stone disease Flashcards
what is the history and examination of acute renal colic?
history
- sudden, severe flank pain radiating to groin/scrotum/labia
- may be constant or colicky
- rolling around, don’t sit still
- history of stones previously
examination
- temperature is significant
- abdo exam may be unremarkable
what are the differential diagnosis in a patient presenting with flank pain?
- pancreatitis
- ruptured AAA
- biliary colic
- appendicitis
- gynae pathology
what are the investigations one in a patient with suspected renal colic?
- urine dip for haematuria (non visible)
- FBC, UE, calcium and urate, LFT and amylase if undiagnosed
- CT KUB is the test of choice (non contrast, unlike CT urogram, which is used for malignancy)
- USS can examine for any associated hydronephrosis
AXR are still used in some centres for initial assessment of stone disease, however AXRs have the disadvantage that not all stones are radio-opaque
what is the actue management for renal colic?
- NSAIDS reduce kidney output of urine = less pressure on obstruction = less pain (oromorph may work quicker)
- opiates as required, ok to use morphine for analgesia, oral or IM/IV
- monitor pain and watch closely for pyrexia and signs of sepsis
- renal stones will pass spontaneously without further intervention, especially if in the lower ureter or <5mm in diameter.
what is infected obstructed kidney?
- fever or signs of sepsis + an obstructed kidney is a urological emergency
- requires emergency decompression with either cystoscopy and retrograde JJ stent insertion or percutaneous nephrostomy
what is a JJ stent?
A JJ stent is a specially designed hollow tube, made of a flexible plastic material that is placed in the ureter with a cystoscope.
what is a nephrostomy?
tube placed in renal pelvis to drain urine into stoma bag attached to the skin at the back.
what is the definitive management for a stone?
conservative
- allow stone to pass
- generally for stones <5mm
extracorporeal shock wave lithotripsy (ESWL)
- stone must be radio -opaque to target
rigid ureteroscopy and laser lithotripsy
Percutaneous nephrolithotomy
- a minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin
- stones bigger than 2cm
what are the types of renal stones?
- calcium oxalate is most common
- calcium phosphate seen in hyper PTH
- urate associated with obesity and diabetes, forms in acidic urine, radiolucent on x ray but seen on CT
- Cystine stone seen in patients with cystinuria
- indinavir stones seen in HIV treated patients, not seen on CT
what is the general preventative advice given to stoneformers?
- 2-3 litres of water a day
- avoid excessive salt/red meat
- citrate is beneficial (lemon in water, apple juice)
- maintain normal calcium intake
what is the general clinical management of stoneformers?
- check serum calcium and rate
- if Ca high likely to have hyperparathyroidism - check PTH and parathyroidectomy
how are renal stones managed?
- extra corporeal shock wave lithotripsy (ESWL)
- flexible ureteroscopy and laser lithotripsy
- Percutaneous nephrolithotomy for larger stones
what is ESWL?
- for retained renal and ureteric stones
- extra corporeal shock wave lithotripsy. where x rays are used to target renal calculi and break them up. can be uncomfortable, patients will be given paracetamol and tramadol before.
- water is poured between patient and table for better conduction of shock waves.
- haematuria after the procedure is normal. drink plenty of fluids to help.
- patients will be brought in for a x ray KUB 3 weeks after to see if stones have passed or if further treatment is required.
what is steinstrasse and how can is occur as a result of ESWL?
large stones remaining in kidney following ESWL as a result of the breakdown of larger stones. these stones can get lodged at the VUJ and block urine flow = patients present a few days later with inability to pass urine and pain. A surgical emergency..
If non obstructive, will see on KUB x ray done routinely 3 weeks after lithotripsy. will see stone hasn’t passed and extra sessions of lithotripsy will be scheduled.
why does breathing need to be relaxed in an ESWL?
as heavy breathing or harsh breathing can move the stone. if patient can’t control their breathing, a compression belt is placed underneath the diaphragm to relax it.
