Background Diagnosis Management AcuteED UrologicalDefinitive The Urological procedures Followup Contents Background Can be ureteric or intrarenal Very common emergency presentation ureteric stones ID: 1030396
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1. John El-KhouryKIDNEY Stones
2. BackgroundDiagnosisManagementAcute/EDUrological/DefinitiveThe Urological procedures.Follow-upContents
3. BackgroundCan be ureteric or intra-renalVery common emergency presentation (ureteric stones)Majority of stones are Calcium OxalateThe rest are made up of eitherUric AcidCystiene Calcium phosphate.Pyruvate
4. History:Renal colic (most common presentation)Can be asymptomatic/ incidental finding especially in the elderly.Nausea/vomiting associated with the painPain 10/10Can have penile tip pain in menCan be associated with LUTS (frequency, urgency symptoms) –when VUJ stone.Ureteric stones
5. Important history to get!!!Are they febrile? (documented fevers! Not just patients telling you that they are febrile)Rigors/sweats- need to distinguish between rigors/sweats and diaphoresis associated with pain (sympathetic response).Are they making urine?Significant PMHxAny previous stones and stone operations?Any previous kidney operations?- i.e nephrectomy!Any urological congenital abnormalities that are known?Are they on any blood thinners?Ureteric stones
6. Usually doesn’t help with diagnosis much but useful to rule out other pathologies:Intra-abdominal pathologiesCheck their obs chart! Are they febrile or have they been febrile at any point since they first sort medical help.Abdomen should be soft and no signs of peritonismCan be tender in RIF/LIF and tender to balloting of the kidney.CHECK THEIR DIPSTICK!?BLOOD ?NITRATESExamination
7. FBEUseful for baseline but that’s really it.Usually patients have elevated WCC and neutrophils but this is NOT an indicator of an infected stone rather it is just a result of having ureteric stones.UECsLooking at GFR. Are they in AKI and how severePatients usually always get some degree of AKI and unless they have only one kidney or bilateral obstruction – usual cause is pre-renal.CRP- not useful at allUrine m/c/s- should send off for all patients no matter the dipstick result.**Coags – if on any blood thinners or if infected obstructed stone should always get these!Bloods
8. Gold Standard:CT KUB (in all adults patients this should be first line)These days very low dose of radiationHelps illustrate exact location of stones and the presence of other stones.XR KUBOnce stone diagnosis is made, all patients should get an XR KUBIllustrates whether the stone is radiopaque. Useful for future follow-upRenal USSPoor at diagnosing stones, can miss stones Very user dependent UROLOGIST HATE RENAL USS FOR EMERGENCY DIAGNOSIS OF STONESGood for follow-up only. IMAGING
9. What information you need to know before calling ME:Age is obviously importantSide, site and size of stone!- any other stones?Any fevers?!? If febrile give this information straight away.Infected obstructed is an emergency!Presence of bilateral ureteric stones?Bilateral obstruction is an emergency!Presence of a contralateral kidney? And does that kidney appear normal?Unilateral obstruction in a single system is an emergency!PAIN IS NOT AS URGENT AS ABOVE!ALWAYS ASK FOR PRIVATE HEALTH!!!Ok so now you have diagnosed a ureteric stone! Yay…well done.
10. PAIN MANAGEMENTIV morphineNSAIDs- either IM ketorolac or PR Indomethacin.ParacetamolIf febrileIV ceftriaxone and ampicillin (some places use Gent and Amp)TAKE MSU AND BLOOD CULTURES PRIOR!If bilateral obstruction or single kidney obstructionNeeds IDC for strict urine output monitoring.Management- ACUTE/ED Management
11. ANY FEBRILE, BILTAERAL OBSTRUCTION OR UNILATERAL SINGLE KIDNEY OBSTRUCTION- must call urology for admission!If stone <6mm and pain is under control and patient is otherwise well, can try MET (medical expulsion therapy)Paracetamol, Tamsulosin, NSAIDs (PR indo is best) and PRN Endone.Ensure has XR KUB and stone is radio-opaqueNeed to go home and strain urine and strict adherence to the above tablets.Needs follow-up with Urology within 4 weeks with repeat imagingIf stone >6mm or <6mm and pain is not under control with maximal therapyRefer to Urology for further management. Any patient with recurrent presentations with the same stone needs urological referral.Management- cont.
12. The Urological Procedures- Acute
13. The Urological procedures- Definitive stone management.
14. Patients discharged with a ureteric stone for conservative management need to be followed up.Even without pain stone can still be there and after 6-8 weeks you can get irreversible nephron damage from a ureteric stone.Need imaging to prove they are stone free otherwise will need urgent management. Patients with multiple different episodes of stones need workup for causeFBC, UEC, CMP, Uric acid, TFT/PTH levels if serum calcium elevated, serum osmolality2 separate 24 hour urine collectionsVolume, pH, UEC, CMP, Uric acid, citrate, cysteine, Follow-up
15. Thank You.