Renal colic
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Transcript of Renal colic
Edited by:
Kamrul Islam Shipo
The urinary tract includes the kidneys, ureters, bladder and urethra. Within each kidney, urine flows from the outer cortex to the inner medulla.
The renal pelvis is the funnel through which urine exits the kidney and enters the ureter.
The kidneys remove wastes, control the body's fluid
balance, and regulate the balance of electrolytes
The medulla is composed of a series of conical
masses called the renal pyramids.
The apex of these pyramids form a papilla which
projects into the lumen of the minor calyces.
The cortex extends between these medullary
pyramids as the renal columns
The minor calyces are cup shaped tubes which
surround the renal papilla. These converge to form
the major calyces, which in turn unite to form the
renal pelvis.
The stones are solid concretions or calculi (crystalaggregations) formed in the kidneys from dissolved urinary minerals
Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase
Urinary calculi are more common in men than in women.
Incidence of urinary calculi peaks between the 3rd and 5th decades of life.
There is seasonal variation with stone occurring more often in the summer months suspecting the role of dehydration in this process
1)Dietetic. (more calcium oxalate containing food)
2)Altered urinary solutes and colloids:(reduced water intake=increased solid deposition >increased crystallization >stone formation.)
3)Reduced urinary citrate .
4)Renal infection.
5)Inadequate water drainage and urinary stasis.
6)Prolonged immobilization.
7)Hyperparathyroidism .(increased calcium deposition .)
8)Gout.
Calcium oxalate
Calcium phosphate
Mixed-Oxalate+Phoaphate
Struvite (Ca, Al, Mg, Phosphate)
Cystine
Xanthine
Matrix
sharp, severe pain
most characteristic manifestation of renal or ureteral calculi
caused by movement of the calculus and consequent irritation
Renal colic originates deep in the lumbar region and radiates around the side and down toward the testicle in the male and the bladder in the female
Ureteral colic radiates toward the genitalia and thigh
When the pain is severe, the patient usually has nausea, vomiting, pallor, grunting respirations, elevated blood pressure and pulse, diaphoresis, and anxiety
Urinary tract infection
Other manifestations of calculi include infection with an elevated temperature and white blood cell (WBC) count and urine obstruction that causes hydroureter, hydronephrosis, or both
Haematuria
Pain resulting from the passage of a calculus down the ureter is intense and collicky.
1. Assessment
Prior stone formation
Renal or bladder colic type pain without objective evidence of calculi formation
Risk factors
Location, character, and duration of current pain
Current and previous radiation patterns (indicates possible location and movement of calculus through the urinary system)
#G/E:
Anemia
Oedema
Dehydration
Increased Pulse and BP.
Raised Temperature.
#Urinary System:
Tenderness on palpation
Passage of stones.
1.Plain x-Ray of KUB region( radio dense shadow)
2.Ultrasonography of KUB region(echogenic structure with shadow)
3.Intravenous urography .
4.Intravenous pyelography .
5.Excretory urography .
6.Unenhanced computer tomography
7.Plain radiograph of the abdomen
Nowadays Unenhanced computer tomography Has been seen more sensitive and specific. It can identify both radioluscent and radio opaque shadow.
90% of the urinary stone is radio opaque .
10% gal bladder stone is radio opaque.
Uric acid stone , Cystine,struvite stones are radioluscent .
#Others :
-Urine RME and C/s
-Serum creatinine
#For Anaesthesia :
>CBC
> RBS
>CX-R
>ECG
# To indentify the cause:
Serum calcium
PTH
Uric acid Urinary calcium Phosphate
Obstructive uropathy compromises the function of the affected kidney.
Microscopic or gross hematuria is rarely associated with significant hemorrhage.
Urosepsis is infection that may cause shock or death without prompt intervention.
Ileus may occur
Stones<5mm,90 percent spontaneous passage.
Hydration
Diuretics
Anti-emetics
involves first visualizing the stone and then destroying it.
Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device through the ureteroscope to fragment and remove the stones.
A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent.
Hospital stays are generally brief, and some patients can be treated as outpatients.
LASER LITHOTRIPSY. A newer treatment for calculi is laser lithotripsy. Lasers are used together with a uretero-scope to remove or loosen impacted stones. Constant water irrigation of the ureter is required to dissipate the heat
ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney.
In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. When the shock wave encounters a substance of different intensity (a renal stone), a compression wave causes the surface of the stone to fragment. Repeated shock waves focused on the stone eventually reduce it to many small pieces.
These small pieces are excreted inthe urine, usually without difficulty.the fragments may be passed upto 3 months after the procedure
Stone size should be 1.5-2 cm
Percutaneous lithotripsy involves the insertion of a guide percutaneously (through the skin) under fluoroscopy near the area of the stone. An ultrasonic wave is aimed at the stone to break it into fragments.
stone size should be >2.5 cm
IMMEDIATE
Pain
Urinary infection
Obstructive uropathy
Haematuria
Urinoma-URINOMA HAPPENS AS A RESULT OF URETERAL
TEAR WHICH ALLOWS THE ENTRY OF FREE FLUID INTO THE
RETROPERITONEUM
Renal and perirenal haematoma
Surrounding organ injury
DELAYED
Renal functional loss
Hypertension
Residual calculi
Recurrent calculi
If the stone is too large or lithotripsy procedures fail to remove it, an open surgical procedure is performed
Cystolithotomy, removal of bladder calculi through a suprapubic incision, is used only when stones cannot be crushed and removed transurethrally. Stricture (abnormal narrowing) is the most common postoperative complication.
A stone is removed from the renal pelvis by pyelo-lithotomy and from the renal calyx by a nephrolithotomy
Despite advances in the treatment of urinary calculi, it is often impossible to remove all stone fragments completely. From 5 to 30 percent of patients have residual stone burden requiring ongoing treatment.
Recurrence rate is approximately 30 percent within years.
Extracorporeal shock wave lithotripsy and endoscopic stone removal techniques have significantly improved long term prognosis of renal function after calculus removal.