RENAL CALCULI
Etiology:
Many theories, the current opinion:
1. Dietetic:
Vit. A deficiency, desquamation, the cell will be the
nidus for the stone.
2. Altered urinary solutes and colloid:
Dehydration increases the conc. Of urinary solutes,
may precipitate. And reduction of urinary colloid
which adsorb solutes, or mucoprotein which
chelate calcium, may result in crystal and stone
formation.
3. Decrease urinary citrate: that important to
calcium phosphate in solution (soluble).
4. Renal infection: stone common with infection,
because change in urine PH.
5. Inadequate urinary drainage and urinary stasis.
6. Prolong immobilization: as paraplegia.
7. Hyperparathyroidism:
Increase mobilization of calcium from the bone to
blood then to urine.
Types of renal calculi:
1. Oxalate stone (calcium oxalate stone): irregular
with sharp projection causing bleeding. Radio
dense.
2. Phosphate calculus: calcium phosphate often
with ammonium magnesium phosphate (struvie)
smooth, grow in infected urine (alkaline) may
become big (stag horn), and may silent. Radio
opaque.
3. Uric acid urate calculi: hard yellow, multiple,
radiolucent if pure, but most of it mix with calcium
so faint radiological shadow.
4. Cystine calculus: uncommon with congenital
error of metabolism that leads to cystinuria.pink or
yellow change to greenish color when exposed to
air. Radio opaque because they contain sulphur,
hard.
5. Xanthine calculus: rare smooth round.
(Autosomal recessive), radiolucent.
Clinical Feature:
Common, between 30-50 years, male/female 4:3.
SILENT CALCULI: even large stag horn may no
symptom but progressing renal damage, and
uremia may be, if bilateral renal; stone.
PAIN: is the leading symptom in 75%, pain the
renal angle, hypochondrium, ureteric colic is
agonizing pain, from the loin to groin. It is sudden,
colic in nature, it radiate to groin, penis, labium, as
stone progressing down to ureter, the severity not
related to the size of the stone, may associated
with hematuria. There is tenderness on deep
bimanual exam. And rarely rigidity of lateral
abdominal muscle.
HAEMATURIA: may leading symptoms, may
microscopic haematuria.
PYURIA: infection is likely, and become dangerous
when the kidney is obstructed, septicemia can
quickly develop.
The mechanical effect of stones irritating the
urothelium may cause pyuria even in the absence
of infection.
Investigation of suspected urinary stone disease:
1. Radiology:
KUB (kidney, ureter, bladder): radio opaque
stone only seen about 85% of stone.
2. Contrast-enhanced computerized tomography:
CT scan (spiral) is the mainstay of investigation for
acute ureteric colic.
3. Excretory urography:
To see the site of the stone and the anatomy of
the urinary system, and some information about
the function of the kidney.
4. Ulrasound scanning:
Is the of the most value in locating the stone.
Surgical treatment of urinary calculi:
1: conservative:
In stone smaller than 0.5 cm, pass spontaneously,
unless associated infection so intervention
indicated, so antibiotics started immediately,
surgical treatment include minimally invasive
technique, sometime open surgery may needed.
2. Modern methods of stone removal of kidney
stone:
Percutaneouse nephrolithotomy (PNL): by
using nephroscopy through a small opening from
the back to extract kidney stone , and destructing
it by pnumoclast or laser.
Extracorporeal shock wave lithotripsy(
ESWL): the stone bombarded with shock wave of
sufficient energy to disintegrate into fragment, the
shock wave should transmitted through water
because it become poor when transmit through
the air so use bath of water or bag of water, and
localization of the stone controlled by radiograph
or ultrasound..
The complication of ESWL include: renal colic,
infection, haematuria, and ecchymosis.
Open surgery for renal calculi:
Including: pyelolithotomy: extract the stone
through renal pelvis
Extended pyelolithotomy by extracting the stone
through a wide incision extending to the calyces.
Nephrolithotomy: through the renal paranchyma.
PREVENTION:
ALL THE STONE FORMER SHOULD BE
INVESTIGATED.
In recurrent stone:
1. Serum calcium, to exclude
hyperparathyroidism.
2. Serum uric acid.
3. 24 urine for urate calcium, and phosphate.
4 stone analysis.
Dietary advice is not usually helpful, unless proved
metabolic error, example calcium oxalate better to
be moderate in eat milk product, spinach,
asparagus…..
Hyperuricaemia: ovoid red meat offal, fish, and
treated with allopurinol.
Restriction of eggs meat and fish rich in sulpher
should be restricted in cystin urea.
Drink a plenty of water which is very important in
all type of stone.
Drug treatment is largely ineffective except in
idiopathic hypercalciuria.
:
By:
Assist. Professor
M.R.Judi