Renal Stones PDF - Causes, Symptoms & Treatment

Renal stones Mohammad Jundy Renal stones: Clinical features: - Nephrolithiasis: Stones in kidney....

Renal stones Mohammad Jundy Renal stones: Clinical features: - Nephrolithiasis: Stones in kidney. - Asymptomatic. (silent renal failure if bilateral) - Ureterolithiasis: Stones in ureter. - Symptomatic (MC): - Cystolithiasis: Stones in urinary bladder. 1) Pain (75%): ➔ Renal pain (distention of renal capsule). Renal stones types: ➔ ureteric colic (Peristaltic movement against obstruction, spasm) ➔ Sudden Sharp, Severe, Colicky (20 – 60 minutes). Stone Ca oxalate Ca phosphate Struvite (MAP) Uric acid Cysteine (Magnesium ammonium phosphate) ➔ Pt. is Rolling around bed, moving (find comfortable position to ↓ pain) Features Most common - 2nd most - Stag horn Hyperuricemia Autosomal ➔ Renal, Upper ureter stone: common calculus - Gout recessive - Ass. with UTI - Tumor lysis mutation ▪ Flank pain - RTA type 1 - Urease (+) Syndrome (PCT don’t absorb ▪ Abd. pain radiates anteriorly & inferiorly cysteine) (distal RTA) bacteria (Chemotherapy) ➔ Lower ureter stone: Citrate Hypocitraturia alkaline alkaline acidic acidic /PH Low PH (acidic) (Elevated PH) (Elevated PH) (decreased PH) decreased PH ▪ iliac fossa pain radiates to thigh & groin (testicle/labia) X-ray Radiopaque Radiopaque Radiopaque Radiolucent Radiolucent or faint 2) Hematuria. opaque 3) Dysuria, frequency, urgency. (LUTS) Etiology: 4) + Fever (not usual, UTI association) - ↑ Soluble material (Ca, uric acid, etc) >> Urine Supersaturation >> crystallization >> Nidus formation. Physical exam: ➔ MC formation site: renal tubules (formation ≠ Impaction) - CVA tenderness (pyelonephritis) - Absence of stones Inhibitor: - Loin swelling (ballotable kidney): hydronephrosis (rare) ➔ Citrate, magnesium, pyrophosphate. ↑ Soluble material - Genital & DRE: testicular torsion. (DDX). - Vit A deficiency >> Epithelium desquamation - UTI: Urea splitting bacteria. Sites of stone impaction: Crystallization - Calyx, ureteropelvic junction, near pelvic brim. Risk factors: Nidus formation - ureterovesical junction (MC) Male - Male, white > black, age 20-40. White - Dehydration. 20 - 40 Outdoor work Investigations: - Hot (warm) weather: outdoor work. Labs: - Previous history or family history. - CBC: Elevated WBC (UTI/pyelonephritis) - Diet: high salt & protein, high oxalate food (tomato, grapefruit) - Urine analysis: - Hypocitraturia, Hypomagnesemia, Hypertension. ➔ Hematuria. - Hyperparathyroidism (Hyper Ca) ➔ PH - Gout (Uric acid stones) ➔ Crystals (cystine hexagonal crystals) - RTA type 1 (CA phosphate) ➔ Pyuria, nitrate (UTI?) - UTI (Stag horn calculus) - KFT: creatinine (AKI?) - Drugs: Acetazolamide, sulfadiazine, loop diuretics.  Renal stones Mohammad Jundy Imaging: Double J catheter (stent): - CT scan Without contrast: (non-enhanced) - Bypass obstruction, relief pain. ➔ Gold Standard investigation (Investigation of choice) - Indications: multiple stones, bilateral obstruction, ➔ Show all types of stones (even uric acid) single kidney, pregnancy ➔ Rule out other DDx. - Ultrasound: Complications: ➔ pregnant females. - Hydronephrosis, super-imposed infections. ➔ Show stone, hydronephrosis. - Acute renal failure, pyelonephritis. (most serious) - X-ray (KUB): ➔ Don’t show all stones. (Rarely used Now) DDx: Radiopaque Radiolucent - Depend on upper or lower ureter (right vs left side). Ca oxalate Uric acid ➔ Gynecological causes, prostate/scrotum pathologies Ca phosphate Cystine ➔ Diverticulitis, appendicitis, cholecystitis, hernia Struvite stone Struvite (MAP) (Stag- horn calculus): Management: - Type: Struvite Conservative: - Shape: stag horn. - All patients + Stones < 5 mm. ➔ large stone that involves > 2 calyces & Renal pelvis. - Hydration & NSAIDS (analgesia). - Compistion: MAP (magnesium, ammonium, phosphate). - Ass. with UTI, by urease positive bacteria (urea splitting): ESWL: (extracorporeal shoch wave Lithotomy) ➔ Proteus mirabilis. (MC) - For stones < 2 cm ➔ Proteus vulgaris - Absolute contraindications: (ORAL) ➔ Others: Klebsiella & staphylococci, pseudomonas. ➔ Pregnancy. ➔ Current UTI (staghorn) Medical Tt of stones: ➔ Coagulopathies Medical treatment Ca phosphate stones Thiazide Urine acidification. Ca oxalate stones Thiazide Urine alkalinization (potassium citrate) Percutaneous nephrolithotomy: (Percutaneous lithotripsy) Uric acid stones Allopurinol Urine alkalinization (potassium citrate) - Stones > 2 cm. Cysteine stones Penicillamine Urine alkalinization (potassium citrate) Struvite stones Difficult –> need surgical approach. Pyelolithotomy: (renal pelvis stone) Bladder stones (Cystolithiasis): Ureteroscopic lithotomy: (Ureteroscopy) - Pain, LUTS (frequency, urgency, dysuria). - From below (urethra) - Pain at end of micturition: - For ureter stones < 2 cm. ▪ referred to tip of penis or labia majora. Open surgery: - Tt: Conservative or transurethral cystolitholapaxy - Large stones (Struvite stones) or failed previous Tt. - 2nd to BPH, foreign body, neurogenic bladder.  Renal stones Mohammad Jundy Urethra stones (Urethrolithiasis): - Males (long & narrower urethra) - Primary: Stricture, meatal stenosis. - Secondary: bladder or upper tract stone. Notes: - Lower urinary stones are Mostly secondary - Hardest type of stone: Ca monohydrate. - MC Microorganism causing renal stones: Proteus mirabilis. - in bilateral renal stones, treat better function kidney first. - Chron’s disease/pancreatic insufficiency: ➔ fat loss that bind with Ca+2 ➔ more circulating free phosphate >> Kidney stones. - Short bowel syndrome >> hyperoxaluria & ca oxalate stones. - High oxalate food: tomato, grapefruit. (ORAL) Done by Mohammad jundy. ‫هي_قضية_الشرفاء‬#