Evaluation of pt with urolithiasis


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Evaluation of pt with urolithiasis

  1. 1. Naveed MaharResident Urology JPMC, Karachi
  2. 2.  Detailed history Examination Metabolic evaluation Radiological investigations
  3. 3. HISTORY Demographic biodata Life style Occupation Diet/fluid intake Drug history Systemic disease Family history History of bowel surgery
  4. 4. OCCUPATION Sedentary 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
  5. 5. DIET Water 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  Sodium  Calcium  PH  Decreased urinary citrate
  6. 6. CLIMATE Summer is the season of urinary stones and dehydration is the key factor  Concentrated urine has a lower ph, encouraging cystine and uric acid stone formation  Exposure to sunlight may also increase endogenous vitamin D production, leading to hypercalciuria.
  7. 7. FAMILY HISTORY Incidence increases with positive family history Familial diseases like  Cystinuria  An auto-somal recessive disorder of transmembrane cystine absorption  RTA  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.
  8. 8. PAST HISTORY Bowel resection Inflammatory bowel disease Systemic diseases i-e - Gout - Hyperparathyroidism - Sarcoidosis
  9. 9. DRUG HISTORY The 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)
  10. 10. PHYSICAL EXAMINATION Pt frequently changes posture to find pain relief Renal colic is associted with tachycardia, sweating,and nausea Costovertebral angle tenderness may be apparent. An abdominal mass may be palpable in patients with hydronephrosis A 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 hernias Epididymorchitis A rectal examination helps exclude other pathologic conditions.
  11. 11. METABOLIC EVALUATION Depends on the stone type(composition) Stone type is analyzed by  Polarizing microscopy  X-ray diffraction  Infrared spectroscopy If stone is not retrieved  Radiological appearance radiolucecy/opacity  Metabolic evaluation
  12. 12. 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.
  15. 15. RADIOLOGIC INVESTIGATIONS1. X-ray KUB2. Ultrasonography3. Intravenous pyelography4. Computed tomography5. Magnetic resonance imaging
  16. 16. PLAIN X-RAY KUB Not useful if stones are  Radiolucent  Smaller than 4mm  Lies over the sacrum or other bony structure. Bowel gases can obscure its efficacy. Can not differentiate between  Stones  Calcified lymph nodes  Phleboliths Sensitivity for diagnosis of stones is 50–70%
  17. 17. X-RAY KUB
  18. 18. 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
  19. 19. U/S KUB
  20. 20. INTRAVENOUS PYELOGRAPHY Useful for patients with suspected indinavir stones Requires trained technician Its an invasive procedure predisposing pts to highly allergic IV contrasts Its very prolonged procedure takes hours Require proper pt preparation Not good investigative modality in acute renal colic
  21. 21. IVPFilms and “phases” of IVP Plain 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 tubule Pyelogram phase:  Much denser than the nephrogram phase.  As concentrated contrast accumulates in plvicalycel system
  22. 22. IVP
  23. 23. X-RAY IVP 3D
  24. 24. COMPUTED TOMOGRAPHY Has greater specificity (95%) and sensitivity (97%) for diagnosing ureteric - stones Noncontrast spiral CT scans are now the imaging modality of choiceAdvantages: It is rapid No need for experienced radiologic technician No need for intravenous contrast. Uric acid stones are also visualizedDisadvantage: 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)
  25. 25. MAGNETIC RESONANCE IMAGING MRI is a poor study to document urinary stone disease. Clue towards obstruction by diagnosing hydronephrosis