renal stones dr.bandar al hubaishy urology department kauh
TRANSCRIPT
Renal stones
Dr.Bandar Al Hubaishy
Urology Department
KAUH
Clinical picture
Renal stones:
Small stones:
Pain
Infection
Hematouria
Large renal stones:
They are asymptomatic e.g. staghorn stones
Which are associated by UTI
Ureteric stones:Renal colic: it is a severe colicky pain in the flank that
can radiate to the groin and scrotum in male
Nausea and vomiting
Hematouria
Irritative symptoms as the stones in the distal part of the ureter
Physical examination
Costovertebral angel tenderness
No peritoneal signs
Work up
Laboratory
Urine analysis
for evidence of hematouria and infection
CBC
for evidence of systemic infection
Serum electrolytes Serum calcium PTH Phosphate Uric acid
Metabolic screen
24 hours urinary collection offor levels of pH, calcium, oxalate, uric acid, sodium, phosphorus, citrate, magnesium, creatinine, and total volume
The goal of metabolic screen
To prevent future stone formation due to metabolic abrnomalities
Indications for metabolic screen
Residual calculi after surgical treatment Initial presentation with multiple calculi Initial presentation before age 30 years Renal failure Solitary kidney (including renal transplant) Family history of calculi More than one stone in the past year Bilateral calculi
Imaging studies
KUB
Renal ultrasound
Spiral C.T abdomen without contrast
IVP
KUB
To detect radiopaque stones
To follow up the radiopaque stone
Ultrasound
For radiolucent stones and for pregnant stones
To assess the presence of hydronephrosis
It can not assess the presence of ureteric stones
IVP
It assess both function and anatomy of the renal system
Delayed nephrogram is the only hallmark for urinary tract obstruction
Contraindications of IVP:
Pregnancy
Pediatric
Allergy
Mettformin
Renal impairment
It is no longer used as the standard for the initial evaluation of a patient with a kidney stone :
Up to 6 hours may be required to complete the study in the presence of severe obstruction.
For optimal results, IVU requires a bowel preparation.
It involves intravenous injection of potentially allergic and mildly nephrotoxic contrast material
Spiral C.T abdomin and Pelvis without contrast
It is the best initial radiographic examination for acute renal colic.
Advantages of a CT scanning include the following: It can reveal other pathology (eg,
abdominal aneurysms, appendicitis, cholecystis). It can be performed quickly. It avoids the use of intravenous contrast materials.
Disadvantages of CT scanning include the following:
It cannot be used to assess individual renal function.
It can fail to reveal some unusual radiolucent stones, such as those caused by indinavir, which are invisible on the CT scan. Because of this possibility, IVUs with contrast should be used for patients taking indinavir.
It is relatively expensive.
It exposes the patient to a relatively high radiation dose. Precise identification of small distal stones is
occasionally difficult. It is not suitable for tracking the progress of the stone
over time, supporting the recommendation for KUB radiography along with the CT scan.
MANAGEMENT
It depends on the site , size and the general condition of the patient
The management involve medical and surgical management
Renal Stones
Small renal stones less than 0.6 mm:
Hydration
Ebimag
Follow up in the clinic with KUB every 2 weeks
Renal stones size 0.7mm-2cm:
ESWL
Hydration
Analgesic
KUB follow up in the clinic
Renal stones bigger than 2 cm
Percutaneous nephrostolithotomy (PCNL)
Ureteric Stones
Non obstructing stone:
Hydration Ebimag Analgesic
Obstructing ureteric stone If the patient is stable, ureteroscopy and
lithotripsy
If the patient is not stable,do double j stent insertion or nephrostomy tube to decompress the obstruction