(Nephrolithiasis, stones, urolithiasis)
Urinary stones are solid structures in the urinary tract. They cause pain, nausea, vomiting, hematuria and sometimes chills and fever resulting from secondary infection. The diagnosis is made by urinalysis and radiologic imaging, usually helical CT without contrast agent (n. D. Talk .: in Germany first by IUA). The therapy consists of the administration of analgesics, antibiotics for the infection, medical expulsive therapy and sometimes shock wave lithotripsy or endoscopic procedures.
In the US, 1/1000 adults are hospitalized each year because of urinary stones that are found at autopsy in 1%. Up to 12% of men and 5% of women develop until the age of 70 years urinary calculi. The size varies from microscopic crystals up to stones of several centimeters in diameter. A large stone (staghorn, Stag stone) can fill the pelvicalyceal system completely.
Urinary stones are solid structures in the urinary tract. They cause pain, nausea, vomiting, hematuria and sometimes chills and fever resulting from secondary infection. The diagnosis is made by urinalysis and radiologic imaging, usually helical CT without contrast agent (n. D. Talk .: in Germany first by IUA). The therapy consists of the administration of analgesics, antibiotics for the infection, medical expulsive therapy and sometimes shock wave lithotripsy or endoscopic procedures. In the US, 1/1000 adults are hospitalized each year because of urinary stones that are found at autopsy in 1%. Up to 12% of men and 5% of women develop until the age of 70 years urinary calculi. The size varies from microscopic crystals up to stones of several centimeters in diameter. A large stone (staghorn, Stag stone) can fill the pelvicalyceal system completely. Etiology In the United States (.. Editor’s note .: in Germany) are 85% of the stones of calcium, mainly calcium oxalate (see Table: composition of urinary stones), 10% of uric acid, 2% cystine. The remainder being mainly magnesium ammonium phosphate (struvite). Composition of urinary calculi composition percentage of all Common causes calcium oxalate 70 hypercalciuria hyperparathyroidism Hypocitrurie Renal tubular acidosis calcium phosphate 15 hypercalciuria hyperparathyroidism Hypocitrurie Renal tubular acidosis cystine 2 Zysteinurie Magnesium ammonium phosphate (struvite) 3 UTI caused by ureolytic bacteria uric acid 10 urine pH <5,5 Occasionally hyperuricosuria main risk factors include disorders of the urinary concentration of salt, either by increased excretion of calcium or uric acid or by decreased excretion of Urinzitrat. vary depending on the population of calcium stones, risk factors. The most important risk factor in the US is hypercalciuria, a hereditary disease that is at 50% of men and 75% of women with calcium stones, so patients have an increased risk of recurrent calculi with a family history of calculi. These patients have normal serum levels of calcium, but the calcium level in the urine is increased> 250 mg / day (> 6.2 mmol / day) in men and> 200 mg / day (> 5.0 mmol / day) in women , A Hypocitrurie (Urincitrat <350 mg / day [1820 .mu.mol / day]) is present at 40-50% of the Kalziumsteinbildner and promotes calcium stone formation because the Harnkalzium normally bound by citrate and so the crystallisation of calcium salts is prevented. Approximately 5-8% of the calculi caused by renal tubular acidosis. Approximately 1-2% of patients with calcium stones have a primary hyperparathyroidism. Rare causes of hypercalciuria are sarcoidosis, vitamin D intoxication, hyperthyroidism, multiple myeloma, metastatic carcinoma and hyperoxaluria. The hyperoxaluria (Harnoxalat> 40 mg / day [> 440 mol / day]) may be primary or by excessive intake of oxalic acid foods (eg. As rhubarb, spinach, cocoa, nuts, pepper, tea) or by excessive Oxalsäureresorption due to various intestinal diseases (eg. as bacterial overgrowth syndrome [ “bacterial overgrowth syndrome”], chronic pancreatic or biliary disease) or a ileojejunalen (z. B. bariatric) surgery your due. Other risk factors include taking high doses of vitamin C (d. H.> 2000 mg / day), a calcium diet (maybe because dietary calcium dietary oxalate binds) and weak Hyperuricosuria. A weak hyperuricosuria is defined as “urinary uric acid”> 800 mg / day (> 5 mmol / day) in men or> 750 mg / day (> 4 mmol / day) in women, and is almost always due to excessive intake of purine caused (in proteins, usually meat, fish and poultry). It can lead to the formation of calcium oxalate ( “hyperuricosuric Ca oxalate nephrolithiasis”). Uric acid calculi most frequently as a result of increased uric acid develop (urinary pH <5.5) or rarely with severe Hyperuricosuria (urinary uric acid> 1500 mg / day [> 9 mmol / day]), the uric acid crystallizes undissociated. Uric acid crystals form either the entire stone or, more commonly, a core around which attaches mixed calcium calcium or uric acid. Cystine stones are formed only in cystinuria. Magnesium ammonium phosphate stones (struvite, infectious stones) suggest the presence of a UTI by urea splitting bacteria (eg. B. Proteus sp., Klebsiella sp.). The stones must be as infected foreign body treated and removed completely. Unlike the other stones magnesium ammonium phosphate stones occur three times more common in women. Rare causes of urinary stones are indinavir, melamine, triamterene and xanthine. Pathophysiology Urinary stones can remain in the renal parenchyma or in the renal collecting system migrate into the bladder via the ureter. the stones can irritate the ureter or trapped during the passage, obstruct the flow of urine and cause a Hydroureter, sometimes hydronephrosis. Some common places where stones are found, include renal pelvis outlet distal ureter (at the level of the iliac vessels) “ureterovesical” crossing Larger stones are more likely to establish themselves. Typically, a stone must have a diameter of> 5 mm have to assess themselves. Stones ? 5 mm pass probably spontaneously. Even a partial obstruction causes a reduction in glomerular filtration, which may persist shortly after the finish of the stone. In hydronephrosis, and increased glomerular pressure of the renal blood flow decreases, which leads to a further deterioration of renal function. However, a permanent renal dysfunction develops without infection until about 28 days after a complete obstruction. With long-standing obstruction secondary infection can be added. However, patients rarely have an infection urine with calcium-containing stones. Symptoms and signs Large stones in the renal parenchyma or in the urinary sytem kidneys are usually asymptomatic, unless they cause obstruction and / or infection. Severe pain, often accompanied by nausea and vomiting occur usually when stones enter the ureter and cause an acute obstruction. Sometimes a gross hematuria occurs. Pain (renal colic) are different intense, but usually excruciating and intermittent, often occurs cyclically and lasts 20-60 minutes. Nausea and vomiting are common. Pain in the flank or in the renal region is broadcast on the stomach, indicate an obstruction of the upper ureter, or renal pelvis. Pain radiating along the ureters into the genital area, point to a lower ureteral obstruction. Suprapubic pain with urination and frequent urination indicate a distal ureter, or bladder stones ureterovesikale out (Obstructive uropathy: symptoms and complaints). On examination, the patient may exhibit extreme discomfort. They are often pale and sweaty. Patients with renal colic can not lie still and running around, bend, constantly change their attitude. The body may be slightly sensitive to pressure on the affected side when the palpation pressure on the already advanced kidney increased (sensitivity of Kostovertrebalwinkels), but missing peritoneal signs of guarding. In some patients, the first symptom is hematuria or either grit or a stone in the urine. Other patients may have symptoms of a urinary tract infection, such as fever, dysuria, or cloudy or foul-smelling urine. Diagnosis Clinical differential diagnosis Urinalysis Imaging methods determine the stone composition symptoms and complaints may indicate other diagnoses, such as. Peritonitis (eg due to appendicitis, ectopic pregnancy or inflammation in the pelvic area.): The pain is usually constant, and patients are calm because movement worsens the pain. Patients often also feel tenderness or stiffness. Cholecystitis: Can often cause of Murphy’s sign colicky pain, usually epigastric or right upper quadrant. Intestinal obstruction: Causes colicky abdominal pain and vomiting, but the pain is bilateral in general and does not occur in the edge or along the ureter in the first place. Pancreatitis: May cause upper abdominal pain and vomiting, but the pain is usually constant, can be bilateral, and is usually not on the side or at the ureter. In most of these diseases urogenital symptoms are unusual and other symptoms may indicate which organ system is actually involved (eg. As vaginal discharge or bleeding in diseases in the pelvic area in women). A dissecting aortic aneurysm should be considered, particularly in the elderly, because when a renal artery is affected hematuria and pain radiating along a “ureteral distribution”, may arise, or both. Other considerations in the general evaluation of acute abdominal pain are discussed elsewhere (Acute abdomen pain: Clarification). Tips and risks The supply of liquid (oral or iv) does not accelerate the passage of urinary stones. Patients suspected of having a calculus that causes colic is, require a urinalysis and imaging in general studies. If a calculus is confirmed following the analysis of the underlying disease, including studies on the composition of the stone. Urinalysis Usually a macro – or microscopic hematuria, but the urine can also be normal despite several stones. There may be a pyuria with or without bacteria. A pyuria suggests an infection, especially if it occurs with suspicious clinical findings, such as malodorous urine, or fever. A stone and various crystalline substances may be present in the sediment. If so, generally no further testing is necessary because the composition of the stone and the crystals can not be conclusively determined by microscopy. The only exception to this is when typical hexagonal cystine crystals in the concentrated acidified urine occur because these highly hinweisen.Bildgebende to a method Cystinuria A helical CT without contrast is the initial imaging study. This investigation can reveal both the localization of the stone and the extent of the obstruction. In addition, the spiral CT can reveal other causes of the pain (eg. As aortic aneurysm). In patients who have recurrent stones, the cumulative radiation dose should be ibeachtet by multiple CT scans, however, the routine use of low-dose Kidney CT may reduce the cumulative radiation dose with little loss of sensitivity (1). For patients with typical symptoms, sonography or Abdomenübersichtsaufnahmen can confirm the presence of stones have minimal or no radiation exposure usually. MRI can not identify stones. Nephrolithiasis (CT scan) ZEPHYR / SCIENCE PHOTO LIBRARY var model = {thumbnailUrl ‘/-/media/manual/professional/images/m1950166-nephrolithiasis-ct-scan-science-photo-library-high_de.jpg?la=de&thn = 0 & mw = 350 ‘, imageUrl’ /-/media/manual/professional/images/m1950166-nephrolithiasis-ct-scan-science-photo-library-high_de.jpg?la=de&thn=0 ‘, title:’ nephrolithiasis ( CT scan) ‘, description:’ u003Ca id = “v37897014 ” class = “”anchor “” u003e u003c / a u003e u003cdiv class = “”para “” u003e u003cp u003eDiesesCT scan shows kidney stones (white cloudiness) in the right kidney u003c / p u003e u003c / div u003e ‘credits’. ZEPHYR / SCIENCE PHOTO LIBRARY’