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STONE DISEASE ( Brief Overview ) Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.), Professor & HOD, Dept. of Urology, Sri Ramachandra Medical College &

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Presentation on theme: "STONE DISEASE ( Brief Overview ) Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.), Professor & HOD, Dept. of Urology, Sri Ramachandra Medical College &"— Presentation transcript:

1 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.

2 COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS Stone analysis in Percentage Form of Lithiasis India USA Japan UK Pure Calcium Oxalate86.13317.439.4 Mixed Calcium Oxalate and4.93450.820.2 Phosphate Magnesium Ammonium 2.71517.415.4 Phosphate (Struvite ) Uric Acid1.28.04.48.0 Cystine0.43.01.02.8

3 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

4 Inhibitors & Promoters of Stone Formation in Urine INHIBITORS Inhibits crystal Growth - Citrate – complexes with Ca Magnesium – complexes with oxalates Pyrphosphate - complexes with Ca Zinc Inhibits crystal Aggregation Glycosaminoglycans Nephrocalcin Tamm- Horsfall Protein PROMOTERS 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

5 SOME DISEASES ASSOCIATED WITH HYPERCALCAEMIA & HYPERCALCIURIA HyperparathyroidismLeukemia SarcoidosisLymphoma Multiple myelomaMyxedema HyperthyroidismAdrenal Insufficiency Metastatic Malig. Neoplasm'sVit. D Intoxication

6 TYPES OF KIDNEY / URETER STONES OXALATE (CALCIUM OXALATE) PHOSPHATE URIC ACID & URATE CYSTINE

7 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)

8 Uncommon Stones TRIAMTERENE – A nti-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

9 Stones – Chemical Constituents Whewelite – Calcium Oxalate Monohydrate – CaC 2 O 4 -H 2 O Weddelite - Calcium Oxalate dihydrate – CaC 2 O 4 -2H 2 O Brushite – Calcium Hydrogen phosphate dihydrate – CaHPO 4 2H 2 O Whitlockite - TriCalcium Phosphate – Ca 2 (PO 4 ) 2 Struvite – Magnesium Ammonium hexahydrate – MgNH 4 PO 4 -6H 2 O

10 DD of Radiolucent filling defect on IVU in Ureter or Kidney Must Know Uric Acid Calculus Matrix Calculus Sloughed Papilla Blood Clots TCC Renal Cysts Vascular Lesions Know For Brownie Points Xanthine Calculus Hydroxyadenine Calculus Ephederine Calculus Infection due to gas forming Org. Fungal Ball Tuberculoma Malacoplakia Hypertrophied Papilla Renal pseudo-tumour

11 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

12 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

13 PHOSPHATE STONES IN ALKALINE URINE ENLARGES RAPIDLY TAKE SHAPE OF CALYCES STAGHORN Struvite can form Stag-horn and appear like coffin lid under microscope

14 CALCIUM PHOSPHATE STONES Hyperparathyroidism Ca P Renal Tubular AcidosisKCO 2 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

15 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

16 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

17 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 Cyanide Nitroprusside Calorimeteric Test for detecting Cystinuria. If positive do amino acid chromatography pKa of cystine is 8.3, hence alkalinisisation above pH7.5 helps to dissolve the stones

18 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

19 HISTORY A.IS PATIENT DRINKING ENOUGH ? B. PROFESSION C.ENQUIRE ABOUT UTI STONES D. FAMILY HISTORY E.LONG ILLNESS BEDRIDDEN STONES

20 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

21 HISTORY (Cont...) B. ASK ABOUT THEIR PROFESSION DEHYDRATION STONES CAN FORM e.g. MARATHON NEAR A FURNACE, BRICK - LAYER, LABOURERS & WEAVERS TRUCK & BUS DRIVERS

22 C.ENQUIRE ABOUT UTI STONES D. FAMILY HISTORY E.LONG ILLNESS BEDRIDDEN STONES HISTORY (Cont...) Zero Gravity state – astronauts on long space flights more prone to stones

23 CLINICAL FEATURES 1.PAIN IN 75 % OF THE CASESRENAL 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

24 CLINICAL FEATURES (Contd....) 2)HAEMATURIA CAN BE FRANK OR ONLY FOUND ON DIP - STICK OR LAB. 3)PYURIA - IF INFECTION CAN HAVE PUS IN URINE

25 ON EXAMINATION 1.ACUTE PRESENTATION ABDOMEN TENSE AND RIGID TENDERNESS PRESENT IN THE LOIN 2.IN ROUTINE PRESENTATION NO FINDINGS IN ABDOMEN

26 INVESTIGATIONS 1.FULL BLOOD COUNT TO CHECK FOR ANAEMIA IF GOING FOR SURGERY 2.SERUM ELECTROLYTES PLUS UREA / CREATININE / CALCIUM / URIC ACID / PHOSPHATE

27 INVESTIGATIONS (Cont...) 3.24-HOURS URINE FOR ELECTROLYTES (Only if recurrent stone former) CALCIUM / OXALATE / URIC ACID / CYSTINE / CITRATE

28 INVESTIGATIONS (Cont...) 4.PLAIN KUB X-RAY OF ABDOMEN (Mandatory) 5.IVU OR IVP (INTRA VENOUS UROGRAM) 6.ULTRASOUND (Mandatory)

29 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

30 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.

31 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.

32 MANAGEMENT OF UROLITHIASIS Non-invasive approach to urinary calculas- HALLMARK of last 20 yrs. Lithotripters – 1.Extra Corporeal Shock wave 2.Intra Corporeal Better fiber optics – Miniturisation of Telescopes Accessories - Innovative variety

33 Modern Management of Urolithiasis 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

34 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)

35 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.

36 ESWL – For Urinary Tract Calculus

37 ESWL- FOUR MAIN ELEMENTS 1.ENERGY SOURCE 2.FOCUSING DEVICE 3.COUPLING DEVICE 4.LOCALIZATION DEVICE

38 ESWL Absolute Contra-indication- Pregnancy Relative Contra-Indications for ESWL – Renal Colic Urinary obstruction Infection Declining Renal Function Significant Hematuria

39 COUPLING DEVICE WATER BATH WATER FILLED CUSHION (KEEP PATIENTS DRY)

40 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

41 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

42 COMPRESSION-TENSILE WAVE CAUSES: Implosion Rather than Explosion

43 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

44 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 )

45 DESIGN BASIC LITHOTRIPSY

46 Renal Lithiasis Blood Pressure Study ( Patients treated 1984-1986 Dallus Study) First Follow Up Second Follow Up 19881990 No.Pts Annualized Rate No.Pts Annualized Rate of Hypertensionof Hypertension ESWL 771 2.5%590 2.1% non-ESWL 195 3.8%155 1.6% Total 966 745

47 Basic Principles of SHOCK WAVE Lithotripsy

48 FRAGMENTATION BY SHOCK WAVES ON COLLISION OF SHOCK WAVES WITH CALCULI- ON FRONT SURFACE – COMPRESIVE FORCES ON BACK SURFACE OF THE STONE- REFLECTION OF COMPRESSION PULSE CREATES NEGATIVE OR TENSILE WAVE THAT TRAVEL BACK WARD THROUGH CALCULI ONCE TENSILE FORCE EXCEEDS COHESIVE STRENGTH OF CALCULI- FRAGMENTATION OCCURS

49 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 Rapidly- evaporates Water & Generators A Shock Wave by expanding Sarrounding Liquid

50 Mechanism of Stone Fragmentation by ESWL On Front Surface – Compresive or positive Forces On Back Surface Of The Stone- Reflection 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

51 Steinstrasse ( or Stone Street) – Post ESWL

52 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

53 LIQUIDS Moderate Amounts :High Amounts : Apple JuiceCocoa BeerFresh Tea Coffee Cola FOODS : Almonds, Asparagus, Cashew Nuts, Currants, Greens, Plums, Raspberries, Spinach

54 HIPPOCRATIC OATH : I Will not cut, even for the stone, but leave such procedures for the practitioners of the craft


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