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B. Wayne Blount, M.D. MPH Professor and Vice-Chair Department of Family Medicine Emory University

NEPHROLITHIASIS. B. Wayne Blount, M.D. MPH Professor and Vice-Chair Department of Family Medicine Emory University. O BJECTIVES. Discuss the recommended work-up to diagnose nephrolithiasis Know the different treatment options for site and size specific stones

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B. Wayne Blount, M.D. MPH Professor and Vice-Chair Department of Family Medicine Emory University

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  1. NEPHROLITHIASIS B. Wayne Blount, M.D. MPH Professor and Vice-Chair Department of Family Medicine Emory University

  2. OBJECTIVES • Discuss the recommended work-up to diagnose nephrolithiasis • Know the different treatment options for site and size specific stones • Recognize the urgent situations of nephrolithiasis • Know when to seek urologic consultation

  3. TODAY’S ROADMAP • Epidemiology • Presentation and Diff. Dx • Diagnostic Work-up • Emergency Situations • Management Strategy • Prevention • Summary

  4. EPIDEMIOLOGY • 2-4% of general population • 2-3 x more common in males • Caucasian > Oriental > African American • Hot climates > temperate

  5. RISK FACTORS • Male Gender • Age (to 65) • Low urine vol. • Situational • Geography • Heredity • Diet • Meds

  6. MEDS CAUSING STONES Drugs that promote calcium stone formation: • Loop diuretics • Antacids • Acetazolamide • Glucocorticoids • Theophylline • Vitamins D and C

  7. MEDS CAUSING STONES Drugs that promote uric acid stone formation: • Thiazides • Salicylates • Probenecid • Allopurinol

  8. MEDS CAUSING STONES Drugs that precipitate into stones: • Triamterine • Acyclovir • Indinavir

  9. PRESENTATION • Abdominal Pain • Renal Colic: Sudden; Not Relieved • Hematuria

  10. DIFFERENTIAL Dx • Gynecologic Processes • Testicular Processes • Appendicitis • Cholecystitis • Hernia • Aneurysm • Tumors

  11. Relationship of Stone Location to Symptoms

  12. Relationship ofStone Location to Symptoms Stone LocationCommon Symptom Kidney Vague Flank Pain, Hematuria

  13. Relationship of Stone Location to Symptoms Stone LocationCommon Symptom Proximal Ureter Renal colic, flank pain, upper abdominal pain

  14. Relationshipof Stone Location to Symptoms Stone LocationCommon Symptom Middle section of Renal colic, anterior ureter abdominal pain, flank pain

  15. Relationshipof Stone Location to Symptoms Stone LocationCommon Symptom Distal ureter Renal colic, dysuria, urinary frequency, anterior abdominal pain, flank pain

  16. Work-Up • History • P.E. • U.A. • Imaging • Labs

  17. History • Focused • PM Hx • Fam Hx • Symptoms of emergencies

  18. P.E. • Abdomen • Pelvis • Rectal • Rules out nonurologic process

  19. U.A. • RBCs • pH • Crystals • Bacteria • Some pyuria expected

  20. Imaging • Essential to confirm Dx & to size and locate stone • Several Options

  21. Imaging Options • Ultrasonography • KUB • Intravenous Pyelography (IVP) • Noncontrast Helical C.T.

  22. Imaging modality Sensitivity (%) Specificity (%) Ultrasonography 19 97 Advantages Limitations Accessible Poor visualization of Good for diagnosing of ureteral stones Hydronephrosis and renal stones Requires no ionizing radiation

  23. Imaging modality Sensitivity (%) Specificity (%) Plain radiography 45 to 59 71 to 77 Advantages Limitations Accessible Stones in middle section & expensive of ureter, phleboliths, radiolucent calculi, extraurinary calcifications and nongenitourinary conditions

  24. Imaging modality Sensitivity (%) Specificity (%) Intravenous 64 to 87 92 to 94 pyelography Advantages Limitations Accessible Variable-quality imaging Provides information Requires bowel preparation on anatomy and & use of contrast media functioning of both Poor visualization of non- kidneys genitourinary conditions Delayed images required in high-grade obstruction

  25. Imaging modality Sensitivity (%) Specificity (%) Noncontrast helical 95 to 100 94 to 96 computed tomography Advantages Limitations Most sensitive & specific Less accessible and radiologic test (i.e., facilitates relatively expensive fast, definitive diagnosis) No direct measure of Indirect signs of the degree of renal function. obstruction Provides information on non- genitourinary conditions

  26. Labs • CBC* • UA* • BMP • Ca • PO4 • Urate • Urine C & S* • Stone Analysis*

  27. A SUGGESTION Patient with abdominal pain History and physical examination Renal colic suspected Diagnostic imaging ??? Patient is pregnant, or cholecystitis or gynecologic process is suspected Patient has history of radiopaque calculi All other patients

  28. Ultrasound Examination Plain-film radiography Intravenous pyelography if CT is not available Noncontrast helical CT Stone detected Stone not detected Stone detected Stone not detected Clinical suspicion of urolithiasis

  29. MANAGEMENT(3 Principles) • Recognize Emergencies • Adequate Analgesia • Impact of size and location on Hx & Rx

  30. MANAGEMENT(3 Principles) Recognize Emergencies • Adequate Analgesia • Impact of size and location on Hx & Rx

  31. MANAGEMENT(3 Principles) • Recognize Emergencies Adequate Analgesia • Impact of size and location on Hx & Rx

  32. MANAGEMENT(3 Principles) • Recognize Emergencies • Adequate Analgesia Impact of size and location on Hx & Rx

  33. Emergencies • Sepsis with obstruction (struvite stones?) • Anuria • ARF • Urologic consultation

  34. Hospitalization? • Emergencies • Refractory Nausea • Debilitation • Extremes of age • Refractory Pain

  35. Analgesia • NSAIDs : also spasmolytic • Narcotics • No NSAIDs < 3 days before lithotripsy (ASA < 7 days) • Ketorolac

  36. Manage The Stone After adequate analgesia and ruling out emergencies Principles here are stone size and location

  37. Probability of Stone Passage

  38. SUGGESTIONS Stones < 4 mm • Passage in 1-2 wks • Analgesia • Strain Urine • F/U KUB Q 1-2 wks • Urology if not passed in 2 wks. (certainly 4 wks as comps  3X) • RTC signs of sepsis

  39. SUGGESTIONS Stones > 5 mm • Urologic Consultation

  40. SUGGESTIONS Stones 4 – 5 mm • Decide based on other parameters

  41. Other Parameters • Location • Composition • Larger Size • Occupation

  42. Location • Renal stones usually can be followed

  43. “Composition” Staghorn renal calculi to urology (assoc. with infections and kidney damage)

  44. Occupation • Pilots cannot fly even with an asymptomatic stone • Get early definitive Rx

  45. Larger Size • Renal calculi of 5 mm – 2 cm : Extra corporeal lithotripsy • Lower pole stones 5 mm – 1 cm : ECL • Ureteral stones 5 mm – 1 cm : ECL

  46. Largerthan 2 cm or when ECL contraindicated or not effective:Renal & Proximal ureteral stones: Percutaneousnephrolithotomy

  47. Ureteroscopes Stones anywhere dependent on technician’s abilities

  48. Treatment Modalities for Renal and Ureteral Calculi Treatment Indications Advantages Extracorporeal Radiolucent calculi Minimally invasive shock wave Renal stones < 2 cm Outpatient lithotripsy Ureteral stones < 1 cm procedure Limitations Complications Requires spontaneous passage Ureteral obstruction by of fragments stone fragments Less effective in patients with Perinephric hematoma morbid obesity or hard stones

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