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F3 E1 Shea > Urolithiasis 1 > Flashcards

Urolithiasis 1 Flashcards

1
Q

Other 5 names for Urolithiasis

A
  • “kidney stones”
  • nephrolithiasis
  • ureterolithiasis
  • cystolithiasis
  • calculus / calculi
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2
Q

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

A

Calcium oxalate

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3
Q

Which stone?

  • Radio-opaque
  • Resistant to dissolution
  • Most commonly caused by dehydration
A

Calcium oxalate

(MC type in US)

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4
Q

Which stone?

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

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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5
Q

Which stone?

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

Magnesium ammonium phosphate (struvite, triple phosphate, MAP)

  • staghorn calculi
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6
Q

Which stone?

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

Cystine

  • recessive
  • hetero –> NOT stone formers
  • Homo –> form stones
  • cystinuria
  • alkaline
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7
Q

Which stone?

  • Associated w/ Proteus UTI
  • Radiolucent
A

Matrix

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8
Q

Which stone?

  • associated w/ UTI & laxative abuse
  • Radiolucent
A

Ammonium Acid Urate

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9
Q

Which stone?

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

Protease Inhibitor Stone

  • Indinavir
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10
Q

A few etiologies of Urolithiasis (8)

A
  • Anatomic
  • Urine characteristics
  • Pt volume status
  • Diet
  • Metabolic
  • Disease states
  • UTI
  • meds
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11
Q

What are the 2 causes of stones due to anatomy?

A
  • Obstruction
  • Stasis
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12
Q

What are the 2 Crystal Inhibitors?

A
  • Citrate (complexes w/ calcium)
  • Urea (increases solubility of uric acid)
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13
Q

3 components of volume status of pt w/ Urolithiasis

A
  • Volume depletion
  • Low UOP
  • Supersaturation of solute
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14
Q

4 etiologies of metabolic urolithiasis

A
  • Hypercalciuria
  • Hypocitrauria
  • Hyperoxauria
  • Hyperuricosuria
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15
Q

UTIs

  • UTIs can decrease _____
  • Hypo-_____
  • Urea splitting organisms
    • Proteus, Klebsiella, Pseudomonas, Serratia, Staph
    • Urea–> ammonia + bicarb –> ____
    • Proteus –> _____
A
  • ureteral peristalsis
  • citraturia
  • struvite
  • matrix stones
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16
Q

Which 7 meds can cause urolithiasis?

A
  • 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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17
Q

4 sxs of urolithiasis

A
  • Flank pain
  • N/V (from the pain)
  • Hematuria
  • Hyperkinetic** (common). Pt is moving all over and pacing the room
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18
Q

3 components of evaluation of urolithiasis

A
  • H&P
  • Labs (creatinine and white count)
  • Imaging (Stone protocol CT WITHOUT contrast)
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19
Q

3 PE findings of urolithiasis

A
  • Fever
  • Hyperkinetic
  • CVAT (costovertebral angle tenderness)
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20
Q

3 labs

A
  • UA (pH, specific gravity, hemoglobin, microscopy)
  • CBC (WBC elevation)
  • BMP (creatinine, BUN, electrolytes)
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21
Q

5 imaging studies

A
  • 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)

22
Q

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 _____
A
  • urinary obstruction
  • urinary obstruction
  • urinary infection
  • solitary
  • creatinine
  • take in POs
  • analgesics
23
Q

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
A
  • ureteral stent placement
  • nephrostomy tube placement
24
Q

Tx of lower tract stones (2 locations?)

  • 4 treatments?
A

Bladder & urethra

  • Cystourethroscopy, cystolitholapxy
  • Extracorporeal shock wave lithotripsy (ESWL)
  • Open stone removal (super rare!)
    Dissolution (meds) - common tx
25
Q

Tx of upper tract stones (2 locations?)

  • 6 tx options
A

kidney & ureter

  • Trial of passage
  • Extracorporeal Shock Wave Lithotripsy (ESWL)
  • Dissolution
  • Open or laparoscopic surgery
  • Ureteroscopy w/ stone manipulation
  • Percutaneous Nephrolithotomy (PCNL)

(TED UOP)

26
Q

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 ____.
A
  • 5
  • tamsulosin
  • hydronephrosis
27
Q

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
A
  • 6.5
  • Sodium bicarb & Potassium citrate
  • 3
  • nephrostomy tube
28
Q

Dissolution (chemolysis) of Cystine Stones

  • Alkalinize urine
    • pH greater than __
    • ____ PO
  • Irrigation of collecting system
    • Sodium bicarb
    • THAM
    • N-acetylcysteine
A
  • 7.5
  • Potassium citrate
29
Q

Dissolution (chemolysis) of Struvite, Calcium phosphate stones

  • Irrigation w/ _____ (___)
A
  • acidic solution (Renacidin)
30
Q

Extracorporeal Shock Wave Lithotripsy

  • 3 good things about ESWL
  • 1 bad thing about ESWL
A
  • Outpatient
  • Non-invasive
  • Sedation
  • Bad: stone fragments not removed
31
Q

5 contraindications of ESWL (extracorporeal shock wave lithotripsy)

A
  • pregnancy
  • coagulopathy
  • UTI
  • Renal Artery Aneurysm
  • AAA

“U CRAP”

32
Q

3 “relative contraindications” of ESWL

(extracorporeal shock wave lithotripsy)

A
  • cystine stone , matrix stone
  • chronic pancreatitis / pancreatic calcification
  • distal obstruction

“COP”

33
Q

ESWL (extracorporeal shock wave lithotripsy)

  • Stone size < __ cm
  • Visible on ____
A
  • 2
  • fluoroscopy
34
Q

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
A
  • sedation/anesthesia
  • fluoroscopic imaging
    • easily seen
    • put up a stent and inject contrast dye
  • against patient’s side
  • cross-hairs
  • 60-90
  • EKG
35
Q

ESWL

  • If bilateral stone disease, may choose to do what?
  • If solitary kidney, use what?
A
  • To do each kidney at separate settings
  • ureteral stent
36
Q

ESWL

  • Decrease ____ function up to 3 weeks
  • 6 complications?
A
  • renal perfusion
  1. renal hematoma / retroperitoneal hematoma
  2. Ecchymosis
  3. UTI –> sepsis
  4. Steinstrasse
  5. Ureteral stricture
  6. Pain
37
Q

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
A

Ureteroscopy w/ stone manipulation

  • “jackhammer”
  • ureteral stent
38
Q

9 Complications of Ureteroscopy w/ manipulation (endoscopy)

  • Ureteral ____
  • Ureteral ____
  • Submucosal ____
  • Ureteral ____ (1%)
  • Extrustion of stone outside the lumen of ureter
  • ____
  • ____
  • _____
A
  • Avulsion
  • perforation
  • tunneling
  • stricture
  • UTI
  • Bleeding
  • Pain
39
Q

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 ___
A
  • 2.5
  • citrate / soda
  • animal
  • C & D
40
Q

3 contraindications of Percutaneous Nephrolithotomy (PCNL)

A
  • UTI
  • Coagulopathy
  • No percutaneous renal access

(CUN)

41
Q

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
A
  • Interventional Radiology or OR
  • skin / flank / fluoroscopic
  • renal collecting system
  • vision
  • lithotripsy stone
  • fragments
42
Q

4 complications of PCNL (percutaneous nephrolithotomy)

A
  • bleeding
  • sepsis
  • renal pelvis perforation
  • pneumothorax / hydrothorax
43
Q

Prevention of Future Stones

  • Reduce ____
  • High ____ lowers urinary citrate
  • Animal protein
  • Limit intake of ____ and _____
  • ____ and _____: low ______
A
  • PRAL (potential renal acid load)
  • PRAL
  • cheese & egg yolks
  • fruits & veggies
44
Q

6 meds to prevent future stones

A
  • potassium citrate (raises pH & citrate level)
  • thiazide
  • allopurinol
  • pyridoxine (B6)
  • Cholesyramine
  • Thiols
45
Q

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
A

Potassium Citrate

46
Q

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?
A

Thiazide

  • weakness & fatigue
47
Q

Which med for Prevention of Future Stones?

  • decreases uric acid levels
  • Only decreases stone incidence if pt had been hyperuricosuric*
A

Allopurinol

48
Q

Which med for Prevention of Future Stones?

  • Involved in metabolism of oxalate
  • Deficiency leads to hyperoxaluria
A

Pyridoxine (B6)

49
Q

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
A

Cholestyramine

50
Q

Which med for Prevention of Future Stones?

  • Tx for cystinuria
  • Increases solubility, prevention of cystine stones
  • Tiopronin
  • D-Penicillamine
A

Thiols

51
Q

What 2 things = emergency?!

A
  • Fever
  • Obstructive stones

F3 E1 Shea (14 decks)

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