SAWA colic

					STONE DISEASE
( Brief Overview )
    :D Ahmed Al-Momtan
           C2
COMPARATIVE INCIDENCES OF FORMS OF URINARY
LITHIASIS
                                 Stone analysis in Percentage

   Form of Lithiasis           India      USA      Japan UK

   Pure Calcium Oxalate        86.1        33       17.4 39.4

   Mixed Calcium Oxalate and   4.9         34       50.8 20.2
   Phosphate

   Magnesium Ammonium          2.7         15       17.4 15.4
   Phosphate (Struvite )

   Uric Acid                   1.2         8.0      4.4    8.0

   Cystine                     0.4         3.0      1.0    2.8
 Cause of Stone Disease
• Supersaturation of urine is the key to stone formation
• Intermittent supersaturation - Dehydration
• Crystal aggregation
• Anatomic Abnormailities – PUJ , MSK
• Bacterial Infection
• Defects in transport of Calcium and Oxalate by Renal
  epithelia

  E.Coli infection increases matrix content in urine . Proteus makes
  urine alkaline
              Inhibitors & Promoters of Stone Formation in
              Urine

INHIBITORS                      PROMOTERS
Inhibits crystal Growth -       •   Bacterial Infection
• Citrate – complexes with Ca   •   Matrix
                                •   Anatomic Abnormalities – PUJ
• Magnesium – complexes
                                    obst., MSK
    with oxalates
                                •   Altered Ca and oxalate
• Pyrphosphate - complexes          transport in renal epithelia
    with Ca                     •   Prolonged immobilisation
• Zinc                          •   Increased uric acid levels I.e
Inhibits crystal Aggregation        taking increased purine subs–
                                    promotes crystalisation of Ca
• Glycosaminoglycans
                                    and oxalate
• Nephrocalcin                  •   ?? Nanobacteria – seen in 97%
• Tamm- Horsfall Protein            of renal stones
SOME DISEASES ASSOCIATED WITH
HYPERCALCAEMIA & HYPERCALCIURIA
    Hyperparathyroidism              Leukemia

    Sarcoidosis                      Lymphoma

    Multiple myeloma                 Myxedema

    Hyperthyroidis                 Adrenal Insufficiency

    Metastatic Malig. Neoplasm's     Vit. D Intoxication
TYPES OF KIDNEY / URETER STONES

    • OXALATE (CALCIUM OXALATE)

    • PHOSPHATE

    • URIC ACID & URATE

    • CYSTINE
Uncommon Stones
XANTHINE STONES

  – (Autosomal Recessive . Def of Xanthine Oxidase leading to Xanthinuria)

DIHYDROXYADENINE STONE

   – ( Def. of enzyme adenine phospo ribosyl transferase )
SlLICATE STONES

  – Rare in humans ( excess intake of Antacid with Mg Trisilicate.       Mostly in
  cattle due to ingestion of Sand )

MATRIX

  - Infection by Proteus  - Radiolucent (all calculi have some amt ( 3%) of
  matrix but matrix calculus has 65% Matrix content in calculi)
Uncommon Stones
TRIAMTERENE

   – Anti-hypertensive used with hydroclorothiazide – spare
   Potassium. Mostly found as a nucleus in Ca oxalate or uric acid
   calculus


Indinavir Stones

   - Drug to treat   AIDS (4 to13%)


Ephedrine or Guifenesin

– Cough medicine - Radiolucent
Stones – Chemical Constituents

• Whewelite – Calcium Oxalate Monohydrate – CaC2O4-H2O

• Weddelite - Calcium Oxalate dihydrate – CaC2O4-2H2O

• Brushite – Calcium Hydrogen phosphate dihydrate – CaHPO4 2H2O

• Whitlockite - TriCalcium Phosphate – Ca2(PO4)2

• Struvite – Magnesium Ammonium hexahydrate – MgNH4PO4-6H2O
                    DD of Radiolucent filling defect on IVU in
                    Ureter or Kidney


Must Know                         Know For Brownie Points

                                  •   Xanthine Calculus
•   Uric Acid Calculus
                                  •   Hydroxyadenine Calculus
•   Matrix Calculus               •   Ephederine Calculus
•   Sloughed Papilla              •   Infection due to gas forming
•   Blood Clots                       Org.
                                  •   Fungal Ball
•   TCC
                                  •   Tuberculoma
•   Renal Cysts                   •   Malacoplakia
•   Vascular Lesions              •   Hypertrophied Papilla
                                  •   Renal pseudo-tumour
                   OXALATE (CALCIUM OXALATE)
• ALSO CALLED MULBERRY STONE

• COVERED WITH SHARP PROJECTIONS

• SHARP MAKES KIDNEY BLEED
 (HAEMATURIA)

• VERY HARD

• RADIO - OPAQUE

      Under microscope looks like Hourglass or Dumbbell shape if monohydrate and
                            Like an Envelope if Dihydrate
             PHOSPHATE STONE

• USUALLY CALCIUM PHOSPHATE

• SOMETIMES  CALCIUM MAGNESIUM
  AMMONIUM PHOSPHATE OR TRIPLE
 PHOSPHATE

• SMOOTH MINIMUM SYMPTOMS

• DIRTY WHITE

• RADIO - OPAQUE
    Calcium Phosphate also called ‘Brushite’ appears like Needle shape
                           under microscope
        PHOSPHATE STONES

            IN ALKALINE URINE
                             
           ENLARGES RAPIDLY
                             
      TAKE SHAPE OF CALYCES
                             
                STAGHORN 

Struvite can form Stag-horn and appear like coffin lid under microscope
                    CALCIUM PHOSPHATE
                    STONES
         • Hyperparathyroidism                                Ca        P

         • Renal Tubular Acidosis                              K        CO2

         • Medullary Sponge Kidney -




PTH Hormone Promotes renal production of 1-25-dihyroxycholecalciferol – active Vit.D and
also increases absorption of Calcium and decreases Phosphorus absorption from Kidneys
 URIC ACID & URATE STONE
• HARD & SMOOTH

• MULTIPLE

• YELLOW OR RED-BROWN

• RADIO - LUCENT (USE
 ULTRASOUND)
        Under microscope appear like irregular plates or rosettes

        pKa of uric acid 5.75 – at this pH 50% of uric acid insoluble.
        If pH falls further - uric acid more insoluble
CYSTINE STONE
     • AUTOSOMAL RECESIVE DISORDER

     • USUALLY IN YOUNG GIRLS

     • DUE TO CYSTINURIA -

     • CYSTINE NOT ABSORBED BY TUBULES

     • MULTIPLE

     • SOFT OR HARD – can form stag-horns

     • PINK OR YELLOW

     • RADIO-OPAQUE

    Under microscope appears like hexagonal or benezene
    ring – ask for first morning sample
     CYSTINE STONE - Management
     • High Fluid Intake and Alkalanise Urine – dissolve most
       of the smaller cystine stones
     • D-Pencillamine or MPG (Mercaptopropionylglycine)
       binds to cystine that is soluble in urine
     • Side effects of Pencillamine restricts it use – Allergic
       rashes, GI problems- Nausea, Vomiting, Diarrhoea
     • MPG better tolerated
     • Large obstructive stones – Surgery required first


pKa of cystine is 8.3, hence alkalinisisation above pH7.5 helps to dissolve the stones

      Cyanide Nitroprusside Calorimeteric Test for detecting Cystinuria. If positive do
                              amino acid chromatography
Surgical Conditions and Stone Disease
• Regional ileitis and Ileal Bypass Surgery for
  eg Obesity can lead to increase oxalate
  absorption and stone ds
• ileostomies - In Chr. Diarrhoea with–
  Bicabonate loss – systemic acidosis and acidic
  urine – increases risk of Uric Acid stones
HISTORY
A. IS PATIENT DRINKING ENOUGH ?

B. PROFESSION

C. ENQUIRE ABOUT UTI STONES

D. FAMILY HISTORY

E. LONG ILLNESS BEDRIDDEN STONES
MANAGEMENT OF STONES
HISTORY :

A. FIND OUT IF DRINKING ENOUGH LIQUIDS

  (NOT DRINKING ENOUGH IMPORTANT
  CAUSE OF STONE FORMATION &
  GROWTH)


   Urinary supersaturation of salts in concentrated urine
   Atleast drink 3 lits to avoid stone formation
HISTORY (Cont...)

   B. ASK ABOUT THEIR PROFESSION:
     DEHYDRATION STONES CAN FORM e.g.

      – MARATHON NEAR A FURNACE,

      – BRICK - LAYER, LABOURERS & WEAVERS

      – TRUCK & BUS DRIVERS
HISTORY (Cont...)


    C. ENQUIRE ABOUT UTI STONES


    D. FAMILY HISTORY


    E. LONG ILLNESS  BEDRIDDEN  STONES

   Zero Gravity state – astronauts on long space flights more prone to
   stones
  CLINICAL FEATURES
 1. PAIN IN 75 % OF THE CASES
     “RENAL COLIC” IF SEVERE AND ACUTE

     A) KIDNEY STONE
          FIXED PAIN IN THE LOIN

     B) URETERIC STONE
          PAIN RADIATES  LOIN TO GROIN

Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting
                         common in renal colic
CLINICAL FEATURES (Contd....)

  2) HAEMATURIA

  •   CAN BE FRANK

  •   OR ONLY FOUND ON DIP - STICK OR LAB.

  3) PYURIA - IF INFECTION CAN HAVE PUS IN URINE
ON EXAMINATION
     1. ACUTE PRESENTATION

     • ABDOMEN TENSE AND RIGID

     • TENDERNESS PRESENT IN THE
      LOIN

     2. IN ROUTINE PRESENTATION

     • NO FINDINGS IN ABDOMEN
  INVESTIGATIONS

1. FULL BLOOD COUNT TO CHECK FOR

 ANAEMIA IF GOING FOR SURGERY


2. SERUM ELECTROLYTES PLUS UREA / CREATININE

 / CALCIUM / URIC ACID / PHOSPHATE
INVESTIGATIONS (Cont...)

   3. 24-HOURS URINE FOR ELECTROLYTES

    (Only if recurrent stone former), bilateral, in a

    child..


    CALCIUM / OXALATE / URIC ACID /

    CYSTINE / CITRATE
INVESTIGATIONS (Cont...)

  4. PLAIN KUB X-RAY OF ABDOMEN

    (Mandatory)


  5. IVU OR IVP (INTRA VENOUS UROGRAM)


  6. ULTRASOUND (Mandatory)
               INVESTIGATIONS

IVU OR IVP (INTRA VENOUS UROGRAM)
• Not Mandatory
• 1in 40,000 patients die due to anaphylactic reaction to
  contrast
• Useful for radio-lucent stones & to detect
  Congenital Anomalies in Urinary tracts
INVESTIGATIONS (Cont...)

     7. CT –TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY


           To differentiate cause of acute colic – stone or anuria

           Suspected due to stone disease


     8. DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY

        FUNCTION OF EACH KIDNEY.
       Bilateral Ureteric Calculus in a patient presenting with Anuria




Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on
Gantry. These are rapidly performed and do not require contrast agents for reconstruction.
MANAGEMENT OF
UROLITHIASIS
• Non-invasive approach to urinary calculas-
  HALLMARK of last 20 yrs.
• Lithotripters –
           1.Extra Corporeal Shock wave
            2.Intra Corporeal

• Better fiber optics – Miniturisation of
  Telescopes
• Accessories - Innovative variety
                   Modern Management of
                   Urolithiasis

•   ESWL
•   Ureterorenoscopy
•   Percutaneous Nephrolithotomy
•   Laparoscopic Approach to stones



Open Ureterolithotomy, Pyelolithotomy or Nephropyelolithotomy is required in
              less than 1 to 2% of modern stone management
TREATMENT (IDEALLY)
  MAJORITY : 80 TO 85 % of all stones can be treated by -
  EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY
  (ESWL)

  MINORITY : 15 TO 20 % SHOULD NEED MINIMALLY
  INVASIVE SURGERY (PCNL / URETEROSCOPY)

  (LESS THAN 1 % SHOULD NEED OPEN SURGERY)
EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY
(ESWL)

    SHOCK WAVES GENERATED UNDER WATER CAN
    TRAVEL   THROUGH    BODY     WITHOUT    ANY
    APPRECIABLE LOSS OF ENERGY. WHEN THEY
    ENCOUNTER STONES THE CHANGES IN DENSITY
    CAUSES   ENERGY    TO   BE   ABSORBED   AND
    REFLECTED BY THE STONE & THIS RESULTS IN
    FRAGMENTATION OF THE STONES.
ESWL – For Urinary Tract Calculus
ESWL- FOUR MAIN ELEMENTS
1.   ENERGY SOURCE
2.   FOCUSING DEVICE
3.   COUPLING DEVICE
4.   LOCALIZATION DEVICE
ESWL
Absolute Contra-indication-
Pregnancy

Relative Contra-Indications for ESWL –
• Renal Colic
•   Urinary obstruction
•   Infection
•   Declining Renal Function
•   Significant Hematuria
COUPLING DEVICE
“WATER BATH”

“WATER FILLED CUSHION”
(KEEP PATIENT’S DRY)
ESWL-HISTORY
1963-EXPERIMENTS WITH “ SHORT
  WAVES” IN W.GERMANY BY
  PHYSICISTS AT DONIER SYSTEMS LTD
1980-DORNIER HUMAN MODEL ( HM-3)
LITHOTRIPTER ARRIVED ON MARKET
(STILL GOLD STANDARD WHEN
  COMPARING RESULTS WITH NEW
  MEASUREMENTS
          ESWL & STAGHORNS

• Dornier HM-3 Monotherapy for STAGSHORNS -
  30% Stone Free Rate (In Dilated Collecting
   System )
• PCNL has higher overall Success
• Combination of PCNL & ESWL can give a
  stone free rates of 90% For ALL STONES IN THE
   KIDNEY
COMPRESSION-TENSILE
WAVE CAUSES:



“Implosion” Rather than “Explosion”
         ESWL & URETERIC CALCULI

• For fragmentation fluid medium around
  stone necessary
• If stones impacted fragmentation may not
  occur
• “PUSH & BANG”-success Marginally
  HIGHER THAN “in situ ESWL”
• Trial of “in situ ESWL” – first choice
• “In situ ESWL” FAILS- “Rescue procedure”
          ESWL COMPLICATIONS

• Haematuria – is quite common ( short term
  antibiotics Recommended )
• Incomplete stone Fragmentation &
  Obstruction
• “Stienstrasse” ( stone street ) usually due to
  a large “ Leading fragment”
  ( Stents Recommended prior to ESWL for
  Calculi > 1.5 cm )
DESIGN BASIC LITHOTRIPSY
Basic Principles of
 “SHOCK WAVE”
    Lithotripsy
FRAGMENTATION BY SHOCK
WAVES
  ON COLLISION OF “ SHOCK WAVES”
  WITH CALCULI-
• ON FRONT SURFACE – COMPRESIVE
  FORCES
• ON BACK SURFACE OF THE STONE-
  REFLECTION OF COMPRESSION
  PULSE CREATES NEGATIVE OR
  TENSILE WAVE THAT TRAVEL BACK
  WARD THROUGH CALCULI
• ONCE TENSILE FORCE EXCEEDS “
  COHESIVE STRENGTH” OF CALCULI-
  FRAGMENTATION OCCURS
ESWL – SPARK GAP/ EHL
• Electro-hydraulic Generator Located at
  Base of Water Bath
• Produces Shock wave by Electric Spark
  Gap of 15,000 to 25,000 Volts Lasting 1
  Sec
• High Voltage Spark Discharge Rapidly-
  evaporates Water & Generators A “Shock
  Wave” by expanding Sarrounding Liquid
Mechanism of Stone Fragmentation by ESWL
 • On Front Surface – Compresive or positive
   Forces
 • On Back Surface Of The Stone-
   Reflection Of Compression Pulse Creates
   Negative Or Tensile Wave That Travel Back
   Ward Through Calculi
 • Once Tensile Force Exceeds “ Cohesive
   Strength” Of Calculi- Fragmentation Occurs
 • Cavitation – Small air bubbles
Steinstrasse ( or Stone Street) – Post
ESWL
 Diet & Fluid Advice
• High Fluid Intake
• Restrict Salt (Na)
• Oxalate Restrict
• Avoid high intake of Purine food
• Increased citrus fruits may help
• If hypercalciuria restrict Ca intake


Role of Potassium Citrate in preventing Cal Oxalate stone ds – KCit
lowers urinary calcium whereas Na Citrate does not lower Calcium
                        due to Sodium load
LIQUIDS
Moderate Amounts :                    High Amounts :

Apple Juice                           Cocoa

Beer                                  Fresh Tea

Coffee

Cola

FOODS :

  Almonds, Asparagus, Cashew Nuts, Currants, Greens,
  Plums, Raspberries, Spinach
HIPPOCRATIC OATH :


“I Will not cut, even for the stone, but leave such

procedures for the practitioners of the craft”

				
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posted:11/27/2011
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