Which stone? Radiolucent Forms in acidic urine (\<6.0) Dissolves in alkalinized urine

Uric acid (urate) Malingering pts know this stone does not show up on x-ray. But will show up on CT

Which stone? Cause: UTI Radio-opaque Forms in alkaline urine Can be dissolved w/ acidification of urine Composition of most ______

Magnesium ammonium phosphate (struvite, triple phosphate, MAP) staghorn calculi

Which stone? Genetic defect, autosomal _____ Heterozygotes usually _____ Homozygotes usually ______ Caused by _____ Dissolved in ____ environment

Cystine recessive hetero --\> NOT stone formers Homo --\> form stones cystinuria alkaline

Which stone? Precipitated drug, such as _____ Radiolucent Not visible on stone-protocol CT

Protease Inhibitor Stone Indinavir

UTIs UTIs can decrease _____ Hypo-_____ Urea splitting organisms Proteus, Klebsiella, Pseudomonas, Serratia, Staph Urea--\> ammonia + bicarb --\> ____ Proteus --\> _____

ureteral peristalsis citraturia struvite matrix stones

UA (pH, specific gravity, hemoglobin, microscopy) CBC (WBC elevation) BMP (creatinine, BUN, electrolytes)

KUB (Kidney, Ureter, Bladder) US abdominal / retroperitoneal / renal & bladder Intravenous Urogram (IVU) (not performed anymore) CT Stone Protocol (abd/pelvis) WITHOUT contrast CT urogram (abd/pelvis) WITH contrast, including delayed phase (if stone protocol is negative, get the CT urogram)

Urolithiasis 1 Flashcards by Shea Green

Other 5 names for Urolithiasis

“kidney stones”
nephrolithiasis
ureterolithiasis
cystolithiasis
calculus / calculi

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What is the most common type of stone in the US?

Calcium oxalate

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Which stone?

Radio-opaque
Resistant to dissolution
Most commonly caused by dehydration

Calcium oxalate

(MC type in US)

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Which stone?

Radiolucent
Forms in acidic urine (<6.0)
Dissolves in alkalinized urine

Uric acid (urate)

Malingering pts know this stone does not show up on x-ray. But will show up on CT

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Which stone?

Cause: UTI
Radio-opaque
Forms in alkaline urine
Can be dissolved w/ acidification of urine
Composition of most ______

Magnesium ammonium phosphate (struvite, triple phosphate, MAP)

staghorn calculi

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Which stone?

Genetic defect, autosomal _____
Heterozygotes usually _____
Homozygotes usually ______
Caused by _____
Dissolved in ____ environment

Cystine

recessive
hetero –> NOT stone formers
Homo –> form stones
cystinuria
alkaline

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Which stone?

Associated w/ Proteus UTI
Radiolucent

Matrix

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Which stone?

associated w/ UTI & laxative abuse
Radiolucent

Ammonium Acid Urate

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Which stone?

Precipitated drug, such as _____
Radiolucent
Not visible on stone-protocol CT

Protease Inhibitor Stone

Indinavir

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A few etiologies of Urolithiasis (8)

Anatomic
Urine characteristics
Pt volume status
Diet
Metabolic
Disease states
UTI
meds

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What are the 2 causes of stones due to anatomy?

Obstruction
Stasis

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What are the 2 Crystal Inhibitors?

Citrate (complexes w/ calcium)
Urea (increases solubility of uric acid)

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3 components of volume status of pt w/ Urolithiasis

Volume depletion
Low UOP
Supersaturation of solute

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4 etiologies of metabolic urolithiasis

Hypercalciuria
Hypocitrauria
Hyperoxauria
Hyperuricosuria

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UTIs

UTIs can decrease _____
Hypo-_____
Urea splitting organisms
- Proteus, Klebsiella, Pseudomonas, Serratia, Staph
- Urea–> ammonia + bicarb –> ____
- Proteus –> _____

ureteral peristalsis
citraturia
struvite
matrix stones

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Which 7 meds can cause urolithiasis?

Vit C
Vit D
Triamterene precipitation
Protease inhibitors (Indinavir)
Furosemide increases urinary calcium excretion
Acetazolamide (CAI) causes RTA state
Uricosuric agents (probenecid, salicylates)

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4 sxs of urolithiasis

Flank pain
N/V (from the pain)
Hematuria
Hyperkinetic** (common). Pt is moving all over and pacing the room

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3 components of evaluation of urolithiasis

H&P
Labs (creatinine and white count)
Imaging (Stone protocol CT WITHOUT contrast)

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3 PE findings of urolithiasis

Fever
Hyperkinetic
CVAT (costovertebral angle tenderness)

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3 labs

UA (pH, specific gravity, hemoglobin, microscopy)
CBC (WBC elevation)
BMP (creatinine, BUN, electrolytes)

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5 imaging studies

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KUB (Kidney, Ureter, Bladder)
US abdominal / retroperitoneal / renal & bladder
Intravenous Urogram (IVU) (not performed anymore)
CT Stone Protocol (abd/pelvis) WITHOUT contrast
CT urogram (abd/pelvis) WITH contrast, including delayed phase

(if stone protocol is negative, get the CT urogram)

Indications for Acute Intervention

Complete or high grade _____
Bilateral _____
Urinary obstruction w/ ______
Urinary obstruction in _____ kidney
Urinary obstruction w/ rising ____
Inability to ____ due to severe N/V
Severe pain uncontrolled by _____

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urinary obstruction
urinary obstruction
urinary infection
solitary
creatinine
take in POs
analgesics

Tx of Urolithiasis

Abx for infection
Acute tx to relieve obstruction:
- _____
- ______
- (to prevent sepsis / renal damage / loss of renal function)
Later proceed to definitive stone management under more controlled circumstances

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ureteral stent placement
nephrostomy tube placement

Tx of lower tract stones (2 locations?)

4 treatments?

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Bladder & urethra

Cystourethroscopy, cystolitholapxy
Extracorporeal shock wave lithotripsy (ESWL)
Open stone removal (super rare!)
Dissolution (meds) - common tx

Tx of upper tract stones (2 locations?) * 6 tx options

**kidney & ureter** * Trial of passage * Extracorporeal Shock Wave Lithotripsy (ESWL) * Dissolution * Open or laparoscopic surgery * Ureteroscopy w/ stone manipulation * Percutaneous Nephrolithotomy (PCNL) **(TED UOP)**

**Candidates for "trial of passage"** * Stones \_\_mm or less (68% pass within __ days) * Taking fluids and analgesics PO * Alpha-blocker (\_\_\_) increase passage percentage, decrease time to passage, decrease pain w/ passage * Filter urine (screen / coffee filter) * Periodic imaging to assess for \_\_\_\_.

* 5 * tamsulosin * hydronephrosis

**_Dissolution (chemolysis) of Uric Acid Stones_** * **Alkalinize urine** * pH greater than \_\_\_ * __ and ___ PO * Can take __ months to work * **Irrigate collecting system** * via \_\_\_\_\_ * sodium bicarb * THAM

* 6.5 * Sodium bicarb & Potassium citrate * 3 * nephrostomy tube

**_Dissolution (chemolysis) of Cystine Stones_** * **Alkalinize urine** * pH greater than \_\_ * ____ PO * **Irrigation of collecting system** * Sodium bicarb * THAM * N-acetylcysteine

* 7.5 * Potassium citrate

**Dissolution (chemolysis) of Struvite, Calcium phosphate stones** * Irrigation w/ _____ (\_\_\_)

* acidic solution (Renacidin)

**Extracorporeal Shock Wave Lithotripsy** * 3 good things about ESWL * 1 bad thing about ESWL

* Outpatient * Non-invasive * Sedation * **Bad:** stone fragments not removed

5 contraindications of ESWL (extracorporeal shock wave lithotripsy)

* pregnancy * coagulopathy * UTI * Renal Artery Aneurysm * AAA **"U CRAP"**

3 "relative contraindications" of ESWL | (extracorporeal shock wave lithotripsy)

* **c**ystine stone , matrix stone * chronic **p**ancreatitis / pancreatic calcification * distal **o**bstruction ## Footnote **"COP"**

**ESWL (extracorporeal shock wave lithotripsy)** * Stone size \< __ cm * Visible on \_\_\_\_

* 2 * fluoroscopy

**ESWL (extracorporeal shock wave lithotripsy)** * Done under \_\_\_\_ * Done w/ _____ imaging * if radio-opaque, \_\_\_\_ * if radiolucent, \_\_\_\_\_ * Shock wave generator positioned where? * Table manipulated to put stone in \_\_\_\_ * Shocks delivered \_\_\_-\_\_\_/ minute * Gated w/ ___ to avoid inducing dysrhythmia

* sedation/anesthesia * fluoroscopic imaging * easily seen * put up a stent and inject contrast dye * against patient's side * cross-hairs * 60-90 * EKG

**ESWL** * If bilateral stone disease, may choose to do what? * If solitary kidney, use what?

* To do each kidney at separate settings * ureteral stent

**ESWL** * Decrease ____ function up to 3 weeks * 6 complications?

* renal perfusion 1. renal hematoma / retroperitoneal hematoma 2. Ecchymosis 3. UTI --\> sepsis 4. Steinstrasse 5. Ureteral stricture 6. Pain

**Which tx?** * Done in OR under general anesthesia * Transurethral approach * Flexible scope placed up ureter * Energy delivered to calculus * laster lithtripsy * ultrasonic lithotripsy * electrohydraulic lithotripsy (EHL) * Pneumatic impactor "\_\_\_\_\_" * Stone broken up * Fragments basketed out * Possible ____ temporarily

**Ureteroscopy w/ stone manipulation** * "jackhammer" * ureteral stent

**9 Complications of Ureteroscopy w/ manipulation (endoscopy)** * Ureteral \_\_\_\_ * Ureteral \_\_\_\_ * Submucosal \_\_\_\_ * Ureteral ____ (1%) * Extrustion of stone outside the lumen of ureter * \_\_\_\_ * \_\_\_\_ * \_\_\_\_\_

* Avulsion * perforation * tunneling * stricture * UTI * Bleeding * Pain

**Prevention of Future Stones** * Fluid intake, should result in a urine volume of ___ L * Encourage fluids w/ _____ , Discourage \_\_\_\_. * Low sodium (less urinary Ca, more urinary citrate) * Low ___ protein intake (amino acid effect) * Low oxalate * Moderate Ca intake * Avoid high doses of vit __ and \_\_\_

* 2.5 * citrate / soda * animal * C & D

3 contraindications of Percutaneous Nephrolithotomy (PCNL)

* UTI * Coagulopathy * No percutaneous renal access ## Footnote **(CUN)**

**Percutaneous Nephrolithotomy (PCNL)** * Access achieved in ____ or \_\_\_\_ * Access through the \_\_\_\_, ____ approach, needle placed under ____ guidance * Needle/catheter advanced to \_\_\_\_\_\_ * Wire, tract dilation * Nephroscopy * Instruments passed under direct \_\_\_ * Energy delivered to \_\_\_\_\_\_ * _____ grasped, removed

* Interventional Radiology or OR * skin / flank / fluoroscopic * renal collecting system * vision * lithotripsy stone * fragments

4 complications of PCNL (percutaneous nephrolithotomy)

* bleeding * sepsis * renal pelvis perforation * pneumothorax / hydrothorax

**Prevention of Future Stones** * Reduce \_\_\_\_ * High ____ lowers urinary citrate * Animal protein * Limit intake of ____ and \_\_\_\_\_ * ____ and \_\_\_\_\_: low \_\_\_\_\_\_

* PRAL (potential renal acid load) * PRAL * cheese & egg yolks * fruits & veggies

6 meds to prevent future stones

* potassium citrate (raises pH & citrate level) * thiazide * allopurinol * pyridoxine (B6) * Cholesyramine * Thiols

**Which med for Prevention of Future Stones?** * Corrects acidosis, which increases urinary citrate and decreases urinary calcium * Binds w/ calcium, inhibits calcium crystallization * **SE:** hyperkalemia\*\* & peptic ulcers * **Caution:** Uncontrolled DM, renal insufficiency, delayed gastric emptying, K sparing diuretics * **Dosing:** titrate per urine pH

Potassium Citrate

**Which med for Prevention of Future Stones?** * Corrects acidosis * Increases reabsorption of Ca into kidneys, decreasing urine calcium excretion * Can worsen stone disease, if it causes hypokalemia\*\* * May be given w/ potassium\*\* * 2 SE?

**Thiazide** * weakness & fatigue

**Which med for Prevention of Future Stones?** * decreases uric acid levels * Only decreases stone incidence if pt had been _hyperuricosuric\*_

Allopurinol

**Which med for Prevention of Future Stones?** * Involved in metabolism of oxalate * Deficiency leads to hyperoxaluria

Pyridoxine (B6)

**Which med for Prevention of Future Stones?** * Ileal resection --\> decreased bile acid absorption * Bile acids increase colonic wall permeability to oxalate --\> increase oxalate absorption * ___ binds bile acids, decreasing colon wall permeability to oxalate

Cholestyramine

**Which med for Prevention of Future Stones?** * Tx for cystinuria * Increases solubility, prevention of cystine stones * Tiopronin * D-Penicillamine

Thiols

What 2 things = emergency?!

* Fever * Obstructive stones

Urolithiasis 1 Flashcards

(51 cards)