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Radiopaque suppositories mimicking bladder calculi.

D T Lesher, R L Scott

    Journal of the Canadian Association of Radiologists
    |March 1, 1979
    PubMed
    Summary
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    Radiopaque suppositories in a paraplegic patient were mistaken for recurrent kidney stones. This diagnostic error led to an unnecessary surgical procedure, highlighting the importance of thorough patient history and imaging review.

    Area of Science:

    • Urology
    • Radiology
    • Patient Safety

    Background:

    • Diagnostic challenges in paraplegic patients.
    • Potential for imaging artifacts to mislead diagnosis.
    • Importance of considering non-pathological causes of radiopacity.

    Observation:

    • A paraplegic patient presented with findings suggestive of recurrent urinary calculi.
    • Radiopaque suppositories were administered to the patient.
    • These suppositories created imaging appearances mimicking calculi.

    Findings:

    • The radiopaque suppositories were misidentified as recurrent urinary calculi on imaging.
    • This misdiagnosis led to an unwarranted cystotomy procedure.
    • The actual cause was exogenous material, not pathological calculi.

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    Implications:

    • Need for enhanced diagnostic vigilance in patients with altered physiology.
    • Importance of correlating imaging findings with clinical context and medication history.
    • Potential for iatrogenic harm due to diagnostic errors.