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RENAL CALCULI

الكلية كلية الطب     القسم  الجراحة     المرحلة 4
أستاذ المادة محمد رضا جودي عبود جلو       17/12/2015 10:03:57


Etiology:
Many theories, the current opinion:
1. Dietetic:
Vit. A deficiency, desquamation, the cell will be the nidus for the stone.
2. Altered urinary solutes and colloid:
Dehydration increases the conc. Of urinary solutes, may precipitate. And reduction of urinary colloid which adsorb solutes, or mucoprotein which chelate calcium, may result in crystal and stone formation.
3. Decrease urinary citrate: that important to calcium phosphate in solution (soluble).
4. Renal infection: stone common with infection, because change in urine PH.
5. Inadequate urinary drainage and urinary stasis.
6. Prolong immobilization: as paraplegia.
7. Hyperparathyroidism:
Increase mobilization of calcium from the bone to blood then to urine.


Types of renal calculi:
1. Oxalate stone (calcium oxalate stone): irregular with sharp projection causing bleeding. Radio dense.
2. Phosphate calculus: calcium phosphate often with ammonium magnesium phosphate (struvie) smooth, grow in infected urine (alkaline) may become big (stag horn), and may silent. Radio opaque.

3. Uric acid urate calculi: hard yellow, multiple, radiolucent if pure, but most of it mix with calcium so faint radiological shadow.

4. Cystine calculus: uncommon with congenital error of metabolism that leads to cystinuria.pink or yellow change to greenish color when exposed to air. Radio opaque because they contain sulphur, hard.

5. Xanthine calculus: rare smooth round. (Autosomal recessive), radiolucent.

Clinical Feature:
Common, between 30-50 years, male/female 4:3.
SILENT CALCULI: even large stag horn may no symptom but progressing renal damage, and uremia may be, if bilateral renal; stone.
PAIN: is the leading symptom in 75%, pain the renal angle, hypochondrium, ureteric colic is agonizing pain, from the loin to groin. It is sudden, colic in nature, it radiate to groin, penis, labium, as stone progressing down to ureter, the severity not related to the size of the stone, may associated with hematuria. There is tenderness on deep bimanual exam. And rarely rigidity of lateral abdominal muscle.
HAEMATURIA: may leading symptoms, may microscopic haematuria.
PYURIA: infection is likely, and become dangerous when the kidney is obstructed, septicemia can quickly develop.
The mechanical effect of stones irritating the urothelium may cause pyuria even in the absence of infection.
Investigation of suspected urinary stone disease:
1. Radiology:
KUB (kidney, ureter, bladder): radio opaque stone only seen about 85% of stone.
2. Contrast-enhanced computerized tomography:
CT scan (spiral) is the mainstay of investigation for acute ureteric colic.
3. Excretory urography:
To see the site of the stone and the anatomy of the urinary system, and some information about the function of the kidney.
4. Ulrasound scanning:
Is the of the most value in locating the stone.

Surgical treatment of urinary calculi:
1: conservative:
In stone smaller than 0.5 cm, pass spontaneously, unless associated infection so intervention indicated, so antibiotics started immediately, surgical treatment include minimally invasive technique, sometime open surgery may needed.
2. Modern methods of stone removal of kidney stone:
Percutaneouse nephrolithotomy (PNL): by using nephroscopy through a small opening from the back to extract kidney stone , and destructing it by pnumoclast or laser.

Extracorporeal shock wave lithotripsy( ESWL): the stone bombarded with shock wave of sufficient energy to disintegrate into fragment, the shock wave should transmitted through water because it become poor when transmit through the air so use bath of water or bag of water, and localization of the stone controlled by radiograph or ultrasound..
The complication of ESWL include: renal colic, infection, haematuria, and ecchymosis.
Open surgery for renal calculi:
Including: pyelolithotomy: extract the stone through renal pelvis
Extended pyelolithotomy by extracting the stone through a wide incision extending to the calyces.
Nephrolithotomy: through the renal paranchyma.

PREVENTION:
ALL THE STONE FORMER SHOULD BE INVESTIGATED.
In recurrent stone:
1. Serum calcium, to exclude hyperparathyroidism.
2. Serum uric acid.
3. 24 urine for urate calcium, and phosphate.
4 stone analysis.

Dietary advice is not usually helpful, unless proved metabolic error, example calcium oxalate better to be moderate in eat milk product, spinach, asparagus…..
Hyperuricaemia: ovoid red meat offal, fish, and treated with allopurinol.
Restriction of eggs meat and fish rich in sulpher should be restricted in cystin urea.

Drink a plenty of water which is very important in all type of stone.
Drug treatment is largely ineffective except in idiopathic hypercalciuria.
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By:
Assist. Professor
M.R.Judi

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