by dr. khalid shakeel babar (ksb) by dr. khalid shakeel babar (ksb)
TRANSCRIPT
MAJOR RISK FACTORS FOR UA STONES
•Low Urine Volume•Hyperuricosuria
•Low Urinary pH
•High Serum Uric Acid Level
PREDISPOSING CONDITIONS
Gout Uricosuric Drugs Uric Acid Overproduction Chronic Diarrhea DM and Metabolic Syndrome
PRESENTATION
1. PAIN IN MOST OF THE CASES
“RENAL COLIC” IF SEVERE AND ACUTE
A) KIDNEY STONE
FIXED PAIN IN THE LOIN
B) URETERIC STONE
PAIN RADIATES ® LOIN TO GROIN
C) BLADDER STONE
PAIN WITH LUTS
Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in renal colic
HISTORY
A. IS PATIENT DRINKING ENOUGH WATER?
B. PROFESSION
C. ENQUIRE ABOUT UTI ® STONES
D. FAMILY HISTORY
E. LONG ILLNESS ® BEDRIDDEN ®
STONES
ON EXAMINATION
1. ACUTE PRESENTATION
ABDOMEN TENSE AND RIGID
TENDERNESS PRESENT IN THE LOIN
Renal Punch positive
2. IN ROUTINE PRESENTATION
NO FINDINGS IN ABDOMEN
INVESTIGATIONS (CONT...)
4. KUB Xray
5. Stone Analysis
6. Serum Uric acid,
Blood urea and serum creatinine
7. 24 hour urine for uric acid
INVESTIGATIONS (CONT...)
8. IVU OR IVP (INTRA VENOUS
UROGRAM)
9. CT Scan
10. Renogram (DMSA / DTPA / MAG3)
TREATMENT
Alkalinization of urine Increased fluid intake Xanthine oxidase inhibiters ( if 24hr
urinary uric acid excretion more than 6 mmol/day)
Dietary restriction of purine rich foods.
DDS
Renal Pyelonephritis. Obstruction of the ureter due to other
causes (such as a blood clot, stricture, papillary necrosis, or urothelial tumour).
Acute renal infarction. Renal rupture. Renal abscess (very rare, and in the UK
usually secondary to stones).
DDS
Gynaecological Ectopic pregnancy. Endometriosis. Ovarian cyst: rupture or torsion. Pelvic inflammatory disease. Salpingitis.
DDS
Gastrointestinal Appendicitis. Diverticulitis. Biliary colic. Bowel obstruction. Bowel ischaemia. Crohn's diseaseOthersAAA
PROGNOSIS
Mortality and morbidity are not increased with uric acid stones compared with other stones; however, the process that leads to excess uric acid production (eg, malignancy, Lesch-Nyhan syndrome) may cause death.
RECURRENCE
Restrict purine rich diet to reduce recurrence.
Repeat Urine pH, serum uric acid, abdominal ultrasound and CT scan for recurrence.
STONES IN PREGNANCY
Rare event Normal physiology of pregnancy Factors favoring stones in pregnancy Most stones appear to be
predominantly composed of calcium phosphate
DIAGNOSIS
Renal and pelvic ultrasound Transvaginal and doppler ultrasoundIf further diagnosis is required
MR urography Low dose CT. limited intravenous pyelogram (IVP)
TREATMENT
Most (75 to 85 percent) stones pass spontaneously
Decompression of the kidney with placement of a ureteral stent percutaneous nephrostomy tube, ureteroscopy to remove the stone may be
required in the patient who is septic, has persistent severe pain, or has persistent obstruction.
shock wave lithotripsy use during pregnancy is contraindicated
CASE PRESENTATION Presentation:On 17th November, 2012, 8:00 AM26 year old boy presented withSevere Radiating Right Lumbar PainAssociated with nausea and vomiting.On examination: Renal Punch +ve on Right Side.Ultrasound Abdomen Report: Normal exceptRight Kidney shows minimal hydronephrosis with
dilated proximal ureter raises the suspicion of distal ureteric obstruction.
Urine R/E Report: Normal , except Urine pH 5.0KUB xray: Normal, No stone seen.
Initially managed with Inj. Diclofenac Sodium i/mInj. Spasfan i/mInj. Gravinate i/v After the pain was relieved patient was
asked detailed history, he told about Family history of stones.
Serum uric acid level advised and it was 7.8 mg/dl (normal range 3.5 – 7.2).
Patient started on conservative treatment
Alkalinization of urine Increased fluid intake24hr urinary uric acid excretion test doneIt was less than 6mmol/day, so patient
did not start Xanthine oxidase inhibiters.
Video
Special Thanks to Dr. Kamran sahib for solving all my queries regarding stones and immensely helping me in preparing presentation.
Thanks to Dr. Qais Falah and Prof; Dr. Zahid Ahmed Hashmi for encouragement and help.