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B. Wayne Blount, M.D. MPH

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... Intravenous pyelography if CT is not available Noncontrast helical CT Stone not detected Clinical suspicion of urolithiasis Stone detected MANAGEMENT ... – PowerPoint PPT presentation

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Title: B. Wayne Blount, M.D. MPH


1
  • B. Wayne Blount, M.D. MPH
  • Professor and Vice-Chair
  • Department of Family Medicine
  • Emory University

2
OBJECTIVES
  • Discuss the recommended work-up to diagnose
    nephrolithiasis
  • Know the different treatment options for site and
    size specific stones
  • Recognize the urgent situations of
    nephrolithiasis
  • Know when to seek urologic consultation

3
TODAYS ROADMAP
  • Epidemiology
  • Presentation and Diff. Dx
  • Diagnostic Work-up
  • Emergency Situations
  • Management Strategy
  • Prevention
  • Summary

4
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5
EPIDEMIOLOGY
  • 2-4 of general population
  • 2-3 x more common in males
  • Caucasian gt Oriental gt African American
  • Hot climates gt temperate

6
RISK FACTORS
  • Male Gender
  • ?Age (to 65)
  • Low urine vol.
  • Situational
  • Geography
  • Heredity
  • Diet
  • Meds

7
MEDS CAUSING STONES
  • Drugs that promote calcium stone formation
  • Loop diuretics
  • Antacids
  • Acetazolamide
  • Glucocorticoids
  • Theophylline
  • Vitamins D and C

8
MEDS CAUSING STONES
  • Drugs that promote uric acid stone formation
  • Thiazides
  • Salicylates
  • Probenecid
  • Allopurinol

9
MEDS CAUSING STONES
  • Drugs that precipitate into stones
  • Triamterine
  • Acyclovir
  • Indinavir

10
PRESENTATION
  • Abdominal Pain
  • Renal Colic Sudden Not Relieved
  • Hematuria

11
DIFFERENTIAL Dx
  • Gynecologic Processes
  • Testicular Processes
  • Appendicitis
  • Cholecystitis
  • Hernia
  • Aneurysm
  • Tumors

12
Relationship of Stone Location to Symptoms
13
Relationship of Stone Location to Symptoms
  • Stone Location Common Symptom
  • Kidney Vague Flank Pain,
    Hematuria

14
Relationship of Stone Location to Symptoms
  • Stone Location Common Symptom
  • Proximal Ureter Renal colic, flank pain,
    upper abdominal pain

15
Relationship of Stone Location to Symptoms
  • Stone Location Common Symptom
  • Middle section of Renal colic,
    anterior
  • ureter abdominal pain, flank pain

16
Relationship of Stone Location to Symptoms
  • Stone Location Common Symptom
  • Distal ureter Renal colic,
    dysuria, urinary frequency, anterior
    abdominal pain, flank pain

17
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18
Work-Up
  • History
  • P.E.
  • U.A.
  • Imaging
  • Labs

19
History
  • Focused
  • PM Hx
  • Fam Hx
  • Symptoms of emergencies

20
P.E.
  • Abdomen
  • Pelvis
  • Rectal
  • Rules out nonurologic process

21
U.A.
  • RBCs
  • pH
  • Crystals
  • Bacteria
  • Some pyuria expected

22
Imaging
  • Essential to confirm Dx to size and locate
    stone
  • Several Options

23
Imaging Options
  • Ultrasonography
  • KUB
  • Intravenous Pyelography (IVP)
  • Noncontrast Helical C.T.

24
Imaging modality Sensitivity ()
Specificity ()
Ultrasonography 19
97
Advantages Limitations
Accessible Poor visualization of Good for
diagnosing of ureteral stones Hydronephrosis
and renal stones Requires no ionizing radiation
25
Imaging modality Sensitivity ()
Specificity ()
Plain radiography 45 to 59
71 to 77
Advantages Limitations
Accessible Stones in middle section
expensive of ureter, phleboliths,
radiolucent calculi, extraurinary
calcifications and nongenitourinary
conditions
26
Imaging modality Sensitivity ()
Specificity ()
Intravenous 64 to 87
92 to 94 pyelography
Advantages Limitations
Accessible Variable-quality imaging Provides
information Requires bowel preparation on
anatomy and use of contrast
media functioning of both Poor visualization of
non- kidneys genitourinary
conditions Delayed images required in
high-grade obstruction
27
Imaging modality Sensitivity ()
Specificity ()
Noncontrast helical 95 to 100
94 to 96 computed tomography
Advantages Limitations
Most sensitive specific Less accessible and
radiologic test (i.e., facilitates relatively
expensive fast, definitive diagnosis) No direct
measure of Indirect signs of the degree of renal
function. obstruction Provides information on
non- genitourinary conditions
28
Labs
  • CBC
  • UA
  • BMP
  • Ca
  • PO4
  • Urate
  • Urine C S
  • Stone Analysis

29
A SUGGESTION
Patient with abdominal pain
History and physical examination
Renal colic suspected
Diagnostic imaging ???
Patient is pregnant, or cholecystitis or
gynecologic process is suspected
Patient has history of radiopaque calculi
All other patients
30

Ultrasound Examination
Plain-film radiography
Intravenous pyelography if CT is not available
Noncontrast helical CT
Stone not detected
Stone detected
Stone detected
Stone not detected
Clinical suspicion of urolithiasis
31
MANAGEMENT(3 Principles)
  • Recognize Emergencies
  • Adequate Analgesia
  • Impact of size and location on Hx Rx

32
MANAGEMENT(3 Principles)
  • Recognize Emergencies
  • Adequate Analgesia
  • Impact of size and location on Hx Rx

33
MANAGEMENT(3 Principles)
  • Recognize Emergencies
  • Adequate Analgesia
  • Impact of size and location on Hx Rx

34
MANAGEMENT(3 Principles)
  • Recognize Emergencies
  • Adequate Analgesia
  • Impact of size and location on Hx Rx

35
Emergencies
  • Sepsis with obstruction (struvite stones?)
  • Anuria
  • ARF
  • Urologic consultation

36
Hospitalization?
  • Emergencies
  • Refractory Nausea
  • Debilitation
  • Extremes of age
  • Refractory Pain

37
Analgesia
  • NSAIDs also spasmolytic
  • Narcotics
  • No NSAIDs lt 3 days before lithotripsy (ASA lt 7
    days)
  • Ketorolac

38
Manage The Stone
  • After adequate analgesia and ruling out
    emergencies
  • Principles here are stone size and location

39
Probability of Stone Passage
Stone location and size Probability of passage ()
Proximal ureter
gt 5 mm 0
5 mm 57
lt 5mm 53
Middle section of ureter
gt 5 mm 0
5 mm 20
lt 5mm 38
Distal ureter
gt 5 mm 25
5 mm 45
lt 5mm 74
40
SUGGESTIONS

Stones lt 4 mm
  • Passage in 1-2 wks
  • Analgesia
  • Strain Urine
  • F/U KUB Q 1-2 wks
  • Urology if not passed in 2 wks. (certainly 4 wks
    as comps ? 3X)
  • RTC signs of sepsis

41
SUGGESTIONS
Stones gt 5 mm
  • Urologic Consultation

42
SUGGESTIONS
Stones 4 5 mm
  • Decide based on other parameters

43
Other Parameters
  • Location
  • Composition
  • Larger Size
  • Occupation

44
Location
  • Renal stones usually can be followed

45
Composition
  • Staghorn renal calculi to
  • urology (assoc. with
  • infections and kidney
  • damage)

46
Occupation
  • Pilots cannot fly even with an asymptomatic stone
  • Get early definitive Rx

47
Larger Size
  • Renal calculi of 5 mm 2 cm Extra corporeal
    lithotripsy
  • Lower pole stones 5 mm 1 cm ECL
  • Ureteral stones 5 mm 1 cm ECL

48
Larger than 2 cm or when ECL contraindicated or
not effectiveRenal Proximal ureteral stones
Percutaneous nephrolithotomy
49
Ureteroscopes
  • Stones anywhere dependent on technicians
    abilities

50
Treatment Modalities for Renal and Ureteral
Calculi
Treatment Indications
Advantages Extracorporeal
Radiolucent calculi Minimally invasive
shock wave Renal stones lt 2 cm
Outpatient lithotripsy Ureteral
stones lt 1 cm procedure
Limitations Complications Requires
spontaneous passage Ureteral obstruction by
of fragments stone fragments
Less effective in patients with Perinephric
hematoma morbid obesity or hard stones
51
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52
Treatment Modalities for Renal and Ureteral
Calculi
Treatment Indications
Advantages Ureteroscopy Ureteral
stones Definitive Outpatient procedure
Limitations Complications Invasive Urete
ral stricture or Commonly requires
injury postoperative ureteral stent
53
Treatment Modalities for Renal and Ureteral
Calculi
Treatment Indications
Advantages Ureterorenoscopy Renal
stones lt 2 cm Definitive Outpatient
procedure
Limitations Complications May be
difficult to clear Ureteral stricture or
injury fragments Commonly requires
postoperative ureteral stent
54
Treatment Modalities for Renal and Ureteral
Calculi
Treatment Indications
Advantages Percutaneous Renal stones
gt2 cm Definitive nephrolithotomy Proximal
ureteral stones gt 1 cm
Limitations Complications Invasive Blee
ding Injury to collecting
system Injury to adjacent structures
55
A SUGGESTED PATHWAY
56
A SUGGESTED PATHWAY
57
Prevention (of Recurrences)
  • Need to analyze the calculi
  • Labs for all recurrences and for children
  • 24 urine Vol, pH,
  • Ca. PO4, Na, Urate, Oxalate, Citrate,
    Creatine, Ca P04, CaOx

58

Optimum Values of 24 h Urine Sample Constituents
Volume gt2 2 5 L
pH gt5 5 and lt 7 0 (a spot urine) specimen will suffice)
Calcium lt0.1 mmol/kg, or lt 7 5 mmol in men, lt6 3 mmol in women
Oxalate 180-350 µmol
Uric acid 1 5 - 4 4 mmol
Citrate 2 4 - 5 1 mmol
Sodium lt200 mmol
Phosphate lt35 2 mmol
To ensure adequacy of collection, urine creatinine should be 7 1 15 9 mmol in men 5 2 14 1 mmol in women To ensure adequacy of collection, urine creatinine should be 7 1 15 9 mmol in men 5 2 14 1 mmol in women
59
Prevention
  • All patients 2-3 L water Q day, 8-12
    oz QHS
  • B rec
  • ?NaCL (2g)
  • ? Animal protein (8 oz)
  • ? Oxalate
  • ? Calcium in diet B rec

C Rec unless dietary excesses
60
Calcium Stones
  • In all patients, increase fluid intake to yield
    an output of at least 2 L of urine per day.
  • In the patient with hypercalciuria
  • Dietary restriction of protein, oxalate
  • and sodium no restriction of dietary
  • calcium
  • Medication thiazides, usually given
  • with potassium citrate amiloride
    (Midamor)

61
Calcium Stones
  • In the patient with hypocitraturia
  • Dietary restriction of protein and
  • sodium
  • Potassium citrate supplementation (sodium
    citrate if potassium citrate is not tolerated)

62
Calcium Stones
  • In the patient with hyperoxaluria
  • Dietary restrictin of oxalate
  • In the patient with hyperuricosuria
  • Dietary restriction of purine (I.e., protein)
    Allopurinol (Zyloprim)

63
Uric Acid Stones
  • Increasing fluid intake is less important for the
    prevention of uric acid stones than calcium
    stones
  • In the patient with a low urinary pH level
  • Dietary restriction of protein and sodium

64
Uric Acid Stones
  • In the patient with hyperuricosuria
  • Dietary restriction of protein and sodium
  • Alkalinization of urine with potassium citrate
    if urinary pH level is low
  • Allopurinol in selected situations

65
SUMMARY
66
Risk for Renal Failure
  • Hereditary stone diseases
  • Struvite stones
  • Infection associated calculi obstruction
  • Frequent relapses
  • No. of urologic interventions
  • Stone size

67
Bibliography
  1. Portis AJ, and Sundaram CP. Diagnosis and Initial
    Management of Kidney Stones. Am Fam
    Physician 2001631329-38.
  2. Goldfarb DS and Coe FL. Prevention of Recurrent
    Nephrolithiasis. Am Fam Physician
    1999602269-76.
  3. Bihl G and Meyers A. Recurrent renal stone
    disease. Lancet 2001358651-6.
  4. Gambaro G, Favaro S, MD, DAngelo A. Risk for
    Renal Failure in Nephrolithiasis. AJKD 2001,
    37233-243.
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