內(nèi)科學(xué)教學(xué)課件：Urolithiasis

Urolithiasis

Urolithiasis=urinarycalculi

=urinarystoneEpidemiology

Whogetsthem?-1-15%lifetimeincidence-Menaffected3-foldsriskaswomen-Patientsage:30~50year’sold

EpidemiologyAfterfirstepisode,stonestendtorecur…At1year15%ofpatientswillgetanotherstoneAt10years…50%

Stonevarieties●

Calciumcalculicalciumoxalatecalciumphosphatecalciumcarbonate

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Noncalciumcalculistruvitestone(magnesiumammoniumphosphate,MAP)cystinestoneuricacidstone(negativestone)

CommonStonesCalciumOxalate/Carbonate/Phospahte75%UnderlyingMetabolicdisorder…(e.g.,idiopathichypercalciuria,hyperoxaluria)Nometabolicdisorderidentifiedin25%Struvite(Magnesium-ammoniumphoshate)10–15%RenalInfection…(Proteus,Klebsiella)UricAcid6%50%idiopathic;Hyperuricemia,hyperuricosuriaCystine1-2%RenaltubulardefectPercentofallstonesEtiologicFactors(Sandhua)Etiology

systematicfactors

localfactors●

Systematicfactors：

Metabolicdisorderhyperparathyroidismhypercalciuria(calciumcalculi)hyperoxaluriahyperuricosuria(uricacidstones)Malnutrition●

Environmentfactor:geography&weather,intakeofwaterEtiologyEtiology

●localfactors：

obstruction,infection,foreignbodyEtiology

Foodandwater-water↓,animalprotein↑,calcium↑,sodium↑,magnesium↓,unbalancedvitaminDrugs-corticalhormone,vitC,VitD.Milk-somemadeinChina

Pathophysiology

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Obstruction

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Infection

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Injury

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Canceration

stoneInfection

obstructionPreventionincreasedfluidintake(3-4L/day).candecreasestone-formingby50%PreventionCalciumstone:RemoveparathyroidtumorReducedairyfood(milk,cheese)lowsodiumdietto100mg/dlemonadecandeceaseurinecalciumPrevention

Cystinestones:

1.highfluidintake2.urinaryalkalinization(potassiumcitrate)

Uricacidstones:1.urinealkalinization(potassiumcitrate);2.allopurinol(別嘌呤醇）Struvitestones(Magnesiumammoniumphospahate):typicallyrequirestoneremovalwithoperation2.Antibiotics3.Easierforminalkalineurine

UrolithiasisUpperurinarytract:renalcalculi,ureteralcalculiLowerurinarytract:vesicalcalculi,urethralcalculi.symptomRenlastone:Noobstruction,nopain!symptomsStonelodgeattheureteropelvicjunctionoracalicesMakeobstructionModeratetosevererenalpain,oftenaccompainwithnausea,vomit,ileus,hematuria

symptomsInfectionsecondarytoobstructionmayleadtohighfeversymptomHematuria:oftenmicroscopichematuriaDischargestonePhysicalexamPercussbackCostovertebralangletendernessAbdomentouchquietSomepatientswithoutabviousphysicalsignLaboratoryfindingsUrinalysismayfindbloodorpus-cellsWithacuteinfection,leukocytosisbefoundinroutinebloodexaminationTotalrenalfunctionimpairedonlyifthestonesarebilateralandchronicinfectionAnalysisofstonecompositionUltrasonography(US)…Firstchoicefordiagnosisofurolithiasisin… 1.pregnantpatients 2.childrenSonographicscanshowsdilatedintrarenalcollectingsystem,consistentwithobstructiveurolithiasis.US…

Advantages1.Safe,non-invasive… idealforpregnantpatients&children2.SensitivefordetectingurinarytractdilationNephrolithiasis(arrows)withouthydronephrosisImagingstudies90%caculiareradiopaque(calcium,cystine),PlainFilmRadiography…Forevaluatinginitialepisodesofsuspectedurolithiasis,theKUB’ssensitivityfordetectingstonesislow(58%-62%)(ACR)§KUBwillmiss:uricacidstonessmallstonesstonesobscuredbybones§KUBwilldetect:calciumstonesstruvitecystinestonesRadiographofleftkidneyshowsalargestone(arrow)IntravenousUrograpgy(IVU/IVP)Intravenouscontrastisfilteredbythekidneyandconcentratedintheurine…Sequentialradiographsareobtainedtoseehowcontrastmovesthroughtheurinarytract…IVU(IVP)Advantages

AllowassessmentofrenalfunctionShowslocationanddegreeofobstructionAssesssizeofstone(sometimes)DisadvantagesRequirescontrastCantakeawhiletocompleteIVPstudyshowingnormalurinaryanatomyNon-ContrastHelicalCT

Thepreferredstudyforwork-upofsuspectedurinarytractcalculi.Advantages1.Fast2.Nocontrast3.Characterizesize&locationofstone…(andguidemanagement?)4.Characterizedegreeofurinarytractobstruction5.Abletoevaluateforothersourcesofpain.6.VirtuallyallstonesareradiopaqueCTFindings…Staghorncalculusinrightrenalpelvis(Curhan)Diagnosisofupperurinarytractstones

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Symptomsandsigns

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Labtest:urinalysis(hematuria)●

Ultrasonicexamination

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Radiologicinvestigations:KUB,IVU,CTExtracorporealshockwavelithotripsy(ESWL)From1983….Onlyinvasivetreatment<2cm10%requirePCNLorSurgicaltreatment

Mini-invasivetreatments

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Extracorporealshockwavelithotripsy(ESWL）indication:renalstone,upperureterstonecontraindications:withdistalurinarytractobstruction,withhemorrhagedisease,withpregnancycomplications:hematuria,renalcolic,stonestreetPCNL(percutaneousnephrolithotripsy)

Symptomaticorlargepelvicstone(>2cm)FlexiableureterorenalscopyOpensurgicalremovalstoneuncommonUreteralstone

Ureteralstoneoriginateinthekindney.Whensymptomsoccur,ureteralobstructionisindicaterenalfunctionendangered.MostureteralstonepassspontaneouslyUreterstenosis:UreteropelvicjunctionoveriliacvesselsureterovesicaljunctionUreteralstoneUreteropelvicjunctionMiddleureterUreterovesicaljunctionThemostimportantsymptoms+(RollingStones)Symptoms

Paincausedbystonemoving§Renalcolic: -acuteonsetofsharp,severe,spasmodicflankpain -episodesofseverepainlast20–60minutes -locationofpaindependsonlocationofstone

Stonesarefoundmostcommonlyat…TheureteropelvicjunctionOveriliacvesselsTheureterovesicaljunctionSymptomsHematuria(microscopicorgross):

-90%ofpatientshavemicroscopichematuria

-Sometimesnauseaandvomiting-infectionsecondarytoobstuction,fevermayhappen-stoneclosetobladder,symptomsimilartocystitisPhysicalexamPE:costovertebralangletendernessAbdomentouchnormalLaboratoryfindingMostpatients’urinalysismayfindredbloodcellsRoutineanalysisofbloodfindleukocytosisornormal.ImagingfindingUltra-sonographyX-rayIVPCTMRUUS…ureteralstone(arrow)hyroureter(arrowheads)(Catalano)KUBNotrecommendIVP

AnabnormalIVUstudyshowingobstructed,dilatedleftureterandcollectingsystemUrogramshowsdilatationofleftureterandcollectingsystemcausedbycalcificdistalureteralstone(arrow).Opacifiedlowerureters(arrows)Opacifieddistalureters(arrows)(McTavish)NormalUrinaryAnatomy

(CTUrography)Findthestone…Mostcommonly,thestonecanbeseendirectlyasanopacitywithintheurinarytract.ImpactedcalculusatureterovesicaljunctionStoneinleftureter(Catalano)CTFindings…secondarysignsofurolithiasiscanhelpmakethediagnosis…Perinephricfatstranding(secondarytoedema)Hydronephrosis(dilationofkidney)Hydroureter:(dilationofureters)SecondarySignsonCT…

PerinephricStranding(Varanelli)(Catalano)SecondarySignsonCT…

Hydroureter

Hydronephrosis(Catalano)Dilatedrenalpelvis(arrowhead)withminimalsurroundingfat-tissuestranding(McDonald)Hydronephrosisinrightkidney(longarrow)andtinyrightrenalcalculus(shortarrow).Leftkidneyisnormal.CTUrography…

Usedprimarilyforfurtherwork-upofabnormalitiesseenoninitialunenhancedCT3-DcoronalreconstructionofCTurographyimage,showingcontrast-enhancedrenalcollectingsystem,ureters,andbladder.Noteduplicatedsystemonleftside.

()AxialCTurographyimageshowingafillingdefectintherightrenalpelvisconsistentwithalargeurothelialtumor.

MagneticResonanceUrography(MRU)Limitedroleinevaluationofurinarytractstones.(Sudah)Dilatationofleftureterandcollectingsystem(bothimages)MRUTheureteralstoneisseenasafillingdefect(arrow)MRurographycanreplaceconventionalexcretoryurography(IVU)whenthelatteriscontraindicatedorundesirable.(Sudah)Diagnosisofupperurinarytractstones

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Symptomsandsigns

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Labtest:urinalysis(hematuria)●

Ultrasonicexamination

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Radiologicinvestigations:KUB,IVU,CTTreatment…

Stones<6mmarelikelytopassspontaneouslyStones>10mmareveryunlikelytopassspontaneouslyAlso,distalstonesaremorelikelytopassspontaneouslyHydration

(IVorPO)Analgesia(NSAIDS&Opiods)&WaveshockOnlyproximalureteralstone<1.5cmUreteroscopeUreteroscopylithotripsyOpensurgicalremoval(ureterolithotomy)Opensurgicalremoval(ureterolithotomy)isveryrare§Treatmentprinciplesofbilateraluppertracturinarystone：●

onesideureteralstoneandtheothersiderenalstone:theureteralstoneshouldbedealtwithfirstly.●

bilateralureteralstones:thesideinwhichobstructionismoreseriousshouldbedealtwithfirstly.Ortreattogetheratthesametime.§Treatmentprinciplesofbilateraluppertracturinarystone：●

bilateralureteralstones(insufficientrenalfunction):treatthebetterone.●

bilateralrenalstones:thesidewhichismoresimpleandsafeshouldbedealtwithfirstly.

●Whenstoneleadtoanuria,measuresshouldbetakenassoonaspossibletoreliefobstructionVesicalstonePrimaryvesicalstoneisrare

Vesical