U.S. Flashcards
(20 cards)
What are the different types of urinary stones?
calcium oxalate/ phosphate (most common)
Struvite
Uric acid
Cystine
What are RF for Nephrolithiasis?
personal or family hx
Low fluid intake, dehydration
Postcolectomy and/ or postileotomy
Hypercalciiuria
Gout
Medications (allopurinol, chemotx, loop diuretics)
Hyperparathyroidism
What is the clinical presentation of nephrolithiasis?
small kidney stones may be asymptomatic and detected incidentally
acute, colicky flank pain (renal colic) radiating to lower abdomen, groin, labia, testicles or perineum
paroxysmal or progressively worsening
costovertebral angle tenderness
hematuria (gross or microscopic in 85%)
nausea, vomiting, reduced bowel sounds
dysuria, frequency and urgency (mimicking cystitis)
patients are unable to sit still and move around frequently
What are the causes & tx of calcium oxalate/ calcium phosphate?
causes: idiopathic hypercalciuria, and 1° hyperparathyroidsm, fat malabsorption
tx: hydration, dietary sodium restriction, thiazide diuretics; do not restrict calcium intake (can lead to hyperoxaluria and increase risk for osteoporosis)
for calcium oxalate: citrate supplements
alkaline urine
What are the causes & tx of Struvite (triple phosphate)?
urease producing organisms (e.g. Proteus)
form staghorn calculi
tx: hydration, treat UTI if present, surgical removal of staghorn stone
alkaline urine
What are the causes & tx of uric acid?
causes: gout, xanthine oxidase deficiency, and high purine turnover states (e.g. chemotx)
acidic urine
tx: hydration, alkalinize urine with citrate, dietary purine restriction (meat) and allopurinol
What are the causes & tx of cystine?
cause: defect in renal transport of certain amino acids (COLA: cystine, Ornithine, Lysine, Arginine)
acidic urine
tx: hydration, dietary sodium restriction, alkalinization of urine, penicillamine or tiopronin
What are the ddx of acute renal colic in adults?
renal or ureteral stones
hydronephrosis
bacterial cystitis or pyelonephritis
acute abdomen (pancreatitis, appendicitis)
gynecologic (ectopic pregnancy, over torsion, PID, over cyst rupture)
referred pain (orchitis)
radicular pain (L1 herpes zoster)
trauma
vascular infarctus/thrombus/dissection
volvulus, intusseption in children
diverticulitis (parenteral abx baslamak gerekir)
testis torsion
What is seen in the physical exam of nephrolithiasis?
patient moves around
costovertebral angle or lower quadrant tenderness
gross or microscopic hematuria
Patient comes in ER presenting as acute renal colic, what do you do?
Acilde önce Vital bulgulara bak
DX: *** gold standard non-contrast helical abdominal CT (kontrastsiz alt ve üst batin BT)
*US if suspected in pregnant woman or children
Lab: CBC, WBC, urinalysis, CRP, kültür, atesi varsa kan kültürü alinabilir
BUN, Cre elevation: acute kidney injury
Describe the tx of Nephrolithiasis?
Analgesia (NSAIDS e.g. ketorolac; 2nd line: opioids)
Antiemetics (e.g. ondansetron)
IV fluid for dehydration
If stone <10mm: a receptor blocker (tamsulosin) and calcium channel blocker (nifedipine) -> relieves ureter muscle spasms, promotes passage of ureteral stones (Medical Expulsion Therapy MET), reduced need for analgesics
<5 mm: may pass spontaneously
5-20 mm: may be treated uretorosopy
>20 mm: percutaneous nephrolithotomy
** fully obstructed or infected collecting systems: decompression either by percutaneous
nephrostomy or ureteral stent placement
** think of infections: fever and elevated WBC, urinalysis (pyuria, bacteriuria)
** majority of stones is <5mm and likely to pass spontaneously
How can you prevent Nephrolithiasis?
dietary chances to prevent calcium stone formation: increase in fluid intake, normal calcium intake, restriction of sodium in take
What are indications for urgent intervention
obstructed upper tract infection
** pain refractory to analgesics
** intractable nausea/vomiting
** impending renal impairment
** patient preference
What are complications of urinary stones?
recurrent UTI -> risk of pyelonephritis, urosepsis and perinephric abscess
urinary obstruction -> inflammation of the kidney and hydronephrosis -> permanent glomerular damage if left untreated
acute kidney injury
Which medication treatment is supplied to urinary stone patients?
diclofenac as pain killer
alpha blockers (as a dilator, not in pregnancy)
calcium blockers
max 14 days for control US but in case of fever and non going pain earlier control
Describe the urinary stone treatment for upper/middle calyx & lower pole?
upper/ middle calyx:
>2 cm: 1) PNL, 2) ESWl, 3) Flexible URS, 4) Laparoscopy
1-2 cm: 1) ESWL, 2) PNL, 3) Flexible URS
<1 cm: 1) ESWL, 2) Flexible URS, 3) PNL
lower pole:
>2 cm: 1) PNL, 2) ESWL
1-2 cm: Favorable Factors for ESWL (YES: PNL, NO: ESWL)
<1 cm: 1) ESWL, 2) Flexible URS
Describe how urinary stones are prevented?
a lot of movement/ water (till 2L Urinary output), low salt (also sodium restriction)
How is the metabolic evaluation done?
done to first (some cases) and repeated stone formers
do: stone composition analysis, 24h urine collection and serum studies
most commonly: low urine volume, hypercalciuria, hypocitraturia
in hypercalciuria: do: animal protein and salt restriction dont: calcium restriction
Describe how the diet can be changed to prevent urinary stones?
calcium stones: reduced consumption of salt and animal protein, red. cons: oxalate- rich foods and supplemental vitamin C; dont: reduce calcium intake since it can lead to hyperoxaluria -> and this is a risk for osteoporosis)
uric acid: low in purine
cystine stones: low in sodium
Describe chemoprophylaxis to prevent urinary stones?
calcium stones: thiazide diuretic (recurrent calcium-containing stones with idiopathic hypercalciuria i.e. no hypercalcemia), allopurinol in case of high urine uric acid
uric acid stones: allopurinol
cystine stones: tiopronin
struvite stones: antibiotic tx for UTI
