Download hydronephrosis, stones

URINARY TRACT OBSTRUCTION
(OBSTRUCTIVE UROPATHY)
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• Hydronephrosis
is the term used to describe
• dilation of the renal pelvis and calyces
• associated with progressive atrophy of the kidney
• due to obstruction to the outflow of urine
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Hydonephrosis
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Partial / complete
Sudden/progressive/intermittent
Unilateral/bilateral
Any level – pelvis/ureter/bladder/urethra
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Hydonephrosis
CAUSES
• Intrinsic – intraluminal/intramural
• Extrinsic
• Congenital/acquired
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Causes of Obstructive Uropathy
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Hydronephrosis:
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Hydronephrosis:
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Hydronephrosis Urolithiasis
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Urolithiasis with hydronephrosis:
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Urolithiasis /nephrolithiasis
(renal calculi
renal stones)
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Kidney stones
• Solid concretions ( crystal aggregations) of
dissolved minerals in urine
• found inside the kidneys or ureters. They
vary in size from as small as a grain of sand
to as large as a grapefruit
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Urolithiasis
• important in everyday urological practice.
• average lifetime risk of stone formation is in
the range of 5-10%.
• men > women (approx. 3:1)
• peak - 4th & 5th decades of life.
• Recurrent stone formation is a common
problem with all types of stones
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Urolithiasis
• males,
• Renal colic, dull ache in loins
• Urinary tract infection recurrent.
• Factors affecting:
Urine pH, Infection, Metabolic
low urine volume, decreased inhibitors
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TYPES
• COMPOSITION
• PATHOGENESIS
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Urolithiasis
Infection
Calcium oxalate (or phosphate)
75%
Magnesium ammonium phosphate
(struvite, or "triple phosphate")
12%
Uric acid
6%
Cystine
1%
Other
6%
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Renal stones
• For precipitation of crystals in urine to occur,
the urine must be "supersaturated" for the
precipitating crystal.
• Stone formation secondary to infection
• obstruction related to a congenital
malformation of the urinary tract (often
present before the age of 5).
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Stone Formation
• The chemical composition of stones depends
on the chemical imbalance in the urine.
• Kidney stones form when there is a high
level of mineral (s) in the urine;
i.e. calcium (hypercalciuria),
oxalate (hyperoxaluria), or
uric acid (hyperuricosuria)
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• Urine normally contains chemicals—citrate,
magnesium, pyrophosphate—that prevent
the formation of crystals
• Low levels of these inhibitors can contribute
to the formation of kidney stones.
• Citrate is thought to be the most important
• a lack of citrate in the urine
•
insufficient water in the kidneys to dissolve
waste products.
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• NIDUS – NUCLEATION (INITIATION)
100 ions
• AGGREGATION (GROWTH)
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HYPERCALCEMIA
(1) increased secretion of PTH with subsequent bone
resorption
- hyperparathyroidism due to parathyroid tumors,
- ectopic secretion of PTH-related protein
by malignant tumors
(2) destruction of bone tissue,
• secondary to primary tumors of bone marrow (multiple
myeloma, leukemia)
• diffuse skeletal metastasis (breast cancer),
• accelerated bone turnover (e.g., Paget disease),
• immobilization;
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HYPERCALCEMIA
(3) vitamin D–related disorders,
• vit D intoxication,
• sarcoidosis (in which macrophages activate a vit D
precursor),
• idiopathic hypercalcemia of infancy characterized
by abnormal sensitivity to vit D;
(4) renal failure,
which causes retention of phosphate, leading to
secondary hyperparathyroidism.
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Calcium oxalate monohydrates
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Single/multiple
Small-large
Dirty yellow/brown
Hard
Calcium oxalate dihydrates
Smooth/rough
Jagged/spikes
Cut surface-laminated
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• Magnesium ammonium phosphate stones
(12-15% of cases)
– Also called struvite, triple phosphate & infection
stones
– Associated with infections by urea splitting bacteria
(Proteus)
– Alkaline Urine
– Stag-horn calculi – typically large – takes on shape of
calyx
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Struvite Stones
• develops when a urinary tract infection
affects the chemical balance (alkalinise) of
the urine.
• Bacteria in the urinary tract are capable of
splitting urea into ammonia
• decreases the acidity of the urine
• enables bacteria to grow more quickly and
promotes struvite stone development.
.
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Struvite
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•
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Single/multiple
small-large
Whitish yellow
Soft friable
STAGHORN
Cut surface - laminated
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• Struvite stones are more common in
women.
• The stones usually develop as jagged
structures called "staghorns" and can grow
to be quite large.
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Staghorn Calculus:
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Staghorn Calculus:
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• Uric acid (urate) - 6%
–Purine metabolism  high turnover of
protein metabolism
(Gout, Leukemias & Lymphomas )
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Uric Acid Stones
• If the acid level in the urine is high or too
much acid is excreted, the uric acid may not
dissolve and uric acid stones may form.
• Uric acid stones form in acidic urine and
often dissolve when the urine is alkalinized.
• They are not visible on X-rays.
• Patients with gout often develop these
stones.
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Uric acid
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•
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Single/multiple
Brown
Hard
Round
Smooth
Cut surface - laminated
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Cystine (1-2%)
– Genetic defects in reabsorption of amino
acids
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Cystine Stones
• Cystine is an amino acid.
• a rare, congenital condition that
results in large amounts of cystine in
the urine(called cystinuria)
• causes cystine stones that are difficult
to treat and requires life-long
therapy.
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Urolithiasis:
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Clinical Manifestations
• Acute obstruction of the urinary tract may
cause renal colic
• a form of severe abdominal pain often
accompanied by nausea and vomiting
• Onset is sudden, often during the night or
in the early morning
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HISTORY
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Onset
Fluid intake
Diet
Medications
Urinary tract infections
Family history
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• A vast majority of stones will contain elements
of calcium within them and therefore are easily
seen on x-ray having the same density as
bone..
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Diagnostic imaging
Routine examination involves a plain abdominal film of the
kidneys, ureters and bladder (KUB)
At least 90% of all renal stones are radiopaque and therefore
readily visible on a plain film of the abdomen
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Type of stone ??
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Diagnostic imaging
Excretory pyelography
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Cystoscopy
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Cystoscopy
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Laboratory Investigations
• Stone analysis:
In every patient one stone should
be analysed.
• Blood analysis:
Calcium Albumin Creatinine Urate
• Urinalysis: Fasting morning spot urine sample
Dip-stick test: pH, Leucocytes/Bacteria
Cystine test, Ca, P, citrate, urate
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