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EVALUATION OF PT WITH UROLITHIASIS
Naveed MaharResident Urology
JPMC, Karachi
Detailed history
Examination
Metabolic evaluation
Radiological investigations
HISTORYDemographic biodataLife styleOccupationDiet/fluid intakeDrug historySystemic diseaseFamily historyHistory of bowel surgery
Urolithiasis is the disease of males between 20 to 5o
years
OCCUPATIONSedentary occupations predispose to stones more
than manual work
Low activity levels predispose to bone demineralization and hypercalciuria.
Physical activity agitate urine and dislodge crystal aggregates
DIETWater intake
Low fluid intake (<1200 ml/day) predisposes to stone formation
A less energy-dense diet may decrease the incidence of stones.
Vegetarians have decreased incidence of urinary stones High sodium intake is associated with increased urinary
SodiumCalciumPHDecreased urinary citrate
CLIMATESummer is the season of urinary stones and
dehydration is the key factorConcentrated urine has a lower ph, encouraging
cystine and uric acid stone formationExposure to sunlight may also increase endogenous
vitamin D production, leading to hypercalciuria.
FAMILY HISTORYIncidence increases with positive family historyFamilial diseases like
Cystinuria An auto-somal recessive disorder of transmembrane cystine
absorptionRTA
Type 1 or distal RTA: the distal tubule is unable to secret H+
Urinary ph(>5.5) Low urinary citrate Hypercalciuria
Type 2 or proximal RTA: failure of bicarbonate resorption in the proximal tubule.
Type 3: a variant of type 1 RTA Type 4 : is seen in diabetic nephropathy and interstitial renal disease.
PAST HISTORYBowel resectionInflammatory bowel diseaseSystemic diseases i-e
- Gout- Hyperparathyroidism- Sarcoidosis
DRUG HISTORYThe antihypertensive(triamterene) is associated
with urinary calculi Long-term use of antacids containing silica leads to
silicate stones. Protease inhibitors in immunocompromised
patients are associated with radiolucent calculi.Corticosteroids (increase enteric absorption of calcium,
leading to hypercalciuria)Chemotherapeutic agents (breakdown products of
malignant cells leads to hyperuricemia)
PHYSICAL EXAMINATIONPt frequently changes posture to find pain reliefRenal colic is associted with tachycardia, sweating,and nausea Costovertebral angle tenderness may be apparent.An abdominal mass may be palpable in patients with hydronephrosisA thorough abdominal examination to exclude other causes of abdominal
pain. Abdominal tumors, Abdominal aortic aneurysms Herniated lumbar disks Pregnancy
Bladder palpation as urinary retention may present with pain similar to renal colic.
Incarcerated inguinal herniasEpididymorchitis A rectal examination helps exclude other pathologic conditions.
METABOLIC EVALUATIONDepends on the stone type(composition) Stone type is analyzed by
Polarizing microscopyX-ray diffractionInfrared spectroscopy
If stone is not retrievedRadiological appearance radiolucecy/opacityMetabolic evaluation
METABOLIC EVALUATION…Urine pH
pH <6 in a patient with radiolucent stones suggests the presence of uric acid stones.
pH consistently >5.5 suggests distal RTA (~70% calcium phosphate stones)
Evaluation for cystinuria Cyanide-nitroprusside colorimetric test (cystine spot test) Measurement of 24-hour urinary cystine (>250 mg is
diagnostic)Evaluation for RTA
If fasting morning urine ph >5.5, the patient is labeled to have distal RTA.
COMPOSITION & PREVELENCE OF RENAL STONES
PH VALUES AND PREDISPOSITION TO STONE TYPE
RADIOLOGIC INVESTIGATIONS
1. X-ray KUB
2. Ultrasonography
3. Intravenous pyelography
4. Computed tomography
5. Magnetic resonance imaging
PLAIN X-RAY KUB
Not useful if stones areRadiolucentSmaller than 4mmLies over the sacrum or other bony structure.
Bowel gases can obscure its efficacy.Can not differentiate between
StonesCalcified lymph nodesPhleboliths
Sensitivity for diagnosis of stones is 50–70%
X-RAY KUB
US KUB
Usually done to compliment x-ray KUB
Its sensitivity for detecting renal calculi is ~95%
Very sensitive for the diagnosis of obstruction and can
detect radiolucent stones missed on KUB
Its non invasive
May miss small stones and ureteral stones
Particularly important in pregnant pt
U/S KUB
INTRAVENOUS PYELOGRAPHY
Useful for patients with suspected indinavir stonesRequires trained technicianIts an invasive procedure predisposing pts to highly
allergic IV contrastsIts very prolonged procedure takes hoursRequire proper pt preparationNot good investigative modality in acute renal colic
IVP
Films and “phases” of IVPPlain film:
This is used to look for calcification overlying the region of the kidneys, ureters, and bladder.
Nephrogram phase: Film taken immediately following iv contrast The nephrogram is produced by filtered contrast within
the lumen of the proximal convoluted tubulePyelogram phase:
Much denser than the nephrogram phase.As concentrated contrast accumulates in plvicalycel system
IVP
X-RAY IVP 3D
COMPUTED TOMOGRAPHY
Has greater specificity (95%) and sensitivity (97%) for diagnosing ureteric - stones
Noncontrast spiral CT scans are now the imaging modality of choice
Advantages:It is rapid No need for experienced radiologic technicianNo need for intravenous contrast.Uric acid stones are also visualized Disadvantage:Distal ureteral calculi can be confused with phleboliths. These images do not give anatomic details as seen on an IVP (for
example, a bifid collecting system)
MAGNETIC RESONANCE IMAGING
MRI is a poor study to document urinary stone disease.
Clue towards obstruction by diagnosing hydronephrosis