W3 Urolithiasis (Joey)

Question 1

Urolithiasis — highly symptomatic, most likely location?
Where does pain radiate?

Answer 1

UVJ — ureter vesicular junction. D/t smaller lumen opening.
These patients have pain that radiates to the scrotum of labia

UPJ is also highly symptomatic but higher up — flank pain

Question 2

Renal colic is 2/2
What is the pain like?

Answer 2

Obstruction
A lot of pain at baseline, and then really severe episodes of pain, d/t moving stone or ureter squeezing on stone (light peristalsis)
“True collicky picture”

Question 3

Where could stones be located that might not present with symptoms?

Answer 3

In the bladder

Question 4

Work up pathway for all urolithiasis

Answer 4

—UA w/ microscopy and crystal analysis
—24h urine
— UT imaging, start with RBUS and XR of abdomen. Once confirmed, move to CT A/P
—stone analysis if you get the stone in your hand!

No contrast
—it can obscure the stone. Want it to light up really well and the contrast lights up white too, you’d miss it.

Uric acid stone won’t show up on imaging because it doesn’t have calcium in up. it’s radiolucent

Question 5

No.1 risk factor for stone types, all

Answer 5

Dehydration

Question 6

Urotlithiasis treatment

Answer 6

BLUF:
—increase H20
—decrease water, salt, beer, wine
—pain control
—alpha blocker: flomax
—if large, lithotripsy

First Line Approaches (more helpful if presentation not acute, pt asx):
● Increase PO water intake, may encourage passage
● Decrease protein, salt, EtOH (beer, wine) intake

Acute / Obstructive Stone Medical Treatments:
● PAIN CONTROL (NSAIDs if no AKIl, opioids if needed, APAP is < helpful)
● Anti Nausea medications
● Medical Expulsive Therapy ( “MET” ): IVF + PO alpha blockers
○ Alpha blockers relax the smooth muscle in the internal urethral
sphincter, bladder neck, proximal prostatic urethra, AND ureters!
○ Flomax most commonly used
○ Alpha blockers +/- anti-achs may also be helpful for spasms

● If small stone is <10 mm, you may consider attempting medical expulsive therapy w/ IVF + alpha blockers (however stones 5 - 10 cm have variable success w/ this approach, > successful in stones <5 mm)
● +/- Abx (very low threshold to start - these pts can get septic quick)

Stone-Specific Treatments & Prevention:
● You all will cover these soon :)

Question 7

Types of stones

Answer 7

Question 8

Urinary tract obstruction algorithm

Answer 8

Question 9

Grab summary slides from each stone

Question 10

Which urolithiasis is a/w a AR rare genetic mutation?
What patient will present?

Answer 10

Cystine

Young boy with kidney stones

Question 11

Which stone is associated with a patient who eats a lot of meat, consumes alcohol and has gout?

Answer 11

Uric acid

Question 12

Which urolithiasis is a/w chronic UTI with klebsiella and proteus species?
What do they produce?

Answer 12

Struvite

Because they produce urease

Question 13

Most common stone
Avoid which juice?

Answer 13

Calcium oxalate
Grapefruit juice

Question 14

Gold standard for urolithiasis dx?

Answer 14

CT scan (spiral CT) without contrast of the abdomen and pelvis is the gold standard for diagnosis

Urinalysis will often show microscopic hematuria

Cannot determine the type of stone from CT so give the patient a strainer and have them strain the urine so you can catch the stone as it passes for identification

Serum chemistry—obtain BUN and Cr levels (for evaluation of renal function) and also calcium, uric acid, and phosphate levels

Question 15

Treatment for urolithiasis

Answer 15

General measures (for all types of stones)

Analgesia: IV morphine, parenteral NSAIDs (ketorolac)

Vigorous fluid hydration—beneficial in all forms of nephrolithiasis

Antibiotics—if UTI is present

Alpha blocker therapy (Flomax) for patients with symptomatic ureteral stones >5 mm and ≤10 mm to facilitate ureteral stone passage (usually given to most patients independent of size)

Outpatient management is appropriate for most patients. Indications for hospital admission include:

Pain not controlled with oral medications

Anuria (usually in patients with one kidney)

Renal colic plus UTI and/or fever

Stones > 5 – 10 mm have a 20% chance of passage and may require elective lithotripsy – patients should be considered for early elective intervention

Stones > 10 mm are not likely to pass spontaneously. Ureteral stent or percutaneous nephrostomy (gold standard) should be used if renal function is jeopardized.

Urgent treatment with extracorporeal shock wave lithotripsy can be used for renal stones of less than 2 cm or for ureteral stones of less than 10 mm

Question 16

Know this

Answer 16

Inferior mesenteric artery is where horseshoe kidney gets stuck
Turner HSK
Hyperparathyroidism HSK
CaOx most common — reducing oral Ca++ is a bad idea, just remove oxalate
Imaging: cystine and Uris acid, how HF units. Best imagine for these is ultrasound. But people use CT for all of them