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Urolithiasis
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- 2. • Urolithiasis isalso called as Kidney stones,Renal Stones or Renal Caliculi. • Urolithiasis, or urinary calculus disease, may affect up to 10% of the population over the course of a lifetime • Calculi are crystalline aggregates of one or more components, most commonly calcium oxalate.
- 3. • The epidemiologyof urolithiasis differs according to geographical area in term of prevalence and incidence, age and sex distribution, stone composition and stone location. • Epidemiological surveys have been previously reviewed showing that in economically developed countries the prevalence rate ranged between 4% and 20% . • Approximately 50% of patients present between the ages of 30 and 50 years • There is a slight male preponderance. Male :Female = 3:1 • The increasing incidence of nephrolithiasis in women might be due to lifestyle associated risk factors, such as obesity.
- 4. • CALCIUM STONES70-80% Calcium Phosphate 5-10% Calcium Oxalate 30-35% Calcium Oxalate 20-30% • Struvite stones15-20% • Cystinestones -3% • Uric acidstones
- 5. • There arevery many causes for urinary tract stone disease which can be classified into the following groups: • Idiopathic calcium urolithiasis: This is present in approximately 70% of patients with urinary tract infections • Hypercalcaemic Disorders: PRIMARY HYPERPARATHYROIDISM PROLONGED IMMOBILISATION MILK-ALKALI SYNDROME SARCOIDOSIS
- 6. • RENAL TUBULARSYNDROMES RENAL TUBULAR ACIDOSIS (RTA) CYSTINURIA • URIC ACID LITHIASIS • ENZYME DISORDERS PRIMARY HYPEROXALURIA XANTHINURIA 2, 8-DIHYDROADENINURIA
- 7. • DIETARY EXCESS Rhubarb,spinach, tea, cocoa, chocolate and pepper commonly increase urinary oxalate • INFECTION • OBSTRUCTION AND STASIS • MEDULLARY SPONGE KIDNEY • DRUGS:Acetazolamide stimulates renal tubular acidosis. Allopurinol may precipitate xanthine stones. Thiazide diuretics can result in uric acid stone formation.
- 8. OTHER FACTORS • Otherfactors include: • geography; • climatic and seasonal factors; • water intake; • diet; • occupation: especially sedentary jobs in hot environments
- 9. • Urinary calculimay occur anywhere in the urinary tract. • They usually are asymptomatic in the renal pelvis or bladder, but they are a very common cause of symptomatic ureteral obstruction • Smaller stones (up to 6 mm) may cause severe symptoms, such as flank pain and nausea • Visible haematuria is rarely present but dipstick haematuria is a frequent accompaniment to the pain
- 10. • Renal/Ureteral Colic(PAIN) –Abrupt onset while asleeporat rest – Crescendoof extremepain – Flankradiating laterally and downward to groin/testicle or round ligament/labiamajora – Impossibleto be still • Mid ureter – lateral flank andabdomen • Lowerureter – suprapubicandurethral – urgencyandfrequency
- 11. • GISymptoms – Nauseaandvomiting – autonomic n.s. – Ileus or diarrhea – DDX:gastroenteritis, appendicitis, colitis, diverticular disease and salpingitis • Hematuria – grossor microscopic – 15%no hematuria! • Pyuria/Fever – Pyuria even without infection – Infection especially infemale
- 12. • The diagnosisof a urinary tract calculus is by with a non-contrast CT scan • A supplementary plain x-ray is often performed to assess if the stone(s) are radio-opaque. • Calcium- and struvite-containing stones often are – visible on plain radiographs.Pure uric acid, indinavir-induced, and cystine calculiare relatively radiolucent on plainradiography • Patients with recurrent stones will benefit from examination of stone composition and 24-hour urine metabolic workup to determine the underlying etiology
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- 14. • The managementof urinary tract stones can be subdivided depending on whether the patient presents in the emergency or elective setting. • In EMERGENCY SETTING, small stones (<5 mm), especially in the distal ureter, are treated expectantly as they are likely to pass spontaneously The patient is usually given a non-steroidal anti-inflammatory drug such as diclofenac for pain relief and observed for further episodes of pain, but also temperature, pulse, blood pressure and white blood count are monitored for signs of developing infection and the estimated glomerular filtration rate (eGFR) is monitored.
- 15. • Obstructing stonesoften are temporizedwith stent placement, which allows proximal collecting system decompression. • When urinary infection coexists with an obstructing stone, a stent can be placed, but a PCN is preferable if the patient demonstrates any instability. • Definitive treatment of renal or ureteral calculi (lithotripsy) is through ureteroscopy, percutaneous nephrostolithotomy (PCNL), or extracorporeal shock wave lithotripsy (ESWL).
- 16. • Ureteroscopy isperformed with a flexible or semirigid device that is passed to the level of the calculus. • Under direct visualization, a laser fiber is passed through the scope, and energy is delivered to fragment the calculus. • Fragments are extracted, although they usually will pass spontaneously. Ureteroscopy. X-ray showing a ureteroscope and guidewire in the ureter
- 17. ) • PCNL isperformed through a percutaneous tract into the kidney, where a larger scope andvarious energy sources (laser, ultrasound) are used to fragment and aspirate large renal calculi • This approach is well suited to staghorn calculi. INDICATIONS • Obese patients in whom ESWL is contraindicated. contraindicated. • 3Lower calyceal stones: these are less likely to pass pass after ESWL. • Stone composition: struvite stones need to be be completely removed because of associated infection. associated infection. As previously mentioned, some mentioned, some stones with a very hard composition composition are difficult to fragment using ESWL, ESWL, including calcium oxalate monohydrate and monohydrate and cystine stones • An obstruction: anatomic abnormalities such as PUJ such as PUJ obstruction, calyceal diverticula or ureteric or ureteric obstruction might prevent the passage of passage of stone fragments after ESWL
- 18. Percutaneous renal stoneremoval. (a) The stone is in the right renal pelvis. (b) Placement of a cannula under radiologicalcontrol into the renal pelvis and through it a balloon catheter to stopfragments migrating into the upper ureter. (c) The stone is disrupted by contact lithotripsy and the fragments have been successfullyremoved by irrigation. (d) A nephrostogram confirms that the renal pelvis is intact.
- 19. • ESWL iscompletely noninvasive and uses a device that delivers convergent shockwave energy to the calculus under fluoroscopic guidance. • This is the common form of treatment these days for renal calculi and stones up to approximately 1.5 cm in size are suitable for this form of treatment. • Cystine stones are relatively resistant to ESWL due to their hardness. • ESWL may result in haematuria, parenchymal haemorrhage and even perirenal haematoma. • Contraindications to ESWL are obese patients, pregnant patients and patients taking oral anticoagulants.
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- 23. • Pyelonephritis isa bacterial infection of the kidney. • It is frequently attributed to ascending bacteria along the path of the ureters and is rarely due to hematogenous bacterial spread. • CAUSES: • Vesicoureteric Reflux • Kidney stones • Urinary tract catheterization • Pregnancy • Diabetes Mellitus
- 24. • Patients typicallypresent with flank pain and fevers • young or elderly patients may not demonstrate these symptoms but rather irritability, poor appetite, or altered mental status • Frequent urination • Strong, persistent urge to urinate • Burning sensation or pain when urinating • Nausea,Vomiting
- 25. • Urineanalysis mayshow sign of UTI • Blood test • Intravenous Pyelography • Urinary tract imaging is not required unless urinary obstruction or stones are suspected or the patient is not responding to antibiotics. • Any patient who is not properly responding to antibiotic therapy after 72 hours should undergo CT imaging to rule out an abscess obstruction • Urine culture
- 26. • Patients whoare not septic and can tolerate fluids can be discharged home on a 2-week course of oral antibiotics. • Otherwise, they should be hospitalized for IV antibiotics. • Fevers from pyelonephritis may take 24 to 48 hours to subside in the setting of effective antibiotic therapy • Incase of repeated Infections,nephrectomy is preferred
- 27. • Pyelonephritis canresult in renal scarring that is accelerated in the setting of urinary obstruction. • Occasionally, pyelonephritis can develop into an abscess that can be located within the renal parenchyma (renal abscess) or between the capsule and Gerota’s fascia
- 28. REFERRENCES • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781200/ • Schwartz’sPrinciples of Surgery Tenth Edition • Bailey & Love's Short Practice of Surgery, 27th Edition