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Acute flank pain is a common presentation to the emergency department (ED), and imaging studies play an important role in establishing an accurate diagnosis. Computed Tomography of Kidneys, Ureters, Bladder (CT KUB) has surpassed all other imaging modalities to become the gold standard in detection of ureteric calculi. The purpose of this study is to identify the range and management of alternative diagnoses established by CT KUB in patients with suspected ureteric colic. Two hundred and fifteen consecutive CT KUB examinations ordered in the ED of a tertiary-care centre for suspected ureteric colic were retrospectively reviewed. This comprised of 134 male (62.3%) and 81 female (37.7%) patients with a mean age of 53 years old. The positive detection rate for ureteric calculi in males was 43.3% compared to a lower rate for females of 29.6% (p < 0.05). Almost two-thirds of patients were discharged following CT KUB imaging, and admission rates were significantly higher in those with alternative radiological findings (p < 0.04) Alternative radiological findings occurred in 72 patients (33.5%), including 15 patients (7.0%) who had clinically important alternative pathology. The rate of clinically important alternative findings was significantly higher in males than females, 9.7% versus 2.5% respectively (p = 0.04). Surgical intervention was more common in patients with alternative radiological findings classified as gastrointestinal (18.2%) compared to non-gastrointestinal (3.6%), however this did not reach statistical significance (p = 0.07). In conclusion, significant alternative pathology was identified using CT KUB in 7% of patients with suspected ureteric colic. The low rates of detection of ureteric calculi and significant alternative pathology in female patients suggests a more thorough clinical assessment is warranted to improve their management, prior to ordering investigations with exposure to radiation.