Stone Diseases (Brief Overview)

8/13/2019 Stone Diseases (Brief Overview)

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STONE DISEASE( Brief Overview )

Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.),

Professor & HOD, Dept. of Urology,Sri Ramachandra Medical College & Research Institution

Consultant Urologist & Renal Transplant Surgeon,Sri Ramachandra Hospital, Porur, Madras.


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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 20.2Phosphate

Magnesium Ammonium 2.7 15 17.4 15.4Phosphate (Struvite )

Uric Acid 1.2 8.0 4.4 8.0

Cystine 0.4 3.0 1.0 2.8


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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


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Inhibitors & Promoters of Stone Formation in Urine

INHIBITORSInhibits crystal Growth - Citrate complexes with Ca Magnesium complexes with

oxalates

Pyrphosphate - complexeswith Ca ZincInhibits crystal Aggregation Glycosaminoglycans Nephrocalcin Tamm- Horsfall Protein

PROMOTERS Bacterial Infection Matrix Anatomic Abnormalities PUJ

obst., MSK Altered Ca and oxalate transport

in renal epithelia Prolonged immobilisation Increased uric acid levels I.e

taking increased purine subs promotes crystalisation of Ca andoxalate

?? Nanobacteria seen in 97% ofrenal stones


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SOME DISEASES ASSOCIATED WITHHYPERCALCAEMIA & HYPERCALCIURIA

Hyperparathyroidism Leukemia

Sarcoidosis Lymphoma

Multiple myeloma Myxedema

Hyperthyroidism Adrenal Insufficiency

Metastatic Malig. Neoplasm's Vit. D Intoxication


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TYPES OF KIDNEY / URETER STONES

OXALATE (CALCIUM OXALATE)

PHOSPHATE

URIC ACID & URATE

CYSTINE


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Uncommon StonesXAN THINE STONES

( Autos omal Recess ive . Def of Xanthine Oxidase leading to Xanthinur ia)

DIHYDROXYADENINE STONE

( Def . of enzym e adenine phospo r ibosyl t ransferase )

SlLICATE STONES

Rare in hum ans ( excess in take of An tac id wi th Mg Tr is i l ica te . Most ly incat t le due to inges t ion o f Sand )

MATRIX

- Infec t ion by Proteus - Radiolucent (al l calculi h ave som e amt ( 3%) of m atrixbut m atr ix ca lculus has 65% Matr ix con tent in ca lcul i )


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Uncommon Stones

TRIAMTERENE

A nt i -hyper tens ive used wi th h ydroc loroth iaz ide spare Potass ium .Most ly found as a nucleus in Ca oxalate or ur ic ac id ca lculus

Ind inavir Stones

- Drug to treat AIDS (4 to13%)

Ephedr ine or Guifenes in

Cough m edic ine - Radiolucent


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Stones Chemical Constituents

Whewelite Calcium Oxalate Monohydrate CaC 2O 4-H2O

Weddelite - Calcium Oxalate dihydrate CaC 2O 4-2H 2O

Brushite Calcium Hydrogen phosphate dihydrate CaHPO 4 2H 2O

Whitlockite - TriCalcium Phosphate Ca 2(PO 4)2

Struvite Magnesium Ammonium hexahydrate MgNH 4PO 4-6H 2O


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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 andLike an Envelope if Dihydrate


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PHOSPHATE STONE

USUALLY CALCIUM PHOSPHATE

SOMETIMES CALCIUM MAGNESIUM AMMONIUMPHOSPHATE OR TRIPLE PHOSPHATE

SMOOTH MINIMUM SYMPTOMS

DIRTY WHITE

RADIO - OPAQUE

Calcium Phosphate also called Brushite appears like Needle shape undermicroscope


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PHOSPHATE STONES

IN ALKALINE URINE

ENLARGES RAPIDLY

TAKE SHAPE OF CALYCES

STAGHORN

Struvite can form Stag-horn and appear like coffin lid under microscope


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CALCIUM PHOSPHATE STONES

Hyperparathyroidism Ca P

Renal Tubular Acidosis K CO 2

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


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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


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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 benezenering ask for first morning sample


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CYSTINE STONE - Management

High Fluid Intake and Alkalanise Urine dissolve most ofthe smaller cystine stones

D-Pencillamine or MPG (Mercaptopropionylglycine) binds tocystine 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

Cyanide Nitroprusside Calorimeteric Test for detecting Cystinuria. If positive doamino acid chromatography

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


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Surgical Conditions and Stone Disease

Regional ileitis and Ileal Bypass Surgery for egObesity can lead to increase oxalate absorptionand stone ds

ileostomies - In Chr. Diarrhoea with Bicabonate

loss systemic acidosis and acidic urine increases risk of Uric Acid stones


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HISTORY

A. IS PATIENT DRINKING ENOUGH ?

B. PROFESSION

C. ENQUIRE ABOUT UTI STONES

D. FAMILY HISTORY

E. LONG ILLNESS BEDRIDDEN STONES


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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 urineAtleast drink 3 lits to avoid stone formation


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HISTORY (Cont...)

B. ASK ABOUT THEIR PROFESSION

DEHYDRATION STONES CAN FORM e.g.

MARATHON NEAR A FURNACE,

BRICK - LAYER, LABOURERS & WEAVERS

TRUCK & BUS DRIVERS


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C. ENQUIRE ABOUT UTI STONES

D. FAMILY HISTORY

E. LONG ILLNESS BEDRIDDEN STONES

HISTORY (Cont...)

Zero Gravity state astronauts on long space flights more prone tostones


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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 inrenal colic


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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


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ON EXAMINATION

1. ACUTE PRESENTATION

ABDOMEN TENSE AND RIGID

TENDERNESS PRESENT IN THE LOIN

2. IN ROUTINE PRESENTATION

NO FINDINGS IN ABDOMEN


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INVESTIGATIONS

1. FULL BLOOD COUNT TO CHECK FOR

ANAEMIA IF GOING FOR SURGERY

2. SERUM ELECTROLYTES PLUS UREA /

CREATININE / CALCIUM / URIC ACID /

PHOSPHATE


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INVESTIGATIONS (Cont...)

4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory)

5. IVU OR IVP (INTRA VENOUS UROGRAM)

6. ULTRASOUND (Mandatory)


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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


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Bilateral Ureteric Calculus in a patient presenting with Anuria

Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows onGantry. These are rapidly performed and do not require contrast agents for reconstruction.


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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


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Modern Management of Urolithiasis

ESWL Ureterorenoscopy Percutaneous Nephrolithotomy Laparoscopic Approach to stones

Open Ureterolithotomy, Pyelolithotomy or Nephropyelolithotomy is required in lessthan 1 to 2% of modern stone management


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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)


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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 F U i T C l l


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ESWL For Urinary Tract Calculus


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ESWL- FOUR MAIN ELEMENTS

1. ENERGY SOURCE2. FOCUSING DEVICE3. COUPLING DEVICE4. LOCALIZATION DEVICE


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COUPLING DEVICE

WATER BATH

WATER FILLED CUSHION (KEEP PATIENTS DRY)


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ESWL-HISTORY

1963- EXPERIMENTS WITH SHORT WAVES INW.GERMANY BY PHYSICISTS AT DONIERSYSTEMS LTD

1980-DORNIER HUMAN MODEL ( HM-3)

LITHOTRIPTER ARRIVED ON MARKET(STILL GOLD STANDARD WHEN COMPARING

RESULTS WITH NEW MEASUREMENTS


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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 THEKIDNEY


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COMPRESSION-TENSILE WAVECAUSES:

Implosion Rather than Explosion


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ESWL & URETERIC CALCULI

For fragmentation fluid medium aroundstone 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


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DESIGN BASIC LITHOTRIPSY


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Basic Principles ofSHOCK WAVE

Lithotripsy


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FRAGMENTATION BY SHOCKWAVES

ON COLLISION OF SHOCK WAVES WITHCALCULI-

ON FRONT SURFACE COMPRESIVE FORCES ON BACK SURFACE OF THE STONE-

REFLECTION OF COMPRESSION PULSECREATES NEGATIVE OR TENSILE WAVE THATTRAVEL BACK WARD THROUGH CALCULI

ONCE TENSILE FORCE EXCEEDS COHESIVESTRENGTH OF CALCULI - FRAGMENTATIONOCCURS


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ESWL SPARK GAP/ EHL

Electro-hydraulic Generator Located at Base ofWater Bath

Produces Shock wave by Electric Spark Gap of15,000 to 25,000 Volts Lasting 1 Sec

High Voltage Spark Discharge Rapidly-evaporates Water & Generators A Shock Waveby expanding Sarrounding Liquid


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Mechanism of Stone Fragmentation by ESWL

On Front Surface Compresive or positive Forces On Back Surface Of The Stone-

Reflection Of Compression Pulse Creates NegativeOr Tensile Wave That Travel Back Ward ThroughCalculi

Once Tensile Force Exceeds Cohesive StrengthOf Calculi- Fragmentation Occurs

Cavitation Small air bubbles


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Steinstrasse ( or Stone Street) Post ESWL


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LIQUIDS


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LIQUIDS

Moderate Amounts : High Amounts :

Apple Juice Cocoa

Beer Fresh Tea

Coffee

Cola

FOODS :

Almonds, Asparagus, Cashew Nuts, Currants, Greens,

Plums, Raspberries, Spinach


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Documents

Stone Diseases (Brief Overview)