In addition they are not always associated with shadowing. These stones may be difficult to detect due to surrounding echogenic renal sinus fat, mesenteric fat, or bowel. The twinkling sign is a color Doppler artifact that appears as a rapidly alternating mixture of red and blue Doppler signals distal to strongly reflective granular surfaces, such as found on urinary stones. The addition of color Doppler revealed a twinkling sign posterior to the focus, as well as a ureteral jet from the right ureter (Fig. The bladder was also examined, which revealed a non-shadowing, hyperechoic focus at the left ureterovesicular junction (UVJ) (Fig. A focused bedside ultrasound was performed by the emergency physician using a 5–2 MHz curvilinear array transducer (Model HD11XE, Philips, Andover, MA), which revealed mild left hydronephrosis (Fig. The patient’s urine beta-hCG was negative and urinalysis showed no pyuria but was positive for blood. The patient had normal vital signs, and physical examination was remarkable only for mild left costovertebral angle tenderness. She denied any recent lifting or trauma, dysuria, hematuria, frequency, urgency, vaginal bleeding, or vaginal discharge. The patient had no significant past medical, surgical, or family history, and no history of similar pains in the past. The pain was described as sharp and intermittent, radiating to the left-lower quadrant of the abdomen, and was associated with nausea and vomiting. The major limitation of our study was that the number of the subjects were small.A 43-year-old female presented to the emergency department (ED) complaining of acute left flank pain for 1 day. Different grades of twinkling artifact on color Doppler ultrasonography were evoked depending on the biochemical composition of renal stones and different central frequencies of transducers. The plastic ball produced grade 1 artifact on L10-5, and grade 0 on other transducers. Type B stone produced grade 1 artifact on all transducers type C stone produced grade 0 artifact on C4-2, grade 2 on C7-4, and grade 1 on L7-4, and L10-5. Type A stone produced grade 1 artifact on C4-2, grade 2 on C7-4 and grade 3 on L7-4 and L10-5. The size of stones ranged from 6 to 10 mm (mean=8 mm). Each artifact was graded by two independent observers, and if there was interobserver difference, the consensus was reached. Color Doppler gain was set to the point just below the threshold for color noise. Grading of twinkling artifact was done: 0=absent, 1=present but occupying less than half of a stone, 3=occupying the entire stone and 2=between 1 and 3. All stones were placed in a depth of between 3 and 4 cm in an agar plate. Three types of renal stones (A=90% calcium oxalate +10% calcium hydrogen phosphate, B=50% calcium oxalate +5% calcium hydrogen phosphate +45% ammonium urate, and C=55% urate 35% calcium oxalate +5% ammonium urater +5% calcium hydrogen phosphate) removed from the subjects and one artificially made plastic-ball (D) were examined in vitro with color Doppler ultrasonography. To evaluate the relationship between the degree of twinkling artifact generated on color Doppler sonography and the biochemical composition of renal stones and different central frequencies of transducers.
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