acute Complicated UTI (Hooton)
• Grading of Hydronephrosis (The POCUS Atlas)
• POCUS for ruling out kidney stones (Clay Smith)
• Ultrasound vs CT for Supected Nephrolithiasis (Smith-Bindman et al, NEJM)
• Sensitivity and Specificity of POCUS for hydronephrosis (Ultrasound GEL)
• Internal Medicine Resident POCUS for Hydronephrosis (Caronia et al, JUM)
