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Department of Physiology

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Title: PowerPoint Presentation Author: Dr. Dwiwedi Last modified by: Arvind Created Date: 9/15/2003 7:08:24 AM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Department of Physiology


1
NEPHROLITHIASIS
Dr.A.K.Dwivedi
BHMS (Gold Medallist),M.D.
H.O D
DIRECTOR
Department of Physiology SKRP
Gujrati Homoeopathic Medical
College, Indore
Advanced Homoeo-Health Center INDORE Ph.
09424083040
2
INDEX
  • INTRODUCTION
  • 2) ETIOLOGY
  • 3) TYPES OF RENAL CALCULI
  • 4) EFFECTS OF STONES
  • 5) CLINICAL FEATURES
  • 6) SPECIAL INVESTIGATIONS
  • 7) TREATMENT
  • 8) GENERAL MEASURES

3
  • NEPHROLITHIASIS
  • Renal stone or calculus or Lithiasis is one of
    the most common diseases of the urinary tract.
  • Occurs more frequently in men than in women
    and
  • in whites than in blacks.
  • Rare in children. It shows a familial
    predisposition.
  • World wide in distribution and common in U.S,
  • SOUTH AFRICA, INDIA , SOUTH EAST
    ASIA
  • Urinary calculus is a stone - like body composed
    of urinary salts bound together by a colloid
    matrix of organic materials.
  • It consists of a nucleus around which
    concentric layers of urinary salts are
    deposited..

4
ETIOLOGY
HYPEREXCRETION OF RELATIVELY INSOLUBLE URINARY
CONSTITUENTS 1. Oxalate Though oxalate is
the major component of 70 of all renal stones,
yet hyperoxaluria as a cause of formation of such
stone is relatively rare. Cabbage, rhubarb,
spinach, tomatoes, black tea and cocoa contain
large amount of oxalate. Ingestion of excessive
amounts of ascorbic acid and orange juice also
increase urinary oxalate excretion. 2. Calcium
- On regular diets normal urinary excretion of
calcium ranges between 200 mg to 300 mg per day.
The major calcium in foods are in milk and
cheese. Milk and dietary protein also cause
increased absorption of calcium from the
gut. 3. Uric acid - Many patients with gout
form uric acid calculi particularly when under
treatment. If the urine is made alkaline and
dilute while treating this disease chance of uric
acid stone formation is less
5
4. Cystine Cystinuria is an
herditary disease which is more common in infants
and children. Only a small percentage of patients
with Cystinuria form stones. 5. Drug induced
stones In rare cases, the long term
use of magnesium trisilicate in the treatment of
peptic ulcer has produced radio opaque silicon
stones.
6
  • PHYSICAL CHANGES IN THE URINE
  • 1. Urinary pH - The mean urinary pH is 5.85. It
    is influenced by diet and medicines. If the urine
    becomes infected with urea splitting bacteria
    e.g. calcium phosphate.
  • 2. Colloid content - As mentioned above it has
    long been claimed that the colloids in the urine
    allow the crystalloids to be held in a
    supersatured state.
  • 3. Decreased concentration of crystalloids -
    This may be due to low fluid intake, excessive
    water losses in febric disease and in hot
    climates, due to excessive perspiration or due to
    excessive water loss from vomiting and diarrhea.
  • 4 Urinary magnesium calcium ratio - This
    probably has notable influence on stone formation
    Acetazolamide (Diamox) causes hypocalcaemia and a
    decrease in the ratio.

7
  C. ALTERED URINARY CRYSTALLOIDS
COLLOIDS. D. DECREASED URINARY OUTPUT OF
CITRATE - The normal citrate concentration in
urine is 300 to 900 mg per day. Excretion
of citrate depends on certain hormones. It is
decreased during menstruation. E. VITAMIN -A
DEFICIENCY - Deficiency of Vitamin-A in the
food tends to induce stone formation in animals.
Stone formation is more common in northern parts
of India and Egypt probably due to this
Deficiency of Vitamin A causes. F. URINARY
INFECTION - Association of stone with infection
is very intimate. In about 80 of cases there is
infection of the urinary trace. Infection
distrubs the colloid content of the urine.
Infection also causes abormality in the colloids
which may cause the crystalloid to be
precipitrated. Infection also changes urinary pH
which helps in stone formation. Infection also
causes increase in concentration of crystalloids.
8
G. URINARY STATIS It goes without saying that
stones are more prone to occur when there is
obstruction to the free passage of urine (a)
Urinary stasis provides a fertile field for
bacterial growth (b) It also cause a shift of
the pH of the urine to the alkaline side (c)
Stasis also predisposes urinary infection (d)
It allows the crystalloids to precipitate. H.
HYPERPARATHYROIDISM Though this
condition is seen in only 2 to 5 of cases of
renal stone, yet its potentiality to form urinary
calculus cannot be underestimated.
In cases of multiple or recurrent urinary
calculi this cause should be eliminated. Due to
overproduction of Parathhormone the bones become
decalcified and calcium concentration in the
urine in increased. This extra
calcium may be deposited in the renal tubules or
in the pelvic to form renal calculus
9
LOCATION OF STONES IN KIDNEY
10
Types of renal
calculi Primary Stones
Are those which appear in apparently healthy
urinary tract without any antecedent
inflammation. These stones are usually formed in
acid urine. Usually consist of
calcium oxalate uric acid, urates, Cystine,
xanthine or calcium carbonate. Secondary Stones
Are usually formed as the result of
inflammation. The urine is usually alkaline as
urea splitting organism are most often the
causative organisms. Secondary stones
are mostly composed of calcium
Ammonium-magnesium phosphate (the
so-called triple phosphates).
11
PRIMARY STONES 1. Oxalate
calculus (calcium oxalate) - This type of stone
is usually single and it extremely hard. It is
dark in color due to staining with altered blood
precipitated on its surface. 2. Uric acid and
urate calculi - Pure uric acid calculi are rate
and are not visible in X-ray (not radio opaque).
These stones usually occur in multiples and so
are typically faceted. The stones are of moderate
hardness. In children, stones of ammonium and
sodium urate are sometimes found. These stoneware
yellow, soft and friable. 3. Cystine calculi -
These stones usually appear in patients with
cystinuria Cystinuria sometimes occurs in young
girls. Cystine is an aminoacid rich in sulphur.
Cystine calculi usually occur in multiple are
soft and yellow or pink in color. 4. Xanthine
calculi - These are extremely rate smooth round
and brick red in colour. 5. Indigo calculi -
12
SECONDRY STONES 1. Phosphate
calculus Majority of these
stones are composed of calcium phosphate, though
few are composed of ammonium magnesium phosphate
'triple phosphate' smooth, soft and friable.
It is usually dirty white in
colour. This type of
calculus usually occurs in infected urine. Urine
is often alkaline. Such stone enlarges rapidly
and gradually fills up pelvic. 2. Mixed Stones
13
EFFECTS OF STONE
The size and position of the
stone usually govern the development of
secondary pathologic changes in the urinary
trace. A. SAME KIDNEY 1.
Obstruction 2. Infection
B OPPOSITE KIDNEY 1.
Compensatory hypertrophy 2. Stone
formation may be bilateral 3.
Infection 4. Calculus anuria
14
. CLINICAL FEATURES Symptoms
- Symptom wise cases can be divided into 4 groups
- 1. Quiescent calculus A few stones,
particularly the phosphate stones, may lie
dormant for quite a long period.
These stone are also discovered due to symptoms
of Urinary Infection 2. Pain - Plain is the
leading symptom of renal calculus in majority of
cases (80). Three types of pain . a) Fixed
renal pain b) Ureteric colic c) Referred
pain 3. Hydronephrosis 4. Occasionally
haematuria is the leading and only symptom.
15
PHYSICAL SIGNS
In majority of cases characteristic
physical signs are not present. The signs which
may be present and should be looked for are
(i) Tenderness (ii) Muscle rigidity over
the kidney may be found in a few
cases.
16
(iii) Swelling - When there is Hydronephrosis or
pyonephrosis associated with renal calculus, a
swelling may be felt in the flank. The
characteristic of a renal swelling are -
(a) Oval or reniform in shape
(b) Swelling is almost fixed and
cannot be moved. (c) A kidney
lump is ballot able.
17
  • SPECIAL INVESTIGATIONS
  • Blood examination
  • Hardly reveals any specific abnormality,
    increased white blood cell associated with
    infection. Anemia may be found, blood urea,
    creatinine.
  • 2. Urinalysis -
  • (i) Physical examination
  • Show smoky urine due to slight
    haematuria or pale scent due to presence of pus.
  • (ii) Chemical examination
  • Show presence of protein due to
    haematuria and blood in the urine. If pH of the
    urine is higher than 7.6, presence of
    urea-splitting organism is assured.
  • (iii) Microscopic examination of urine
  • Show R.B.C. pus cells and casts.
    Different crystals may be seen in the sediment to
    givea clue as to the type of stone present. Uric
    acid of glacial acetic acid, which lowers the
    urinary pH to about 4.
  • (iv) Bacteriological examination of urine
  • Highly important including
    culture and sensitivity tests.
  • (v) Renal function tests
  • Always be performed in calculus
    cases. The PSP may be normal even in presence of
    bilateral stag horn calculi.

18
3.Radiography A) STRAIGHT X-RAY - Before
taking straight X-ray for KUB region (both
kidneys, ureters and bladder), the bowels must be
made empty by giving laxative. B)
Excretory Urogram 4 Ultrasonography
Helpful to distinguish between opaque and
non-opaque stones. It is also of value in
locating the stones for treatment with extra
corporeal shock wave therapy. 5 Computed
topography Particularly helpful in the
diagnosis of non-opaque stones. 6 Renal Scan 7
Instrumental examination - Cystoscopy 8
Examination of the stone
19
TREATMENT
ESWL (Extra corporeal Shock Wave Lithotripsy)
In this technique the
stone is removed with shock wave without the need
for instrumental penetration of the body. The
stone in the kidney is fragmented by repeated
shock waves which are focused towards the kidney
stone. The fragments are made so small that they
are automatically passed through the urine. In
some instances a ureteroscope may be required for
the passage of fragments. This method is
gradually replacing operative methods of removal
of renal calculi.
20
Nephrectomy
21
Ureteroscopy (URS)
22
Open Surgery Pyelolithotomy Nephrolithotomy
Partial nephrectomy
23
HOMOEOPATHIC REMEDIES FOR
NEPHROLITHIASIS  
24
I. B E R B E R I S V U L G A R I S Pain in
small of back very sensitive to touch in renal
region lt when sitting and lying, from jar, from
fatigue. Burning and soreness in region of
kidneys Numbness, stiffness,
lameness with painful pressure in renal and
lumbar regions. Pale, earthy complexion, with
sunken cheeks and hollow, blue-encircled eyes.
Stitching, cutting pain from left kidney
following course of ureter into bladder and
urethra ,Renal colic, lt left side Urine
greenish, blood-red, with thick, slimy mucus
transparent, reddish or
jelly-like sediment. Movement
brings on or increase urinary complaints.
Aggravation - Motion, walking or carriage-riding
any sudden jarring movement. Solitude is
unbearable desires company. Anguish he
sits, then walks, then lies, never long in one
place
25
II. L Y C O P O D I U M C L A V A T U M
Red sand in urine, on child's diaper
Child cries before urinating Pain in
back, Relieved by urinating Right
sided renal colic
26
III. M E D O R R H I N U M Severe pain
(backache) in renal region, gt by
profuse, urination Renal colic intense pain in
ureters, with sensation of
passing of calculus
27
IV. S A R S A P A R I L L A Severe, almost
unbearable pain at conclusion of urination
Passage of gravel or small calculi
renal colic Stone in bladder
Bloody urine. Urine bright
and clear but irritating scanty, slimy,
flaky, sandy,
copious, passed without sensation deposits
white sand.
28
General measures The
general measures or advises which should be given
to the patient regardless of the type of stone
are - (a) Fluid intake should be high at all
times. Fluids should be taken at bed
time so that nocturia will occur.
This will prevent dehydration. (b) Avoidance of
milk, cheese and great deal of calcium should be
advised. If renal function is
satisfactory sodium cellulose phosphate 5g.
T.D.S. with meals should be
prescribed to reduce calcium absorption. (c) Uri
ne should be kept acid all the time. Alkalies
should be prohibited or used in less
quantities in those patients who are suffering
from peptic ulcer. (d) Vitamin D
should be stopped or used in very low quantity
29
. C O N S E R V A T I V E M E A S U R E S
Not all patients with renal stones require
surgery. (i) When the stones are sufficiently
small, these can be naturally eliminated and
expectant policy is best adopted in these
cases. (ii) In the elderly, poor risk patients
a curalliform stone is best left alone unless it
causes significant
symptoms. (iii) Chemical dissolution of renal
stones requires indwelling urethral
catheters for constant through and through
irrigation with Renacidin or with G
solution. Sometimes stone fragments occlude the
ureteral catheters and cause acute
obstruction. With the advent
of percutneous Extra corporeal shock wave
Lithotripsy (ESWL), this method has mostly become
obsolete.
30
P r e v e n t i o n
As the patients who
have already undergone treatment for renal stones
should be managed prophylactic ally in an attempt
to prevent recurrence. With more knowledge of
stone formation, responsibilities lie on the
surgeons to prevents further stone formation and
cannot be left solely to God to prevent
recurrence or to fully cure the
patient. A. False recurrence, which means a
tiny stone was overlooked at the time of
operation, B. True recurrence - A patient with
renal stone is usually liable to produce further
stone subsequently. So attempt should always be
made to prevent such recurrence
31
T H A N K S
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