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Met3 > Urology: Stones > Flashcards

Urology: Stones Flashcards

1
Q

What is the cause of a Mg NH4 P stone? [1]

A

UTI

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2
Q

What is the cause of a urate stone? [1]

A

Hyperuricaemia: elevated uric acid level in the blood (purine rich diet)

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3
Q

What causes a cystine stone? [1]

A

Renal tubular defect:
- Inherited defect in the transport of the amino acid cystine leading to excessive excretion in the kidney, causing cystinuria.
- Cystinuria causes supersaturation in the kidney, predisposing to the development of stones

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4
Q

Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

A

Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

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5
Q

Which of the following is the location for the obstructing urinary tract stone?

ureteropelvic junction
mid-ureter
ureterovesical junction
urethra

A

Which of the following is the location for the obstructing urinary tract stone?

ureteropelvic junction
mid-ureter
ureterovesical junction
urethra

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6
Q

Which of the following stone type appears as smooth, brown & radiolucent on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

A

Which of the following stone type appears as smooth, brown & radiolucent on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

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7
Q

Which of the following stone type appears as a stag-horn on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

A

Which of the following stone type appears as a stag-horn on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

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8
Q

Which of the following stone type appears as a spiky & radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

A

Which of the following stone type appears as a spiky & radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

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9
Q

Why would time of year influence stone formation? [1]

A

Variations in calcium and oxalate levels are influenced by vit. D synthesis

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10
Q

Which drug classes increase the chance of urinary tract calculi? [5]

A

allopurinol (treat gout)
loop-diuretics
antacids
acetazolamide
corticosteroids
aspirin

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11
Q

What causes an increased risk of infection from urinary tract calculi? [1]

A

If voiding impaired

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12
Q

How does pain present in urinary tract calculi?

A

Excruciating pain that spreads from loin to groin that can cause nausea and vomiting in colicky fashion

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13
Q

How does pain present in urinary tract calculi?

How does pain presentation differ if the stone is
- Obstructing the kidney [2]
- Obstructing mid ureter [1]
- Obstructing lower ureter [2]
- Obstructing bladder or urethra [3]

A

Obstructing the kidney:
- felt in loin;
- between rib 12 and lateral edge of lumbar muscles

Obstructing mid ureter:
- mimics appendicitis / diverticulitis

Obstructing lower ureter
- may lead to symptoms of bladder iritability and pain in scrotum, penile tip or labia

Obstructing bladder or urethra:
- pelvic pain
- dysuria
- strangury

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14
Q

What differential will CT-KUB help to exclude? [1]

A

Ruptured AA

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15
Q

An AXR which show which type of stones [1] but not shw which type? [1]

A

An abdominal x-ray can show calcium-based stones, but uric acid stones will not show up (they are radiolucent).

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16
Q

Describe the analgesic therapy offered for urinary tract calculi [1]

A

IM diclofenac
IV paracetamol 2nd line

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17
Q

How do you treat stones < 5mm in lower ureter? [1]

A

~90-95% will pass asymptotically

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18
Q

Describe the treatment algorithim for a patient who has a confirmed obstructed kidney stone? [2]

A

1.urgent decompression:
- ureteric stent past the obstruction and achieve drainage.
- a percutaneous nephrostomy tube can be placed by interventional radiology.

  1. urgent antibiotics
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19
Q

Why does low Ca2+ levels lead to kidney stones? [1]

A

Low Ca2+ diets promote oxalate excretion

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20
Q

What can you prescribe to lower Ca2+ levels if detected to be high? [1]

A

Thiazide-like duiretics

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21
Q

State the most common types of renal stones [4]

A

Calcium oxalate: most common
Urate
Calcium phosphate
Magnesium Ammonium Phosphate

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22
Q

What is the most common composition of renal stones? [1]

A

Calcium oxalate and phosphate

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23
Q

Calcium phosphate stones are commonly found in which structure? [1]

A

Bladder - found with urinary stasis

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24
Q

Calcium phosphate stones are clinically associated with which 3 conditions? [3]

A

Hyperparathyroidism
Medullary Sponge Kidney (MSK)
Distal Renal Tubular Acidosis (Type 1)

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25
Q

How are urate stones formed? [1]
How do they appear? [1]

A

Yellow
Acidic urine forms stones; uric acid entering urine

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26
Q

Urate stones are associated with which syndrome? [1]

A

Metabolic syndrome

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27
Q

Magnesium Ammonium Phosphate aka [] stones? [1]

A

struvite stones

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28
Q

Struvite stones are associated with what type of infection? [1]

A

Bacterial infection; (form when bacteria meet a surface and make urine more alkali; Mg binds and builds up): UTI

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29
Q

Which disease are cystine stones associated with? [1]

A

Cystine – associated with cystinuria, an autosomal recessive disease

30
Q

When lasering a kidney stone is smells of egg. Which type of renal stone is this? [1]

A

Cysteine

31
Q

What is a staghorn calculus? [1]

A

A staghorn calculus is where the stone forms in the shape of the renal pelvis, giving it a similar appearance to the antlers of a deer stag.

The body sits in the renal pelvis with horns extending into the renal calyces. They may be seen on plain x-ray films.

32
Q

Staghorn calculi are most commonly associated with which type of stone [1]

A

Struvite / Magnesium Ammonium Phosphate stones

33
Q

Describe the free theory of stone formation [4]

A

Free theory:
- Unsaturated urine increases in concentration; goes beyond the solubility product, at which point the urine becomes saturated
- Above this level, the urine is saturated but crystals are prevent from forming by inhibitors
- Above the formation product, crystals form spontaneously
- Stone formers sit at both the metastable and spontaneous regions; they have less inhibitors

34
Q

Describe the formation of stones via fixed theory [2]

A

Normally, need high energy to form crystal lattice

But, if have rough surface, e.g. from urate crystals, then energy required to form lattice is lower

35
Q

Describe how uric acid stones are formed [2]

A

Urate stones are formed from both theories:

Free theory:
- Urate has pK value of 5.4 (crystals will form when pH meets pK value); urate crystal formation is pH dependent

Fixed theory:
- Prescence of urate crystals forming acts as a nidus for stone formation

36
Q
A
37
Q

What is a Randall’s plaque? [1]

Where do they form? [1]

A

Wn attachment site over which calcium oxalate stones form, begins in the basement membranes of thin limbs of the loop of Henle.

38
Q

Label A

A
39
Q

What is a Duct of Bellini? [1]

How are stones formed here? [2]

A

The duct of Bellini represents the most distal portion of the collecting duct.

  • Stones formed within the tubules
  • Duct of Bellini narrows
  • Stones gets “stuck” at papillary surface
40
Q

Name a stone inhibitor [1] and how it works [1]

A

Tamm Horfshall Protein (aka uromodulin)

Bind to crystal structures and prevent from binding to renal epithelial cells

41
Q

How do you differentiate between a bowel colic and uteric colic [1]

A

Ureteric colic pain
- usually comes and goes with a background of pain completely between bouts

Bowel colic
- pain comes and goes, going away completely between bouts

42
Q

State the overarching reasons why calcium stones are formed [2]

A

Hypercalciuria
Hyperoxaluria

43
Q

State reasons why hypercalciuria [4] and hyperoxaluria [3] may be occurring and thus causing calcium stones

A

Hypercalciuria:
- Hyperparathyroidism
- Excess Ca2+ intake
- Increased Ca2+ gut absorption
- Poylcystic ovaries or medullary sponge disease

Hyperoxaluria:
- High diet in oxalates
- Low dietary Ca2+ (leading to decreased binding to oxalate)
- Increased intestinal resorption (e.g Crohns)

44
Q

Name 3 foods high in oxalate [3]

A

spinach
tea
rhubarb

45
Q

Describe urination with kidney stones

A
  • Dysuria, burning when peeing
  • Often blood in it
46
Q

Important differential diagnoses? [6]

A

AAA: older patients
Bilary colic (presents more with RUQ pain)
Ectopic pregnancy
Pyelonephritis
MI
Pneumonia

47
Q

What (non-radiological) investigations would you conduct for renal stones? [3]

A

Urine dipstick:
- 80% have blood
- check for infection (nitrates; leukocytes)
- urine pH (will indicate urate stones if low)

MSU
- check for microbiology culture and sensitivity

Bloods:
- serum urea, electrolytes
- FBC and CRPs
- Check calcium and urate levels

48
Q

Which radiological investigations would you conduct for renal stones? [5]

A

1. CT-KUB - Non-contrast Computerised Tomography
- GOLD STANDARD
- can measure how hard stone is (can determine treatment), position and size

  1. If CT-KUB is postive; then perform KUBXR to look at stone position

3. Ultrasound:
- Shows kidney stones and renal pelvis dilatation well but ureteric stones can be missed
- useful in pregnant and younger recurrent stone-formers (no radiation risk)

  1. IVU (intravenous urogram)
    - Rarely used
  2. MRI
    - used for pregnancy
49
Q

Which anti-emetics are prescribed for kidney stones? [3]

A

Anti-emetics to prevent vomiting: metoclopramide, prochlorperazine or cyclizine

50
Q

State 4 surgical interventions for kidney stones [4]

A

Extracorporeal shock wave lithotripsy (ESWL)

Ureteroscopy and laser lithotripsy

Percutaneous nephrolithotomy (PCNL)

Open surgery

51
Q
A

Extracorporeal shock wave lithotripsy (ESWL):
* ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass.

Ureteroscopy and laser lithotripsy:
* A camera is inserted via the urethra, bladder and ureter, and the stone is identified. It is then broken up using targeted lasers, making the smaller parts easier to pass.

Percutaneous nephrolithotomy (PCNL):
* PCNL is performed in theatres under a general anaesthetic. A nephroscope (small camera on a stick) is inserted via a small incision at the patient’s back. The scope is inserted through the kidney to assess the ureter. Stones can be broken into smaller pieces and removed. A nephrostomy tube may be left in place after the procedure to help drain the kidney.

Open surgery:
- Open surgery can be used to access the kidneys and remove the stones. This is rarely needed as other, less invasive, methods are usually effective.

52
Q

What lifestyle advise can you give to prevent stone reoccurrence? [6]

A

Potassium citrate in patients with calcium oxalate stones and raised urinary calcium (but v poorly tolerated)

Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium

53
Q

What is really important to consider with kidney stones? [1]

A

Check for infection !

(clinical scenario; temperature; pyuria; urine drip)

54
Q

Which type of ureteric stone is most radiolucent?

Cystine
Urate
Calcium phosphate
Struvite
Calcium oxalate

A

Which type of ureteric stone is most radiolucent?

Cystine
Urate
Calcium phosphate
Struvite
Calcium oxalate

55
Q

A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely?

Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
E-Coli
Staphylococcus epidermidis

A

A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely?

Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
E-Coli
Staphylococcus epidermidis

Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a urease producing enzyme. This will tend to favor urinary alkalinisation which is a relative per-requisite for the formation of staghorn calculi.

56
Q

State the medical expulsive therapy that can be used for treating kidney stones [2]

A

Medical expulsive therapy:
- nifedipine
- tamulosin (alpha blocker)

57
Q

Describe the treatment plan for a renal stone < 10 mm that fails to pass despite initial conservative management [3]

A

Offer shock wave lithotripsy (SWL)
Consider ureteroscopy if SWL is contraindicated, fails, or is not indicated because of anatomical reasons
Consider percutaneous nephrolithotomy (PCNL) if SWL and ureteroscopy are not suitable options or have failed.

58
Q

Name two AEs of shock wave litrotripsy [2]

A

The passage of shock waves can result in the development of solid organ injury.
Fragmentation of larger stones may result in the development of ureteric obstruction

59
Q

What is the first line treatment for pregnant person with stone? [1]

A

If the patient has no evidence of infection, the specialist will arrange ureteroscopy. Ureteroscopy has been demonstrated to be safe in pregnancy.[74]

60
Q

Describe the treatment plan for a renal stone > 20 mm [1]

A

Percutaneous nephrolithotomy

61
Q

A 32-year-old female with a history of Crohn’s disease presents for review with left loin pain consistent with renal colic. On examination she has a large midline abdominal scar suggestive of previous small bowel resection. Plain abdominal X-ray reveals multiple renal calculi.

What type of renal calculi fit best with this clinical picture?

Uric acid stones

Cystine stones

Calcium oxalate stones

Calcium carbonate stones

Magnesium carbonate stones

A

A 32-year-old female with a history of Crohn’s disease presents for review with left loin pain consistent with renal colic. On examination she has a large midline abdominal scar suggestive of previous small bowel resection. Plain abdominal X-ray reveals multiple renal calculi.

What type of renal calculi fit best with this clinical picture?

Uric acid stones

Cystine stones

Calcium oxalate stones

Calcium carbonate stones

Magnesium carbonate stones

Increased urinary oxalate may be genetic (primary oxaluria), idiopathic or enteric (either due to severe bowel inflammation and malabsorption or to extensive small bowel resection, as is the case here).

62
Q

Namet two contraindications for shockwave lithotripsy? [2]

A

Pregnancy and coagulopathy

63
Q

Which of the following best describes

radiolucent, so they are not seen on X-ray. [2]

Uric acid stones

Cystine stones

Calcium oxalate stones

Calcium carbonate stones

Magnesium carbonate stones

A

Which of the following best describes

radiolucent, so they are not seen on X-ray.

Uric acid stones

Cystine stones

Calcium oxalate stones

Calcium carbonate stones

Magnesium carbonate stones

64
Q

Which of the following are related to urinary tract infections

Uric acid stones

Cystine stones

Calcium oxalate stones

Calcium carbonate stones

Magnesium carbonate stones

A

Which of the following are related to urinary tract infections

Uric acid stones

Cystine stones

Calcium oxalate stones

Calcium carbonate stones

Magnesium carbonate stones

65
Q
A
66
Q

What imaging modility is first line for non-pregnant patients for suspected kidney stones?

MRI
XR-KUB
CT-KUB
US

A

What imaging modility is first line for non-pregnant patients for suspected kidney stones?

MRI
XR-KUB
CT-KUB
US

67
Q

What imaging modility is first line for pregnant patients for suspected kidney stones?

MRI
XR-KUB
CT-KUB
US

A

What imaging modility is first line for pregnant patients for suspected kidney stones?

MRI
XR-KUB
CT-KUB
US

68
Q

What is the first line treatment for pregnant person with stone? [1]

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)

A

What is the first line treatment for pregnant person with stone? [1]

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)

69
Q

What is the first line treatment for pregnant person with stone size of less than 2cm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

A

What is the first line treatment for pregnant person with stone size of less than 2cm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

70
Q

What is the first line treatment for pregnant person with stone size of < 5mm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

A

What is the first line treatment for pregnant person with stone size of < 5mm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

71
Q

What is the first line treatment for person with stone size of 12 mm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

A

What is the first line treatment for person with stone size of 12 mm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

72
Q

What is the first line treatment for person with stone size of 24 mm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

A

What is the first line treatment for person with stone size of 24 mm?

Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting

Met3 (52 decks)

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