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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STONE DISEASE ( Brief Overview ) Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.), Professor & HOD, Dept. of Urology, Sri Ramachandra Medical College &
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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.
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 20.2
Phosphate
Magnesium Ammonium 2.7 15 17.4 15.4
Phosphate (Struvite )
Uric Acid 1.2 8.0 4.4 8.0
Cystine 0.4 3.0 1.0 2.8
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
Inhibitors & Promoters of Stone Formation in Urine
Under microscope looks like Hourglass or Dumbbell shape if monohydrate and Like an Envelope if Dihydrate
PHOSPHATE STONE
• USUALLY CALCIUM PHOSPHATE
• SOMETIMES CALCIUM MAGNESIUM AMMONIUM
PHOSPHATE OR TRIPLE PHOSPHATE
• SMOOTH MINIMUM SYMPTOMS
• DIRTY WHITE
• RADIO - OPAQUE
Calcium Phosphate also called ‘Brushite’ appears like Needle shape under microscope
PHOSPHATE STONES
IN ALKALINE URINE
ENLARGES RAPIDLY
TAKE SHAPE OF CALYCES
STAGHORN
Struvite can form Stag-horn and appear like coffin lid under microscope
CALCIUM PHOSPHATE STONES
• Hyperparathyroidism Ca P
• Renal Tubular Acidosis K CO2
• 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
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
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 benezene ring – ask for first morning sample
CYSTINE STONE - Management
• High Fluid Intake and Alkalanise Urine – dissolve most of
the smaller cystine stones
• D-Pencillamine or MPG (Mercaptopropionylglycine) binds
to cystine 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 do amino acid chromatography
pKa of cystine is 8.3, hence alkalinisisation above pH7.5 helps to dissolve the stones
Surgical Conditions and Stone Disease
• Regional ileitis and Ileal Bypass Surgery for eg Obesity can lead to increase oxalate absorption and stone ds
• ileostomies - In Chr. Diarrhoea with– Bicabonate loss – systemic acidosis and acidic urine – increases risk of Uric Acid stones
HISTORY
A. IS PATIENT DRINKING ENOUGH ?
B. PROFESSION
C. ENQUIRE ABOUT UTI STONES
D. FAMILY HISTORY
E. LONG ILLNESS BEDRIDDEN STONES
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
HISTORY (Cont...)
B. ASK ABOUT THEIR PROFESSION
DEHYDRATION STONES CAN FORM e.g.
• MARATHON NEAR A FURNACE,
• BRICK - LAYER, LABOURERS & WEAVERS
• TRUCK & BUS DRIVERS
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 to stones
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 in renal colic
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
ON EXAMINATION
1. ACUTE PRESENTATION
• ABDOMEN TENSE AND RIGID
• TENDERNESS PRESENT IN THE LOIN
2. IN ROUTINE PRESENTATION
• NO FINDINGS IN ABDOMEN
INVESTIGATIONS
1. FULL BLOOD COUNT TO CHECK FOR
ANAEMIA IF GOING FOR SURGERY
2. SERUM ELECTROLYTES PLUS UREA /
CREATININE / CALCIUM / URIC ACID /
PHOSPHATE
INVESTIGATIONS (Cont...)
3. 24-HOURS URINE FOR ELECTROLYTES
(Only if recurrent stone former)
CALCIUM / OXALATE / URIC ACID /
CYSTINE / CITRATE
INVESTIGATIONS (Cont...)
4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory)
5. IVU OR IVP (INTRA VENOUS UROGRAM)
6. ULTRASOUND (Mandatory)
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
INVESTIGATIONS (Cont...)
7. CT –
TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY
To differentiate cause of acute colic – stone or anuria
Suspected due to stone disease
8. DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY FUNCTION OF
EACH KIDNEY.
Bilateral Ureteric Calculus in a patient presenting with Anuria Bilateral Ureteric Calculus in a patient presenting with Anuria
Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on Gantry. These are rapidly performed and do not require contrast agents for reconstruction.
MANAGEMENT OF UROLITHIASIS
• Non-invasive approach to urinary calculas-HALLMARK of last 20 yrs.