By Dr. Khalid Shakeel Babar (KSB) By Dr. Khalid Shakeel Babar (KSB)

Low Urine Volume Hyperuricosuria Low Urinary pHHigh Serum Uric Acid Level

lighterheavier pHUrinaryLow High Serum Uric Acid Level Low Urine Volume Hyperuricosuria

Dietary IngestionDe Novo Purine SynthesisDecrease in Elimination

 Gout  Uricosuric Drugs  Uric Acid Overproduction  Chronic Diarrhea  DM and Metabolic Syndrome

1.PAIN IN MOST 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 C) BLADDER STONE PAIN WITH LUTS Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in renal colic

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

1.ACUTE PRESENTATION  ABDOMEN TENSE AND RIGID  TENDERNESS PRESENT IN THE LOIN  Renal Punch positive 2.IN ROUTINE PRESENTATION  NO FINDINGS IN ABDOMEN

1. FULL BLOOD COUNT 2. Abdominal Ultrasound 3. URINE R/E

4. KUB Xray 5. Stone Analysis 6. Serum Uric acid, Blood urea and serum creatinine hour urine for uric acid

8. IVU OR IVP (INTRA VENOUS UROGRAM) 9.CT Scan 10. Renogram (DMSA / DTPA / MAG3)

 Alkalinization of urine  Increased fluid intake  Xanthine oxidase inhibiters ( if 24hr urinary uric acid excretion more than 6 mmol/day)  Dietary restriction of purine rich foods.

 Renal  Pyelonephritis.  Obstruction of the ureter due to other causes (such as a blood clot, stricture, papillary necrosis, or urothelial tumour).  Acute renal infarction.  Renal rupture.  Renal abscess (very rare, and in the UK usually secondary to stones).

 Gynaecological  Ectopic pregnancy.  Endometriosis.  Ovarian cyst: rupture or torsion.  Pelvic inflammatory disease.  Salpingitis.

 Gastrointestinal  Appendicitis.  Diverticulitis.  Biliary colic.  Bowel obstruction.  Bowel ischaemia.  Crohn's disease Others AAA

 Mortality and morbidity are not increased with uric acid stones compared with other stones; however, the process that leads to excess uric acid production (eg, malignancy, Lesch-Nyhan syndrome) may cause death.

 Restrict purine rich diet to reduce recurrence.  Repeat Urine pH, serum uric acid, abdominal ultrasound and CT scan for recurrence.

 Rare event  Normal physiology of pregnancy  Factors favoring stones in pregnancy  Most stones appear to be predominantly composed of calcium phosphate

 Renal and pelvic ultrasound  Transvaginal and doppler ultrasound If further diagnosis is required MR urography Low dose CT. limited intravenous pyelogram (IVP)

 Most (75 to 85 percent) stones pass spontaneously  Decompression of the kidney with  placement of a ureteral stent  percutaneous nephrostomy tube,  ureteroscopy to remove the stone may be required in the patient who is septic, has persistent severe pain, or has persistent obstruction.  shock wave lithotripsy use during pregnancy is contraindicated

 Presentation: On 17 th November, 2012, 8:00 AM 26 year old boy presented with Severe Radiating Right Lumbar Pain Associated with nausea and vomiting. On examination: Renal Punch +ve on Right Side. Ultrasound Abdomen Report: Normal except Right Kidney shows minimal hydronephrosis with dilated proximal ureter raises the suspicion of distal ureteric obstruction. Urine R/E Report: Normal, except Urine pH 5.0 KUB xray: Normal, No stone seen.

 Initially managed with Inj. Diclofenac Sodium i/m Inj. Spasfan i/m Inj. Gravinate i/v  After the pain was relieved patient was asked detailed history, he told about Family history of stones.  Serum uric acid level advised and it was 7.8 mg/dl (normal range 3.5 – 7.2).

Patient started on conservative treatment  Alkalinization of urine  Increased fluid intake 24hr urinary uric acid excretion test done It was less than 6mmol/day, so patient did not start Xanthine oxidase inhibiters.

 Video  Special Thanks to Dr. Kamran sahib for solving all my queries regarding stones and immensely helping me in preparing presentation.  Thanks to Dr. Qais Falah and Prof; Dr. Zahid Ahmed Hashmi for encouragement and help.