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CT Abdomen & Pelvis - Visual Interpretation

Important disclaimer: This is a visual assessment of photographs of printed CT films - not a reading of the original DICOM data. Subtle findings, small lesions, and precise densitometry cannot be reliably assessed from photographs. This does NOT replace an official radiologist's report.

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Study Details

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Findings by Region

1. Liver

• Normal size and contour visible on upper axial and coronal slices.
• No grossly obvious large hypoattenuating (dark) or hyperattenuating (bright) focal masses visible at photograph resolution.

2. Spleen

• Normal size, homogeneous density.
• No gross splenomegaly or focal lesions identified.

3. Kidneys

• Both kidneys appear symmetric in size and position.
• No gross hydronephrosis (collecting system dilatation) or large exophytic masses visible.

4. Pancreas & Gallbladder

• Grossly unremarkable on available views; no large pancreatic masses or obvious biliary dilatation seen.

5. Gastrointestinal Tract

• Bowel gas and fluid distribution appears normal.
• No evidence of high-grade mechanical bowel obstruction.
• Rectosigmoid colon appears normal caliber, no obvious wall thickening.

6. Peritoneal Cavity

• No large-volume free fluid (ascites) visible in the paracolic gutters, perihepatic, or perisplenic spaces.
• No free air (pneumoperitoneum) identified.

7. Pelvis - Uterus & Adnexa

• The uterus is centrally located, normal size for a 35-year-old female.
• No grossly distorting large uterine or adnexal masses identified.
• No large ovarian cysts or solid masses clearly visible.
• Small physiological free fluid in the Pouch of Douglas cannot be excluded at this resolution (normal for premenopausal women).

8. Urinary Bladder

• Partially filled, smooth symmetric walls.
• No obvious intraluminal filling defects or gross wall thickening.

9. Lymph Nodes

• No bulky retroperitoneal or pelvic lymphadenopathy (enlarged nodes) visible.
• Normal-sized lymph nodes are not resolvable on photograph-resolution images.

10. Lumbar Spine & Bony Pelvis

• Normal lumbar lordosis preserved on sagittal views.
• Vertebral body heights appear maintained; no obvious compression fractures.
• Pelvic bones (iliac, sacrum, pubic rami) appear intact with normal joint spaces at the sacroiliac joints and hip joints.
• Color overlays (green/yellow, pink) visible on the sagittal reconstructions represent software-generated segmentation/annotation of the lumbar vertebrae (L2-L5) and sacrum - likely used for volumetric measurement, AI-assisted analysis, or highlighting a region of clinical interest (e.g., lower back pain evaluation).

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Summary

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Recommended Next Steps

1. Obtain the official written radiology report - the radiologist reviewing digital DICOM images will have documented precise measurements, Hounsfield unit densities, and any subtle findings not visible on photograph.
2. Window/level review - soft tissue, bone, and lung windows each reveal different pathology; only one window is visible per photograph frame.
3. If pelvic pathology is suspected: Pelvic Ultrasound (transvaginal) or Pelvic MRI provides far superior soft-tissue contrast for uterine/ovarian assessment.
4. If spinal pathology is the concern: MRI Lumbar Spine is the gold standard for disc disease, nerve root compression, and marrow pathology.

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Report 1 — Ultrasound Whole Abdomen

Findings Summary

Impression (USG)

Right proximal ureter dilatation - likely obstructive etiology. Possibility of right ureteric calculus.

• NCCT KUB recommended for further evaluation.

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Report 2 — NCCT KUB (Non-Contrast CT of Kidneys, Ureters, Bladder)

Findings Summary

Impression (NCCT KUB)

Normal study of KUB region.

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Clinical Correlation & What This Means

The Key Finding

The NCCT KUB Result

• No calculus or calcification anywhere in the KUB tract bilaterally
• No hydronephrosis
• Normal ureteric caliber bilaterally

Interpretation

Bottom Line

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Recommended Next Steps

1. Clinical correlation - is the patient symptomatic (right flank pain, hematuria)? If symptoms persist, further evaluation is warranted.
2. Urine routine/microscopy - check for hematuria or infection, which would support a recent stone passage.
3. Follow-up USG - if mild right hydronephrosis recurs on repeat imaging, urological evaluation should be sought.
4. No immediate intervention needed based on current imaging.

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The Three Views in an NCCT KUB

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1. AXIAL VIEW (Cross-Sectional / "Slice" View)

What it looks like

• Oval/circular frames showing a horizontal "slice" of the body at each level
• Like cutting a loaf of bread - you see the inside at that exact level
• Visible in Film Sheet 1 (page 1/3) - the large grid of oval images

What is evaluated in each slice

• Size, shape, and outline of each kidney
• Parenchymal (kidney tissue) density - should be uniform gray
• Collecting system (renal pelvis) - should not be dilated/bright white
• Stones appear as bright white (hyperdense) spots - easy to spot on non-contrast CT
• Perirenal fat - should be clean, not "dirty/stranded" (which would suggest infection or inflammation around a stone)
• Aorta and IVC visible centrally

• Ureters are thin tubes running along the psoas muscle, just beside the spine
• Normally very thin (~3 mm) - you follow them slice by slice going downward
• A stone appears as a bright white dot within the ureteric lumen
• "Soft tissue rim sign" - soft tissue halo around a bright dot = confirms it is in the ureter (not a vascular calcification)

• Bladder appears as a large oval structure in the pelvis
• Uterus visible posterior to bladder in females
• VUJ (vesico-ureteric junction) - where the ureter enters the bladder - most common site for stones to get stuck
• Stones at VUJ appear as bright dots at the bladder wall

• All axial slices showed normal kidney size (R: 81×46 mm, L: 77×41 mm)
• No bright hyperdense foci anywhere along the ureteric course
• No perinephric fat stranding (no inflammation)

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2. CORONAL VIEW (Front-to-Back Reconstruction)

What it looks like

• Long vertical images showing the full body from front to back
• You can see both kidneys, both ureters, and the bladder all at once in a single image
• Visible in Film Sheet 3 (page 3/3) - top rows of tall vertical images, and also seen on the multiplanar film sheets

What is evaluated

• Both kidneys seen simultaneously - easy to compare size and position
• The entire course of both ureters from kidney to bladder can be traced in sequence
• Collecting system anatomy (renal calyces, pelvis, ureteropelvic junction / UPJ)
• Hydronephrosis (dilated collecting system) is very obvious on coronal view - appears as a black (fluid-filled) branching pattern within the kidney
• Any stone causing obstruction causes dilation above it - seen as the "column of fluid" above the bright stone dot

• Lumbar vertebrae seen in midline
• Psoas muscles on either side - ureters run along these
• Iliac vessels, bowel loops visible

• Coronal views confirmed both collecting systems are normal (no black branching hydronephrosis pattern)
• No ureteric dilation seen along the full length of either ureter
• The colored segmentation overlays (green/yellow on sagittal spine) are software annotations - not pathology

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3. SAGITTAL VIEW (Side-Profile Reconstruction)

What it looks like

• Side-profile view, like slicing the body from left to right
• Shows spine, aorta, bladder, uterus in profile
• Visible in Film Sheet 3 (page 3/3) - the lower rows with the spine visible

What is evaluated

• Lumbar vertebral alignment, disc spaces
• Sacrum and pelvis in profile

• Relationship between bladder (front) and uterus/rectum (behind) clearly seen
• Bladder wall thickness measured
• Post-void residual can be estimated

• Abdominal aorta runs anterior to the spine
• Aortic calcification would be visible as bright deposits on the vessel wall

• Sagittal is less useful for the ureter specifically (ureters run front-to-back and are better seen on axial and coronal)
• However, it helps confirm no retroperitoneal mass displacing the ureters

• Normal lumbar lordosis
• No obvious disc collapse or vertebral pathology
• Bladder appears normal in profile

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Summary Table: Three Views Compared

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Why NCCT (Non-Contrast) Specifically?

• Stones are calcium-based and naturally bright (hyperdense) on CT without any contrast
• Adding contrast dye would actually obscure small stones (the bright dye fills the ureter and hides the stone)
• NCCT is faster, cheaper, no allergic risk from contrast
• Sensitivity for stones: ~97%, which is why it is the gold standard over USG

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Miss Abhiruchi's Result Across All Three Views

• ✅ Normal kidneys bilaterally
• ✅ No calculus or calcification anywhere in KUB tract
• ✅ No hydronephrosis or ureteric dilation
• ✅ Normal bladder
• ✅ No perinephric fat stranding

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Further Management Plan

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Step 1 — Immediate Clinical Assessment

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Step 2 — Urine Investigations (Order Now)

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Scenario A — Patient is Asymptomatic (Most Likely Given Normal NCCT)

Interpretation

• The right proximal ureteric dilatation was likely a transient finding - stone probably passed spontaneously before NCCT was done
• NCCT is 97-99% sensitive for stones; a normal NCCT effectively rules out active obstruction

Management

1. Increase fluid intake - Target urine output >2 liters/day
   • Dilutes urine, reduces stone re-formation risk
   • Drink at least 2.5-3 liters of water daily
2. Dietary advice:
   • Reduce sodium intake (high sodium increases urinary calcium excretion)
   • Moderate animal protein intake
   • Adequate calcium in diet (do NOT restrict calcium - paradoxically increases oxalate absorption)
   • Reduce oxalate-rich foods if calcium oxalate stones suspected (spinach, nuts, chocolate, tea)
3. Follow-up USG KUB after 4-6 weeks to confirm resolution of right ureteric dilatation
4. Metabolic stone workup if there is any family history of stones or recurrent episodes:
   • 24-hour urine for calcium, oxalate, uric acid, citrate, phosphate, sodium, creatinine

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Scenario B — Patient Has Active Symptoms (Flank Pain / Hematuria)

Pain Management (Acute Renal Colic)

NSAIDs are the first-line analgesic for ureteric colic - they are superior to opioids per evidence - Brenner & Rector's The Kidney

Medical Expulsive Therapy (MET)

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Scenario C — Red Flags Requiring Urgent Urology Referral

Surgical Options (if needed)

Open surgery is now a final resort when all minimally invasive options have been exhausted - Comprehensive Clinical Nephrology, 7th Ed.

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Long-Term Prevention (Stone Recurrence)

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Summary Action Plan

TODAY:
✅ Urine routine + microscopy + culture
✅ Serum creatinine, calcium, uric acid
✅ If symptomatic: Tab. Diclofenac + Tab. Tamsulosin 0.4 mg OD
✅ Advise high fluid intake

IN 4-6 WEEKS:
✅ Repeat USG KUB - confirm resolution of right proximal ureteric dilatation
✅ 24-hour urine metabolic workup if recurrent or strong family history

REFER UROLOGY if:
⚠️ Symptoms persist >72 hours
⚠️ Fever/infection signs
⚠️ Rising creatinine
⚠️ Repeat imaging shows new/worsening hydronephrosis

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Active Symptom Management for Miss Abhiruchi Sonkar

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Why She Has Back Pain + Nausea — The Mechanism

"Renal colic pain occurs as the kidney stone is propelled through the ureter — a consequence of increased intraluminal pressure, causing stimulation of nerve endings in the ureteral mucosa. Pain originates in the back or flank, radiating around the torso to the groin. Renal colic can be associated with nausea and vomiting because the GI tract shares common innervation with the genitourinary system."

• Brenner & Rector's The Kidney

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Immediate Treatment Protocol

🔴 Step 1 — Pain Relief (Most Important Right Now)

⚠️ Avoid NSAIDs if: Gastric ulcer history, kidney function impaired, or patient is dehydrated

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🟡 Step 2 — Nausea Control (Give First if Vomiting is Active)

Give antiemetic before or with analgesic - nausea must be controlled so oral medications can be taken

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🔵 Step 3 — IV Fluids & Hydration

High fluid intake increases urine flow which helps push a small stone distally toward the bladder

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🟢 Step 4 — Medical Expulsive Therapy (Start Today)

• Cochrane review (67 studies, 10,509 patients) confirms alpha blockers shorten stone expulsion time
• Both AUA and EAU guidelines recommend tamsulosin for ureteral stones
• Continue for 4-6 weeks or until symptoms resolve
• Advise: may cause dizziness on standing - take at bedtime to minimize this

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🔵 Step 5 — Antispasmodic

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Prescription Summary (What to Write)

1. Inj. Ondansetron 4 mg IV stat (for nausea)
2. Inj. Diclofenac 75 mg IM stat (for pain)
3. IV NS 500 mL over 1 hour
4. Tab. Tamsulosin 0.4 mg HS (at bedtime) × 4 weeks
5. Tab. Drotaverine 80 mg TDS × 5 days
6. Tab. Ondansetron 4 mg TDS × 3 days (oral, after vomiting settles)
7. Tab. Diclofenac SR 75 mg BD after meals × 3-5 days
8. Tab. Pantoprazole 40 mg OD before breakfast
   (always give PPI with NSAIDs to protect stomach)
9. Oral fluids: minimum 3 liters water daily

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⚠️ Warning Signs — Admit/Refer Immediately If:

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Follow-Up Plan

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Ureteroscopy (URS) — Complete Explanation

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What is Ureteroscopy?

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Types of Ureteroscopes

For Miss Abhiruchi's right proximal ureteric location (above iliac vessels): flexible ureteroscopy is preferred, especially in females where semirigid can sometimes access proximal ureter too. - Hinman's Atlas of Urologic Surgery

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Step-by-Step Procedure

Pre-operative Preparation

• Urine culture done and infection cleared (never proceed if pus/infection found - stent first, URS later)
• Antibiotics given before the procedure
• Patient under general or spinal anesthesia (regional preferred for better stone visualization)
• Patient positioned in lithotomy position (legs raised in stirrups)
• Foley catheter inserted, bladder drained

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Step 1 — Cystoscopy & Ureteral Access

• Rigid cystoscope inserted through urethra into bladder
• The right ureteral orifice is identified at the trigone of the bladder
• A guidewire (hydrophilic tip) is passed through the ureteral orifice up into the right renal pelvis under fluoroscopic guidance
• A retrograde pyelogram is performed - contrast injected to map the stone location and collecting system anatomy
• A second safety guidewire is placed alongside the first
  • The safety wire is critical - it maintains access if the scope needs to be withdrawn and a stent placed

"Ureteroscopy should not proceed without a safety wire, which provides access to the collecting system when a case is terminated early." - Hinman's Atlas

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Step 2 — Ureteroscope Insertion

• The ureteroscope is passed alongside the safety wire, through the ureteral orifice and up the ureter
• If the ureteral orifice is too narrow: balloon dilation or serial dilators are used
• The scope is advanced carefully under direct vision + fluoroscopy until the stone is reached

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Step 3 — Stone Visualization

• Stone is directly visualized through the ureteroscope's camera
• Stone characteristics (size, shape, color, hardness) are assessed
• An antiretropulsion device (stone cone/basket) may be placed just above the stone to prevent it from being pushed back up into the kidney during fragmentation

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Step 4 — Stone Fragmentation (Lithotripsy)

"Ho:YAG laser is clearly the current most efficacious and safe laser available... we recommend Ho:YAG as the first-line option." - Hinman's Atlas

Success rates with laser: Stones ≤10 mm: 91-97% stone-free. Stones >10 mm: 71-89% stone-free - Campbell-Walsh-Wein Urology

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Step 5 — Fragment Extraction

• Small fragments (<2 mm) are washed out with irrigation fluid ("dusting" technique)
• Larger fragments are grasped with a stone basket or grasping forceps and removed
• Caution: never basket a stone too large for the ureter - risk of ureteral avulsion

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Step 6 — DJ Stent Placement (Post-procedure)

Kidney (upper J curl) ←— stent ——→ Bladder (lower J curl)

• Stent duration: Usually 1-4 weeks, then removed via cystoscopy
• Stentless URS is possible in uncomplicated low-risk cases

"A double pigtail ureteral stent can then be placed. Stentless ureteroscopy is an option in uncomplicated, low-risk patients." - Hinman's Atlas

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Step 7 — Post-procedure

• Recovery: few hours in hospital, often day-care procedure
• Discharge: same day or next day
• Expects: blood-tinged urine for 2-3 days (normal), mild burning, frequent urination
• Return to work: 2-5 days

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Indications for URS (When to Do It)

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Contraindications

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Complications

"Complications include ureteral avulsion, perforation, extravasation, mucosal damage, hematuria, infection, and stricture. Advances in laser technology reduce the need for graspers and baskets and hence reduce complications." - Comprehensive Clinical Nephrology, 7th Ed.

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URS vs Other Treatments — When to Choose What

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Relevance to Miss Abhiruchi Sonkar

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Hematuria — Complete Guide

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Definition

"Hematuria is a concerning urologic sign in adults and must be evaluated because it may signal the presence of a urologic cancer in up to 25% of patients."

• Campbell-Walsh-Wein Urology

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In Miss Abhiruchi's Context

• Expected as a confirmatory sign of ureteric stone/colic
• If present on urine microscopy = strongly supports stone disease diagnosis
• If absent = does NOT rule out stone (hematuria is absent in ~15-20% of confirmed stone cases)

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Causes of Hematuria — Full Classification

A. Urological (Non-Glomerular) Causes

B. Nephrological (Glomerular) Causes

C. Systemic / Other Causes

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How to Distinguish the Cause — Urine Microscopy is Key

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Stream of Hematuria Tells the Location

"Initial stream hematuria = prostatic/urethral source; Terminal hematuria = bladder neck; Total stream hematuria = bladder or upper tract"

• Campbell-Walsh-Wein Urology

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Clot Shape Clue

"Clots formed in the upper tract often have a vermiform (worm-shaped) shape; cuboid clots are likely produced in the bladder."

• Campbell-Walsh-Wein Urology

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Evaluation Protocol — AUA Guidelines

Pillar 1 — History & Physical

• Duration and onset of hematuria
• Associated symptoms: pain, fever, burning, frequency, urgency
• Smoking history (bladder cancer risk)
• Chemical/industrial exposure (aromatic amines → bladder cancer)
• Family history of kidney disease, polycystic kidneys, VHL syndrome
• Drug history (anticoagulants, cyclophosphamide)
• Recent exercise, menstruation, trauma, catheterization

Pillar 2 — Laboratory Tests

"The urine dipstick alone is NOT sufficient for determining true hematuria - always confirm with microscopy." - Campbell-Walsh-Wein Urology

Pillar 3 — Imaging + Cystoscopy

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Hematuria in Stone Disease — Specifically

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When is Hematuria an Emergency?

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What to Do Now for Miss Abhiruchi

1. Urine routine + microscopy — STAT
   → If ≥3 RBCs/HPF with eumorphic cells = confirms ureteric stone/colic
   → If dysmorphic RBCs + proteinuria = refer nephrology
   → If WBCs + bacteria = UTI, treat first

2. Urine culture — send simultaneously
   → Essential before any procedure (URS)

3. Serum creatinine — assess right kidney function

4. If gross hematuria with clots → urgent urology referral
5. If microscopic hematuria resolves with stone treatment → no further hematuria workup needed
6. If hematuria persists after stone treatment resolves → full AUA hematuria evaluation including cystoscopy

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Key Points Summary

• Hematuria in this patient is almost certainly from right ureteric stone injury (eumorphic RBCs, associated colic)
• Urine microscopy confirms and characterizes it - always do microscopy, not just dipstick
• Stone-related hematuria resolves with stone treatment
• Painless gross hematuria in any patient = bladder cancer until proven otherwise - this is the most important alarm signal
• AUA guidelines mandate complete evaluation even if one cause is found - other causes (tumor, glomerular) must be excluded if hematuria persists