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Stone Disease PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "STONE DISEASE” by Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.).

This medical PowerPoint presentation is about acute stone disease, also known as urolithiasis or kidney stones. Stone disease is a condition characterized by the formation of small, hard mineral deposits in the urinary tract, including the kidneys, bladder, ureters, and urethra. These stones can range in size from a grain of sand to a golf ball and can cause severe pain and discomfort as they move through the urinary tract.

The most common types of kidney stones include calcium stones, uric acid stones, struvite stones, and cystine stones. Factors that increase the risk of developing kidney stones include dehydration, a diet high in salt and protein, obesity, certain medications, and certain medical conditions such as hyperparathyroidism and inflammatory bowel disease.

Symptoms of kidney stones can include severe pain in the back, abdomen, or side, pain during urination, blood in the urine, and frequent urination. Treatment options for kidney stones depend on the size and location of the stones and may include medications to manage pain and facilitate stone passage, as well as procedures such as shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy to break up or remove the stones. Prevention strategies include staying well-hydrated, maintaining a healthy diet, and managing any underlying medical conditions.

Tags : stone disease, urolithiasis, kidney stones, urinary tract, kidneys, bladder, ureters, urethra, Nephrology, Nephrology PowerPoint presentation

Published on : Jun 07, 2023 | Views : 780 | Downloads : 0

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Slide 1-

STONE DISEASE ( Brief Overview ) Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.), Professor & HOD, Dept. of Urology,Sri Ramachandra Medical College & Research InstitutionConsultant Urologist & Renal Transplant Surgeon,Sri Ramachandra Hospital, Porur, Madras.
Slide 2-

COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS Stone analysis in Percentage Form of Lithiasis India USA Japan UK Pure Calcium Oxalate 86.1 33 17.4 39.4 Mixed Calcium Oxalate and 4.9 34 50.8 20.2Phosphate Magnesium Ammonium 2.7 15 17.4 15.4Phosphate (Struvite ) Uric Acid 1.2 8.0 4.4 8.0 Cystine 0.4 3.0 1.0 2.8
Slide 3-

Cause of Stone Disease Supersaturation of urine is the key to stone formation Intermittent supersaturation - Dehydration Crystal aggregation Anatomic Abnormailities – PUJ , MSK Bacterial Infection Defects in transport of Calcium and Oxalate by Renal epithelia E.Coli infection increases matrix content in urine . Proteus makes urine alkaline
Slide 4-

Inhibitors & Promoters of Stone Formation in Urine INHIBITORS Inhibits crystal Growth - Citrate – complexes with Ca Magnesium – complexes with oxalates Pyrphosphate - complexes with Ca Zinc Inhibits crystal Aggregation Glycosaminoglycans Nephrocalcin Tamm- Horsfall Protein PROMOTERS Bacterial Infection Matrix Anatomic Abnormalities – PUJ obst., MSK Altered Ca and oxalate transport in renal epithelia Prolonged immobilisation Increased uric acid levels I.e taking increased purine subs– promotes crystalisation of Ca and oxalate ?? Nanobacteria – seen in 97% of renal stones
Slide 5-

SOME DISEASES ASSOCIATED WITH HYPERCALCAEMIA & HYPERCALCIURIA Hyperparathyroidism Leukemia Sarcoidosis Lymphoma Multiple myeloma Myxedema Hyperthyroidism Adrenal Insufficiency Metastatic Malig. Neoplasm's Vit. D Intoxication
Slide 6-

TYPES OF KIDNEY / URETER STONES OXALATE (CALCIUM OXALATE) PHOSPHATE URIC ACID & URATE CYSTINE
Slide 7-

Uncommon Stones XANTHINE STONES – (Autosomal Recessive . Def of Xanthine Oxidase leading to Xanthinuria) DIHYDROXYADENINE STONE – ( Def. of enzyme adenine phospo ribosyl transferase ) SlLICATE STONES – Rare in humans ( excess intake of Antacid with Mg Trisilicate. Mostly in cattle due to ingestion of Sand ) MATRIX - Infection by Proteus - Radiolucent (all calculi have some amt ( 3%) of matrix but matrix calculus has 65% Matrix content in calculi)
Slide 8-

Uncommon Stones TRIAMTERENE – Anti-hypertensive used with hydroclorothiazide – spare Potassium. Mostly found as a nucleus in Ca oxalate or uric acid calculus Indinavir Stones - Drug to treat AIDS (4 to13%) Ephedrine or Guifenesin – Cough medicine - Radiolucent
Slide 9-

Stones – Chemical Constituents Whewelite – Calcium Oxalate Monohydrate – CaC2O4-H2O Weddelite - Calcium Oxalate dihydrate – CaC2O4-2H2O Brushite – Calcium Hydrogen phosphate dihydrate – CaHPO4 2H2O Whitlockite - TriCalcium Phosphate – Ca2(PO4)2 Struvite – Magnesium Ammonium hexahydrate – MgNH4PO4-6H2O
Slide 10-

DD of Radiolucent filling defect on IVU in Ureter or Kidney Must Know Uric Acid Calculus Matrix Calculus Sloughed Papilla Blood Clots TCC Renal Cysts Vascular Lesions Know For Brownie Points Xanthine Calculus Hydroxyadenine Calculus Ephederine Calculus Infection due to gas forming Org. Fungal Ball Tuberculoma Malacoplakia Hypertrophied Papilla Renal pseudo-tumour
Slide 11-

OXALATE (CALCIUM OXALATE) ALSO CALLED MULBERRY STONE COVERED WITH SHARP PROJECTIONS SHARP ® MAKES KIDNEY BLEED (HAEMATURIA) VERY HARD RADIO - OPAQUE Under microscope looks like Hourglass or Dumbbell shape if monohydrate and Like an Envelope if Dihydrate
Slide 12-

PHOSPHATE STONE USUALLY ® CALCIUM PHOSPHATE SOMETIMES ® CALCIUM MAGNESIUM AMMONIUM PHOSPHATE OR TRIPLE PHOSPHATE SMOOTH ® MINIMUM SYMPTOMS DIRTY WHITE RADIO - OPAQUE Calcium Phosphate also called ‘Brushite’ appears like Needle shape under microscope
Slide 13-

PHOSPHATE STONES IN ALKALINE URINE ¯ ENLARGES RAPIDLY ¯ TAKE SHAPE OF CALYCES ¯ STAGHORN ® Struvite can form Stag-horn and appear like coffin lid under microscope
Slide 14-

CALCIUM PHOSPHATE STONES Hyperparathyroidism Ca P Renal Tubular Acidosis K CO2 Medullary Sponge Kidney - PTH Hormone Promotes renal production of 1-25-dihyroxycholecalciferol – active Vit.D and also increases absorption of Calcium and decreases Phosphorus absorption from Kidneys
Slide 15-

URIC ACID & URATE STONE HARD & SMOOTH MULTIPLE YELLOW OR RED-BROWN RADIO - LUCENT (USE ULTRASOUND) Under microscope appear like irregular plates or rosettes pKa of uric acid 5.75 – at this pH 50% of uric acid insoluble. If pH falls further - uric acid more insoluble
Slide 16-

CYSTINE STONE AUTOSOMAL RECESIVE DISORDER USUALLY IN YOUNG GIRLS DUE TO CYSTINURIA - CYSTINE NOT ABSORBED BY TUBULES MULTIPLE SOFT OR HARD – can form stag-horns PINK OR YELLOW RADIO-OPAQUE Under microscope appears like hexagonal or benezene ring – ask for first morning sample
Slide 17-

CYSTINE STONE - Management High Fluid Intake and Alkalanise Urine – dissolve most of the smaller cystine stones D-Pencillamine or MPG (Mercaptopropionylglycine) binds to cystine that is soluble in urine Side effects of Pencillamine restricts it use – Allergic rashes, GI problems- Nausea, Vomiting, Diarrhoea MPG better tolerated Large obstructive stones – Surgery required first Cyanide Nitroprusside Calorimeteric Test for detecting Cystinuria. If positive do amino acid chromatography pKa of cystine is 8.3, hence alkalinisisation above pH7.5 helps to dissolve the stones
Slide 18-

Surgical Conditions and Stone Disease Regional ileitis and Ileal Bypass Surgery for eg Obesity can lead to increase oxalate absorption and stone ds ileostomies - In Chr. Diarrhoea with– Bicabonate loss – systemic acidosis and acidic urine – increases risk of Uric Acid stones
Slide 19-

HISTORY A. IS PATIENT DRINKING ENOUGH ? B. PROFESSION C. ENQUIRE ABOUT UTI ® STONES D. FAMILY HISTORY E. LONG ILLNESS ® BEDRIDDEN ® STONES
Slide 20-

MANAGEMENT OF STONES HISTORY : A. FIND OUT IF DRINKING ENOUGH LIQUIDS (NOT DRINKING ENOUGH IMPORTANT CAUSE OF STONE FORMATION & GROWTH) Urinary supersaturation of salts in concentrated urine Atleast drink 3 lits to avoid stone formation
Slide 21-

HISTORY (Cont...) B. ASK ABOUT THEIR PROFESSION DEHYDRATION ® STONES CAN FORM e.g. MARATHON NEAR A FURNACE, BRICK - LAYER, LABOURERS & WEAVERS TRUCK & BUS DRIVERS
Slide 22-

C. ENQUIRE ABOUT UTI ® STONES D. FAMILY HISTORY E. LONG ILLNESS ® BEDRIDDEN ® STONES HISTORY (Cont...) Zero Gravity state – astronauts on long space flights more prone to stones
Slide 23-

CLINICAL FEATURES 1. PAIN IN 75 % OF THE CASES “RENAL COLIC” IF SEVERE AND ACUTE A) KIDNEY STONE FIXED PAIN IN THE LOIN B) URETERIC STONE PAIN RADIATES ® LOIN TO GROIN Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in renal colic
Slide 24-

CLINICAL FEATURES (Contd....) 2) HAEMATURIA CAN BE FRANK OR ONLY FOUND ON DIP - STICK OR LAB. 3) PYURIA - IF INFECTION CAN HAVE PUS IN URINE
Slide 25-

ON EXAMINATION 1. ACUTE PRESENTATION ABDOMEN TENSE AND RIGID TENDERNESS PRESENT IN THE LOIN 2. IN ROUTINE PRESENTATION NO FINDINGS IN ABDOMEN
Slide 26-

INVESTIGATIONS 1. FULL BLOOD COUNT TO CHECK FOR ANAEMIA IF GOING FOR SURGERY 2. SERUM ELECTROLYTES PLUS UREA / CREATININE / CALCIUM / URIC ACID / PHOSPHATE
Slide 27-

INVESTIGATIONS (Cont...) 3. 24-HOURS URINE FOR ELECTROLYTES (Only if recurrent stone former) CALCIUM / OXALATE / URIC ACID / CYSTINE / CITRATE
Slide 28-

INVESTIGATIONS (Cont...) 4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory) 5. IVU OR IVP (INTRA VENOUS UROGRAM) 6. ULTRASOUND (Mandatory)
Slide 29-

INVESTIGATIONS IVU OR IVP (INTRA VENOUS UROGRAM) Not Mandatory 1in 40,000 patients die due to anaphylactic reaction to contrast Useful for radio-lucent stones & to detect Congenital Anomalies in Urinary tracts
Slide 30-

INVESTIGATIONS (Cont...) CT – TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY To differentiate cause of acute colic – stone or anuria Suspected due to stone disease 8. DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY FUNCTION OF EACH KIDNEY.
Slide 31-

Bilateral Ureteric Calculus in a patient presenting with Anuria Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on Gantry. These are rapidly performed and do not require contrast agents for reconstruction.
Slide 32-

MANAGEMENT OF UROLITHIASIS Non-invasive approach to urinary calculas-HALLMARK of last 20 yrs. Lithotripters – 1.Extra Corporeal Shock wave 2.Intra Corporeal Better fiber optics – Miniturisation of Telescopes Accessories - Innovative variety
Slide 33-

Modern Management of Urolithiasis ESWL Ureterorenoscopy Percutaneous Nephrolithotomy Laparoscopic Approach to stones Open Ureterolithotomy, Pyelolithotomy or Nephropyelolithotomy is required in less than 1 to 2% of modern stone management
Slide 34-

TREATMENT (IDEALLY) MAJORITY : 80 TO 85 % of all stones can be treated by - EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) MINORITY : 15 TO 20 % SHOULD NEED MINIMALLY INVASIVE SURGERY (PCNL / URETEROSCOPY) (LESS THAN 1 % SHOULD NEED OPEN SURGERY)
Slide 35-

EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY(ESWL) SHOCK WAVES GENERATED UNDER WATER CAN TRAVEL THROUGH BODY WITHOUT ANY APPRECIABLE LOSS OF ENERGY. WHEN THEY ENCOUNTER STONES THE CHANGES IN DENSITY CAUSES ENERGY TO BE ABSORBED AND REFLECTED BY THE STONE & THIS RESULTS IN FRAGMENTATION OF THE STONES.
Slide 36-

ESWL – For Urinary Tract Calculus
Slide 37-

ESWL- FOUR MAIN ELEMENTS ENERGY SOURCE FOCUSING DEVICE COUPLING DEVICE LOCALIZATION DEVICE
Slide 38-

ESWL Absolute Contra-indication- Pregnancy Relative Contra-Indications for ESWL – Renal Colic Urinary obstruction Infection Declining Renal Function Significant Hematuria
Slide 39-

COUPLING DEVICE “WATER BATH” “WATER FILLED CUSHION” (KEEP PATIENT’S DRY)
Slide 40-

ESWL-HISTORY 1963-EXPERIMENTS WITH “ SHORT WAVES” IN W.GERMANY BY PHYSICISTS AT DONIER SYSTEMS LTD 1980-DORNIER HUMAN MODEL ( HM-3) LITHOTRIPTER ARRIVED ON MARKET (STILL GOLD STANDARD WHEN COMPARING RESULTS WITH NEW MEASUREMENTS
Slide 41-

ESWL & STAGHORNS Dornier HM-3 Monotherapy for STAGSHORNS - 30% Stone Free Rate (In Dilated Collecting System ) PCNL has higher overall Success Combination of PCNL & ESWL can give a stone free rates of 90% For ALL STONES IN THE KIDNEY
Slide 42-

COMPRESSION-TENSILE WAVE CAUSES: “Implosion” Rather than “Explosion”
Slide 43-

ESWL & URETERIC CALCULI For fragmentation fluid medium around stone necessary If stones impacted fragmentation may not occur “PUSH & BANG”-success Marginally HIGHER THAN “in situ ESWL” Trial of “in situ ESWL” – first choice “In situ ESWL” FAILS- “Rescue procedure”
Slide 44-

ESWL COMPLICATIONS Haematuria – is quite common ( short term antibiotics Recommended ) Incomplete stone Fragmentation & Obstruction “Stienstrasse” ( stone street ) usually due to a large “ Leading fragment” ( Stents Recommended prior to ESWL for Calculi > 1.5 cm )
Slide 45-

DESIGN BASIC LITHOTRIPSY
Slide 46-

Renal Lithiasis Blood Pressure Study ( Patients treated 1984-1986 Dallus Study) First Follow Up Second Follow Up 1988 1990 No.Pts Annualized Rate No.Pts Annualized Rate of Hypertension of Hypertension ESWL 771 2.5% 590 2.1% non-ESWL 195 3.8% 155 1.6% Total 966 745
Slide 47-

Basic Principles of “SHOCK WAVE” Lithotripsy
Slide 48-

FRAGMENTATION BY SHOCK WAVES ON COLLISION OF “ SHOCK WAVES” WITH CALCULI- ON FRONT SURFACE – COMPRESIVE FORCES ON BACK SURFACE OF THE STONE- REFLECTION OF COMPRESSION PULSE CREATES NEGATIVE OR TENSILE WAVE THAT TRAVEL BACK WARD THROUGH CALCULI ONCE TENSILE FORCE EXCEEDS “ COHESIVE STRENGTH” OF CALCULI- FRAGMENTATION OCCURS
Slide 49-

ESWL – SPARK GAP/ EHL Electro-hydraulic Generator Located at Base of Water Bath Produces Shock wave by Electric Spark Gap of 15,000 to 25,000 Volts Lasting 1 Sec High Voltage Spark Discharge Rapidly- evaporates Water & Generators A “Shock Wave” by expanding Sarrounding Liquid
Slide 50-

Mechanism of Stone Fragmentation by ESWL On Front Surface – Compresive or positive Forces On Back Surface Of The Stone- Reflection Of Compression Pulse Creates Negative Or Tensile Wave That Travel Back Ward Through Calculi Once Tensile Force Exceeds “ Cohesive Strength” Of Calculi- Fragmentation Occurs Cavitation – Small air bubbles
Slide 51-

Steinstrasse ( or Stone Street) – Post ESWL
Slide 52-

Diet & Fluid Advice High Fluid Intake Restrict Salt (Na) Oxalate Restrict Avoid high intake of Purine food Increased citrus fruits may help If hypercalciuria restrict Ca intake Role of Potassium Citrate in preventing Cal Oxalate stone ds – KCit lowers urinary calcium whereas Na Citrate does not lower Calcium due to Sodium load
Slide 53-

LIQUIDS Moderate Amounts : High Amounts : Apple Juice Cocoa Beer Fresh Tea Coffee Cola FOODS : Almonds, Asparagus, Cashew Nuts, Currants, Greens, Plums, Raspberries, Spinach
Slide 54-

HIPPOCRATIC OATH : “I Will not cut, even for the stone, but leave such procedures for the practitioners of the craft”