Transcript STONE DISEASE - Medindia

STONE DISEASE
( Brief Overview )
Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.),
Professor & HOD, Dept. of Urology,
Sri Ramachandra Medical College & Research Institution
Consultant Urologist & Renal Transplant Surgeon,
Sri Ramachandra Hospital, Porur, Madras.
COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS
Stone analysis in Percentage
Form of Lithiasis
India
USA
Japan
UK
Pure Calcium Oxalate
86.1
33
17.4
39.4
Mixed Calcium Oxalate and
Phosphate
4.9
34
50.8
20.2
Magnesium Ammonium
Phosphate (Struvite )
2.7
15
17.4
15.4
Uric Acid
1.2
8.0
4.4
8.0
Cystine
0.4
3.0
1.0
2.8
Cause of Stone Disease
• Supersaturation of urine is the key to stone formation
• Intermittent supersaturation - Dehydration
• Crystal aggregation
• Anatomic Abnormailities – PUJ , MSK
• Bacterial Infection
• Defects in transport of Calcium and Oxalate by Renal
epithelia
E.Coli infection increases matrix content in urine . Proteus makes urine alkaline
Inhibitors & Promoters of Stone Formation in Urine
INHIBITORS
PROMOTERS
Inhibits crystal Growth • Citrate – complexes with Ca
• Magnesium – complexes with
oxalates
• Pyrphosphate - complexes
with Ca
• Zinc
Inhibits crystal Aggregation
• Glycosaminoglycans
• Nephrocalcin
• Tamm- Horsfall Protein
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Bacterial Infection
Matrix
Anatomic Abnormalities – PUJ
obst., MSK
Altered Ca and oxalate transport
in renal epithelia
Prolonged immobilisation
Increased uric acid levels I.e
taking increased purine subs–
promotes crystalisation of Ca and
oxalate
?? Nanobacteria – seen in 97% of
renal stones
SOME DISEASES ASSOCIATED WITH
HYPERCALCAEMIA & HYPERCALCIURIA
Hyperparathyroidism
Leukemia
Sarcoidosis
Lymphoma
Multiple myeloma
Myxedema
Hyperthyroidism
Adrenal Insufficiency
Metastatic Malig. Neoplasm's
Vit. D Intoxication
TYPES OF KIDNEY / URETER STONES
• OXALATE (CALCIUM OXALATE)
• PHOSPHATE
• URIC ACID & URATE
• CYSTINE
Uncommon Stones
XANTHINE STONES
– (Autosomal Recessive . Def of Xanthine Oxidase leading to Xanthinuria)
DIHYDROXYADENINE STONE
– ( Def. of enzyme adenine phospo ribosyl transferase )
SlLICATE STONES
– Rare in humans ( excess intake of Antacid with Mg Trisilicate.
Mostly in
cattle due to ingestion of Sand )
MATRIX
- Infection by Proteus
- Radiolucent (all calculi have some amt ( 3%) of matrix
but matrix calculus has 65% Matrix content in calculi)
Uncommon Stones
TRIAMTERENE
– Anti-hypertensive used with hydroclorothiazide – spare Potassium.
Mostly found as a nucleus in Ca oxalate or uric acid calculus
Indinavir Stones
- Drug to treat
AIDS (4 to13%)
Ephedrine or Guifenesin
– Cough medicine - Radiolucent
Stones – Chemical Constituents
• Whewelite – Calcium Oxalate Monohydrate – CaC2O4-H2O
• Weddelite - Calcium Oxalate dihydrate – CaC2O4-2H2O
• Brushite – Calcium Hydrogen phosphate dihydrate – CaHPO4 2H2O
• Whitlockite - TriCalcium Phosphate – Ca2(PO4)2
• Struvite – Magnesium Ammonium hexahydrate – MgNH4PO4-6H2O
DD of Radiolucent filling defect on IVU in Ureter or
Kidney
Must Know
Know For Brownie Points
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Uric Acid Calculus
Matrix Calculus
Sloughed Papilla
Blood Clots
TCC
Renal Cysts
Vascular Lesions
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Xanthine Calculus
Hydroxyadenine Calculus
Ephederine Calculus
Infection due to gas forming
Org.
Fungal Ball
Tuberculoma
Malacoplakia
Hypertrophied Papilla
Renal pseudo-tumour
OXALATE (CALCIUM OXALATE)
• ALSO CALLED MULBERRY STONE
• COVERED WITH SHARP PROJECTIONS
• SHARP MAKES KIDNEY BLEED (HAEMATURIA)
• VERY HARD
• RADIO - OPAQUE
Under microscope looks like Hourglass or Dumbbell shape if monohydrate and
Like an Envelope if Dihydrate
PHOSPHATE STONE
• USUALLY CALCIUM PHOSPHATE
• SOMETIMES  CALCIUM MAGNESIUM AMMONIUM
PHOSPHATE OR TRIPLE PHOSPHATE
• SMOOTH MINIMUM SYMPTOMS
• DIRTY WHITE
• RADIO - OPAQUE
Calcium Phosphate also called ‘Brushite’ appears like Needle shape under
microscope
PHOSPHATE STONES
IN ALKALINE URINE
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ENLARGES RAPIDLY
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TAKE SHAPE OF CALYCES
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STAGHORN 
Struvite can form Stag-horn and appear like coffin lid under microscope
CALCIUM PHOSPHATE STONES
• Hyperparathyroidism
Ca
P
• Renal Tubular Acidosis
K
CO2
• Medullary Sponge Kidney -
PTH Hormone Promotes renal production of 1-25-dihyroxycholecalciferol – active Vit.D and also
increases absorption of Calcium and decreases Phosphorus absorption from Kidneys
URIC ACID & URATE STONE
• HARD & SMOOTH
• MULTIPLE
• YELLOW OR RED-BROWN
• RADIO - LUCENT (USE ULTRASOUND)
Under microscope appear like irregular plates or rosettes
pKa of uric acid 5.75 – at this pH 50% of uric acid insoluble.
If pH falls further - uric acid more insoluble
CYSTINE STONE
• AUTOSOMAL RECESIVE DISORDER
• USUALLY IN YOUNG GIRLS
• DUE TO CYSTINURIA • CYSTINE NOT ABSORBED BY TUBULES
• MULTIPLE
• SOFT OR HARD – can form stag-horns
• PINK OR YELLOW
• RADIO-OPAQUE
Under microscope appears like hexagonal or benezene
ring – ask for first morning sample
CYSTINE STONE - Management
• High Fluid Intake and Alkalanise Urine – dissolve most of
the smaller cystine stones
• D-Pencillamine or MPG (Mercaptopropionylglycine) binds to
cystine that is soluble in urine
• Side effects of Pencillamine restricts it use – Allergic
rashes, GI problems- Nausea, Vomiting, Diarrhoea
• MPG better tolerated
• Large obstructive stones – Surgery required first
pKa of cystine is 8.3, hence alkalinisisation above pH7.5 helps to dissolve the stones
Cyanide Nitroprusside Calorimeteric Test for detecting Cystinuria. If positive do
amino acid chromatography
Surgical Conditions and Stone Disease
• Regional ileitis and Ileal Bypass Surgery for eg
Obesity can lead to increase oxalate absorption
and stone ds
• ileostomies - In Chr. Diarrhoea with– Bicabonate
loss – systemic acidosis and acidic urine –
increases risk of Uric Acid stones
HISTORY
A. IS PATIENT DRINKING ENOUGH ?
B. PROFESSION
C. ENQUIRE ABOUT UTI STONES
D. FAMILY HISTORY
E. LONG ILLNESS BEDRIDDEN STONES
MANAGEMENT OF STONES
HISTORY :
A. FIND OUT IF DRINKING ENOUGH LIQUIDS
(NOT DRINKING ENOUGH IMPORTANT CAUSE
OF STONE FORMATION & GROWTH)
Urinary supersaturation of salts in concentrated urine
Atleast drink 3 lits to avoid stone formation
HISTORY (Cont...)
B. ASK ABOUT THEIR PROFESSION
DEHYDRATION STONES CAN FORM e.g.
• MARATHON NEAR A FURNACE,
• BRICK - LAYER, LABOURERS & WEAVERS
• TRUCK & BUS DRIVERS
HISTORY (Cont...)
C. ENQUIRE ABOUT UTI STONES
D. FAMILY HISTORY
E. LONG ILLNESS  BEDRIDDEN  STONES
Zero Gravity state – astronauts on long space flights more prone to
stones
CLINICAL FEATURES
1. PAIN IN 75 % 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
Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in
renal colic
CLINICAL FEATURES (Contd....)
2) HAEMATURIA
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CAN BE FRANK
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OR ONLY FOUND ON DIP - STICK OR LAB.
3) PYURIA - IF INFECTION CAN HAVE PUS IN URINE
ON EXAMINATION
1. ACUTE PRESENTATION
• ABDOMEN TENSE AND RIGID
• TENDERNESS PRESENT IN THE LOIN
2. IN ROUTINE PRESENTATION
• NO FINDINGS IN ABDOMEN
INVESTIGATIONS
1. FULL BLOOD COUNT TO CHECK FOR
ANAEMIA IF GOING FOR SURGERY
2. SERUM ELECTROLYTES PLUS UREA /
CREATININE / CALCIUM / URIC ACID /
PHOSPHATE
INVESTIGATIONS (Cont...)
3. 24-HOURS URINE FOR ELECTROLYTES
(Only if recurrent stone former)
CALCIUM / OXALATE / URIC ACID /
CYSTINE / CITRATE
INVESTIGATIONS (Cont...)
4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory)
5. IVU OR IVP (INTRA VENOUS UROGRAM)
6. ULTRASOUND (Mandatory)
INVESTIGATIONS
IVU OR IVP (INTRA VENOUS UROGRAM)
• Not Mandatory
• 1in 40,000 patients die due to anaphylactic reaction to
contrast
• Useful for radio-lucent stones & to detect
Congenital Anomalies in Urinary tracts
INVESTIGATIONS (Cont...)
7. CT –
TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY
To differentiate cause of acute colic – stone or anuria
Suspected due to stone disease
8. DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY
FUNCTION OF EACH KIDNEY.
Bilateral Ureteric Calculus in a patient presenting with Anuria
Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on
Gantry. These are rapidly performed and do not require contrast agents for reconstruction.
MANAGEMENT OF UROLITHIASIS
• Non-invasive approach to urinary calculasHALLMARK of last 20 yrs.
• Lithotripters –
1.Extra Corporeal Shock wave
2.Intra Corporeal
• Better fiber optics – Miniturisation of Telescopes
• Accessories - Innovative variety
Modern Management of Urolithiasis
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ESWL
Ureterorenoscopy
Percutaneous Nephrolithotomy
Laparoscopic Approach to stones
Open Ureterolithotomy, Pyelolithotomy or Nephropyelolithotomy is required in less
than 1 to 2% of modern stone management
TREATMENT (IDEALLY)
MAJORITY : 80 TO 85 % of all stones can be treated by EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)
MINORITY : 15 TO 20 % SHOULD NEED MINIMALLY
INVASIVE SURGERY (PCNL / URETEROSCOPY)
(LESS THAN 1 % SHOULD NEED OPEN SURGERY)
EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY
(ESWL)
SHOCK WAVES GENERATED UNDER WATER CAN
TRAVEL THROUGH BODY WITHOUT ANY APPRECIABLE
LOSS OF ENERGY. WHEN THEY ENCOUNTER STONES
THE CHANGES IN DENSITY CAUSES ENERGY TO BE
ABSORBED AND REFLECTED BY THE STONE & THIS
RESULTS IN FRAGMENTATION OF THE STONES.
ESWL – For Urinary Tract Calculus
ESWL- FOUR MAIN ELEMENTS
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2.
3.
4.
ENERGY SOURCE
FOCUSING DEVICE
COUPLING DEVICE
LOCALIZATION DEVICE
ESWL
Absolute Contra-indicationPregnancy
Relative Contra-Indications for ESWL –
• Renal Colic
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Urinary obstruction
Infection
Declining Renal Function
Significant Hematuria
COUPLING DEVICE
“WATER BATH”
“WATER FILLED CUSHION”
(KEEP PATIENT’S DRY)
ESWL-HISTORY
1963-EXPERIMENTS WITH “ SHORT WAVES” IN
W.GERMANY BY PHYSICISTS AT DONIER
SYSTEMS LTD
1980-DORNIER HUMAN MODEL ( HM-3)
LITHOTRIPTER ARRIVED ON MARKET
(STILL GOLD STANDARD WHEN COMPARING
RESULTS WITH NEW MEASUREMENTS
ESWL & STAGHORNS
• Dornier HM-3 Monotherapy for STAGSHORNS 30% Stone Free Rate (In Dilated Collecting System )
• PCNL has higher overall Success
• Combination of PCNL & ESWL can give a
stone free rates of 90% For ALL STONES IN THE
KIDNEY
COMPRESSION-TENSILE WAVE
CAUSES:
“Implosion” Rather than “Explosion”
ESWL & URETERIC CALCULI
• For fragmentation fluid medium around
stone necessary
• If stones impacted fragmentation may not
occur
• “PUSH & BANG”-success Marginally
HIGHER THAN “in situ ESWL”
• Trial of “in situ ESWL” – first choice
• “In situ ESWL” FAILS- “Rescue procedure”
ESWL COMPLICATIONS
• Haematuria – is quite common ( short term
antibiotics Recommended )
• Incomplete stone Fragmentation & Obstruction
• “Stienstrasse” ( stone street ) usually due to a
large “ Leading fragment”
( Stents Recommended prior to ESWL for
Calculi > 1.5 cm )
DESIGN BASIC LITHOTRIPSY
Renal Lithiasis Blood Pressure
Study ( Patients treated 1984-1986
Dallus Study)
First Follow Up
Second Follow Up
1988
1990
No.Pts Annualized Rate No.Pts Annualized Rate
of Hypertension
of Hypertension
ESWL
771
2.5% 590
2.1%
non-ESWL 195
3.8%
155
1.6%
Total
966
745
Basic Principles of
“SHOCK WAVE”
Lithotripsy
FRAGMENTATION BY SHOCK
WAVES
ON COLLISION OF “ SHOCK WAVES” WITH
CALCULI• ON FRONT SURFACE – COMPRESIVE FORCES
• ON BACK SURFACE OF THE STONEREFLECTION OF COMPRESSION PULSE
CREATES NEGATIVE OR TENSILE WAVE THAT
TRAVEL BACK WARD THROUGH CALCULI
• ONCE TENSILE FORCE EXCEEDS “ COHESIVE
STRENGTH” OF CALCULI- FRAGMENTATION
OCCURS
ESWL – SPARK GAP/ EHL
• Electro-hydraulic Generator Located at Base of
Water Bath
• Produces Shock wave by Electric Spark Gap of
15,000 to 25,000 Volts Lasting 1 Sec
• High Voltage Spark Discharge Rapidlyevaporates Water & Generators A “Shock Wave”
by expanding Sarrounding Liquid
Mechanism of Stone Fragmentation by ESWL
• On Front Surface – Compresive or positive Forces
• On Back Surface Of The StoneReflection Of Compression Pulse Creates Negative
Or Tensile Wave That Travel Back Ward Through
Calculi
• Once Tensile Force Exceeds “ Cohesive Strength”
Of Calculi- Fragmentation Occurs
• Cavitation – Small air bubbles
Steinstrasse ( or Stone Street) – Post ESWL
Diet & Fluid Advice
• High Fluid Intake
• Restrict Salt (Na)
• Oxalate Restrict
• Avoid high intake of Purine food
• Increased citrus fruits may help
• If hypercalciuria restrict Ca intake
Role of Potassium Citrate in preventing Cal Oxalate stone ds – KCit lowers
urinary calcium whereas Na Citrate does not lower Calcium due to Sodium load
LIQUIDS
Moderate Amounts :
High Amounts :
Apple Juice
Cocoa
Beer
Fresh Tea
Coffee
Cola
FOODS :
Almonds, Asparagus, Cashew Nuts, Currants, Greens,
Plums, Raspberries, Spinach
HIPPOCRATIC OATH :
“I Will not cut, even for the stone, but leave such
procedures for the practitioners of the craft”