Title: B. Wayne Blount, M.D. MPH
1- B. Wayne Blount, M.D. MPH
- Professor and Vice-Chair
- Department of Family Medicine
- Emory University
2OBJECTIVES
- 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
3TODAYS ROADMAP
- Epidemiology
- Presentation and Diff. Dx
- Diagnostic Work-up
- Emergency Situations
- Management Strategy
- Prevention
- Summary
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5EPIDEMIOLOGY
- 2-4 of general population
- 2-3 x more common in males
- Caucasian gt Oriental gt African American
- Hot climates gt temperate
6RISK FACTORS
- Male Gender
- ?Age (to 65)
- Low urine vol.
- Situational
- Geography
- Heredity
- Diet
- Meds
7MEDS CAUSING STONES
- Drugs that promote calcium stone formation
- Loop diuretics
- Antacids
- Acetazolamide
- Glucocorticoids
- Theophylline
- Vitamins D and C
8MEDS CAUSING STONES
- Drugs that promote uric acid stone formation
- Thiazides
- Salicylates
- Probenecid
- Allopurinol
9MEDS CAUSING STONES
- Drugs that precipitate into stones
- Triamterine
- Acyclovir
- Indinavir
10PRESENTATION
- Abdominal Pain
- Renal Colic Sudden Not Relieved
- Hematuria
11DIFFERENTIAL Dx
- Gynecologic Processes
- Testicular Processes
- Appendicitis
- Cholecystitis
- Hernia
- Aneurysm
- Tumors
12Relationship of Stone Location to Symptoms
13Relationship of Stone Location to Symptoms
- Stone Location Common Symptom
- Kidney Vague Flank Pain,
Hematuria
14Relationship of Stone Location to Symptoms
- Stone Location Common Symptom
- Proximal Ureter Renal colic, flank pain,
upper abdominal pain
15Relationship of Stone Location to Symptoms
- Stone Location Common Symptom
- Middle section of Renal colic,
anterior - ureter abdominal pain, flank pain
16Relationship of Stone Location to Symptoms
- Stone Location Common Symptom
- Distal ureter Renal colic,
dysuria, urinary frequency, anterior
abdominal pain, flank pain
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18Work-Up
- History
- P.E.
- U.A.
- Imaging
- Labs
19History
- Focused
- PM Hx
- Fam Hx
- Symptoms of emergencies
20P.E.
- Abdomen
- Pelvis
- Rectal
- Rules out nonurologic process
21U.A.
- RBCs
- pH
- Crystals
- Bacteria
- Some pyuria expected
22Imaging
- Essential to confirm Dx to size and locate
stone - Several Options
23Imaging 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
28Labs
29A 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
31MANAGEMENT(3 Principles)
- Recognize Emergencies
- Adequate Analgesia
- Impact of size and location on Hx Rx
32MANAGEMENT(3 Principles)
- Recognize Emergencies
- Adequate Analgesia
- Impact of size and location on Hx Rx
33MANAGEMENT(3 Principles)
- Recognize Emergencies
- Adequate Analgesia
- Impact of size and location on Hx Rx
34MANAGEMENT(3 Principles)
- Recognize Emergencies
- Adequate Analgesia
- Impact of size and location on Hx Rx
35Emergencies
- Sepsis with obstruction (struvite stones?)
- Anuria
- ARF
- Urologic consultation
36Hospitalization?
- Emergencies
- Refractory Nausea
- Debilitation
- Extremes of age
- Refractory Pain
37Analgesia
- NSAIDs also spasmolytic
- Narcotics
- No NSAIDs lt 3 days before lithotripsy (ASA lt 7
days) - Ketorolac
38Manage The Stone
- After adequate analgesia and ruling out
emergencies - Principles here are stone size and location
39Probability 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
40SUGGESTIONS
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
41SUGGESTIONS
Stones gt 5 mm
42SUGGESTIONS
Stones 4 5 mm
- Decide based on other parameters
43Other Parameters
- Location
- Composition
- Larger Size
- Occupation
44Location
- Renal stones usually can be followed
45Composition
- Staghorn renal calculi to
- urology (assoc. with
- infections and kidney
- damage)
46Occupation
- Pilots cannot fly even with an asymptomatic stone
- Get early definitive Rx
47Larger 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
48Larger than 2 cm or when ECL contraindicated or
not effectiveRenal Proximal ureteral stones
Percutaneous nephrolithotomy
49Ureteroscopes
- Stones anywhere dependent on technicians
abilities
50Treatment 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
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52Treatment 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
53Treatment 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
54Treatment 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
55A SUGGESTED PATHWAY
56A SUGGESTED PATHWAY
57Prevention (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
59Prevention
- 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
60Calcium 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)
61Calcium Stones
- In the patient with hypocitraturia
- Dietary restriction of protein and
- sodium
- Potassium citrate supplementation (sodium
citrate if potassium citrate is not tolerated)
62Calcium Stones
- In the patient with hyperoxaluria
- Dietary restrictin of oxalate
- In the patient with hyperuricosuria
- Dietary restriction of purine (I.e., protein)
Allopurinol (Zyloprim)
63Uric 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
64Uric 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
-
65SUMMARY
66Risk for Renal Failure
- Hereditary stone diseases
- Struvite stones
- Infection associated calculi obstruction
- Frequent relapses
- No. of urologic interventions
- Stone size
67Bibliography
- Portis AJ, and Sundaram CP. Diagnosis and Initial
Management of Kidney Stones. Am Fam
Physician 2001631329-38. - Goldfarb DS and Coe FL. Prevention of Recurrent
Nephrolithiasis. Am Fam Physician
1999602269-76. - Bihl G and Meyers A. Recurrent renal stone
disease. Lancet 2001358651-6. - Gambaro G, Favaro S, MD, DAngelo A. Risk for
Renal Failure in Nephrolithiasis. AJKD 2001,
37233-243.