3. HISTORY
Demographic biodata
Life style
Occupation
Diet/fluid intake
Drug history
Systemic disease
Family history
History of bowel surgery
4.
5. OCCUPATION
Sedentary occupations predispose to stones more
than manual work
Low activity levels predispose to bone
demineralization and hypercalciuria.
Physical activity agitate urine and dislodge crystal
aggregates
6. DIET
Water intake
Low fluid intake (<1200 ml/day) predisposes to stone
formation
A less energy-dense diet may decrease the incidence of
stones.
Vegetarians have decreased incidence of urinary stones
High sodium intake is associated with increased urinary
Sodium
Calcium
PH
Decreased urinary citrate
7. CLIMATE
Summer is the season of urinary stones and
dehydration is the key factor
Concentrated urine has a lower ph, encouraging
cystine and uric acid stone formation
Exposure to sunlight may also increase endogenous
vitamin D production, leading to hypercalciuria.
8. FAMILY HISTORY
Incidence increases with positive family history
Familial diseases like
Cystinuria
An auto-somal recessive disorder of transmembrane cystine
absorption
RTA
Type 1 or distal RTA: the distal tubule is unable to secret H+
Urinary ph(>5.5)
Low urinary citrate
Hypercalciuria
Type 2 or proximal RTA: failure of bicarbonate resorption in the
proximal tubule.
Type 3: a variant of type 1 RTA
Type 4 : is seen in diabetic nephropathy and interstitial renal disease.
9. PAST HISTORY
Bowel resection
Inflammatory bowel disease
Systemic diseases i-e
- Gout
- Hyperparathyroidism
- Sarcoidosis
10. DRUG HISTORY
The antihypertensive(triamterene) is associated with
urinary calculi
Long-term use of antacids containing silica leads to
silicate stones.
Protease inhibitors in immunocompromised patients
are associated with radiolucent calculi.
Corticosteroids (increase enteric absorption of
calcium, leading to hypercalciuria)
Chemotherapeutic agents (breakdown products of
malignant cells leads to hyperuricemia)
11. PHYSICAL EXAMINATION
Pt frequently changes posture to find pain relief
Renal colic is associted with tachycardia, sweating,and nausea
Costovertebral angle tenderness may be apparent.
An abdominal mass may be palpable in patients with hydronephrosis
A thorough abdominal examination to exclude other causes of
abdominal pain.
Abdominal tumors,
Abdominal aortic aneurysms
Herniated lumbar disks
Pregnancy
Bladder palpation as urinary retention may present with pain similar
to renal colic.
Incarcerated inguinal hernias
Epididymorchitis
A rectal examination helps exclude other pathologic conditions.
12. METABOLIC EVALUATION
Depends on the stone type(composition)
Stone type is analyzed by
Polarizing microscopy
X-ray diffraction
Infrared spectroscopy
If stone is not retrieved
Radiological appearance radiolucecy/opacity
Metabolic evaluation
13. METABOLIC EVALUATION…
Urine pH
pH <6 in a patient with radiolucent stones suggests the
presence of uric acid stones.
pH consistently >5.5 suggests distal RTA (~70% calcium
phosphate stones)
Evaluation for cystinuria
Cyanide-nitroprusside colorimetric test (cystine spot test)
Measurement of 24-hour urinary cystine (>250 mg is
diagnostic)
Evaluation for RTA
If fasting morning urine ph >5.5, the patient is labeled to
have distal RTA.
17. PLAIN X-RAY KUB
Not useful if stones are
Radiolucent
Smaller than 4mm
Lies over the sacrum or other bony structure.
Bowel gases can obscure its efficacy.
Can not differentiate between
Stones
Calcified lymph nodes
Phleboliths
Sensitivity for diagnosis of stones is 50–70%
19. US KUB
Usually done to compliment x-ray KUB
Its sensitivity for detecting renal calculi is ~95%
Very sensitive for the diagnosis of obstruction and
can detect radiolucent stones missed on KUB
Its non invasive
May miss small stones and ureteral stones
Particularly important in pregnant pt
21. INTRAVENOUS PYELOGRAPHY
Useful for patients with suspected indinavir stones
Requires trained technician
Its an invasive procedure predisposing pts to highly
allergic IV contrasts
Its very prolonged procedure takes hours
Require proper pt preparation
Not good investigative modality in acute renal colic
22. IVP
Films and “phases” of IVP
Plain film:
This is used to look for calcification overlying the region of
the kidneys, ureters, and bladder.
Nephrogram phase:
Film taken immediately following iv contrast
The nephrogram is produced by filtered contrast within
the lumen of the proximal convoluted tubule
Pyelogram phase:
Much denser than the nephrogram phase.
As concentrated contrast accumulates in plvicalycel
system
25. COMPUTED TOMOGRAPHY
Has greater specificity (95%) and sensitivity (97%) for
diagnosing ureteric - stones
Noncontrast spiral CT scans are now the imaging modality of
choice
Advantages:
It is rapid
No need for experienced radiologic technician
No need for intravenous contrast.
Uric acid stones are also visualized
Disadvantage:
Distal ureteral calculi can be confused with phleboliths.
These images do not give anatomic details as seen on an IVP
(for example, a bifid collecting system)
26. MAGNETIC RESONANCE IMAGING
MRI is a poor study to document urinary stone disease.
Clue towards obstruction by diagnosing
hydronephrosis