nephrolithiasis abrahim syed february 2013 paul lewis md
TRANSCRIPT
![Page 1: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/1.jpg)
Nephrolithiasis
Abrahim Syed
February 2013
Paul Lewis MD
![Page 2: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/2.jpg)
History
2
• 65 y/o woman with a history of nephrolithiasis who presents with intermittent gross hematuria for several weeks. Not typically associated flank in the past. Referred to urology.
• PMH: HTN, A-fib, CAD, OA, lymphocytic colitis• PSH: Brain surgery (abscess), coronary stent• Meds: Tramadol PRN, Vit D2, lyrica, lisinopril,
rosuvastatin, metoprolol, Plavix, alendronate• NKDA• ROS: No urinary incontinence, dysuria previously
![Page 3: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/3.jpg)
• Vitals: 130/90, HR:65, T:98F, BMI:23.08• Back: No CVA tenderness• Abdomen: Soft, non-distended, non-tender,
normal bowel sounds
Physical Exam
3
![Page 4: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/4.jpg)
• 2/14/13– Abnormal Urine Culture:• Positive for K. Pneumoniae
Labs
4
• 1/19/13:– NA: 142– K: 4.4– Cl: 108– HCO3: 22– Ca: 9.9– BUN: 14– Cr: 0.92
![Page 5: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/5.jpg)
• Differential Diagnosis:– Kidney stone– Polycystic kidney disease, hydronephrosis– Cancer: kidney, ureter, bladder– Intrinsic glomerular disease– Pyelonephritis, urethritis
• Plan: – Imaging
Management
5
![Page 6: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/6.jpg)
Imaging
6
![Page 7: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/7.jpg)
Imaging
7
![Page 8: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/8.jpg)
KUB
Abdominal Plain Film (x-ray)
acc 5200827
![Page 9: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/9.jpg)
Normal KUB
Abdominal Plain Film (x-ray)
![Page 10: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/10.jpg)
IVP
Abdominal Plain Film (x-ray)http://drugline.org/medic/term/kub/
![Page 11: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/11.jpg)
KUB
Abdominal Plain Film (x-ray)
acc 5200827
![Page 12: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/12.jpg)
Abdomen
CT Abdomen with IV Contrast - Axial
acc 5200827
![Page 13: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/13.jpg)
CT Abdomen with IV Contrast - Axial
acc 5200827
![Page 14: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/14.jpg)
Abdomen
CT Abdomen with IV Contrast - Coronal
acc 5200827
![Page 15: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/15.jpg)
Abdomen
CT Abdomen with IV Contrast - Coronal
acc 5200827
![Page 16: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/16.jpg)
Abdomen
acc 5200827
CT Abdomen with IV Contrast - Saggital
![Page 17: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/17.jpg)
Abdomen
acc 5200827
CT Abdomen with IV Contrast - Saggital
![Page 18: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/18.jpg)
• Imaging modalities– Non-Contrast Helical CT– Intravenous Pyelography– Plain Radiography (KUB)– Ultrasonography
Diagnosis
18
![Page 19: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/19.jpg)
• Gold Standard– 95-100% Sensitivity, 94-96% Specificity– Can distinguish radiolucent stones– Detects secondary signs of urinary tract obstruction
• Hydronephrosis, ureteral dilatation, perineprhic fat stranding and/or fluid collection
• Soft-tissue rim sign– Circumferential edema from ureteral lithiasis– Differentiates from phlebolith
• Disadvantages– Expense, x-ray exposure, cannot assess renal function
Non-Contrast Helical CT
19
![Page 20: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/20.jpg)
Non-Contrast Helical CT
2010.1148/radiol.2291020690Radiology 2003; 229:239
![Page 21: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/21.jpg)
• Previous Gold Standard– Up to 87% Sensitivity, 94% Specificity– Provides information on anatomy and function of
kidneys
• Disadvantages– Variable quality– Requires use of contrast media– Poor visualization of non-genitourinary conditions– Delayed images for high-grade obstruction– Radiation exposure
IVP
21
![Page 22: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/22.jpg)
IVP
22
![Page 23: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/23.jpg)
• Advantages:– Accessible, inexpensive– Less radiation exposure
• Disadvantages– Will miss radiolucent stones, small stones, and those
obscured by bone– Will not detect obstruction– Up to 70% Sensitivity and 77% Specificity– Phleboliths
KUB
23
![Page 24: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/24.jpg)
• Advantages– No radiation exposure– Readily available– Use of color Doppler– Good for hydronephrosis– Can detect radiolucent stones– Up to 70% Sensitivity, 97% Specificity
• Disadvantages– May miss small stones and ureteral stones– Skill of ultrasonographer
Ultrasound
24
![Page 25: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/25.jpg)
Ultrasound
25
Stones seen as echogenic foci and produce distal acoustic shadowing
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Hematuria.htm
![Page 26: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/26.jpg)
• ≤5 mm in diameter pass spontaneously• Conservative management: pain control, hydration
• Stones ≥10 mm in diameter, less likely to pass• Medication: nifedipine, tamsulosin• Shock wave lithotripsy (SWL), ureteroscopic lithotripsy with
electrohydraulic or laser probes, percutaneous nephrolithotomy and laparoscopic stone removal
Treatment
26
![Page 27: Nephrolithiasis Abrahim Syed February 2013 Paul Lewis MD](https://reader036.vdocument.in/reader036/viewer/2022081519/56649e625503460f94b5e0cc/html5/thumbnails/27.jpg)
Begg, James D. "How to Look at an Abdominal X-ray." Abdominal X-rays Made Easy. Edinburgh: Churchill Livingstone, 2006. 1-38. US Elsevier Health Bookshop. Elsevier. Web. 26 Feb. 2013
http://www.uptodate.com/contents/diagnosis-and-acute-management-of-suspected-nephrolithiasis-in-adults?source=search_result&search=kidney+stone+differential&selectedTitle=1%7E150#H17
http://www.aafp.org/afp/2001/0401/p1329.html
http://emedicine.medscape.com/article/437096
References
27