Obstruction is One of the Most Important Abnormalities of the Urinary Tract
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Transcript of Obstruction is One of the Most Important Abnormalities of the Urinary Tract
HYDRONEPHROSIS SINISTRA ET CAUSA PARTIAL STAGHORN CALCULI OBSTRUCTION SINISTRA
Devyana E.Taslim 1, Marta Hendry 2
1Clinical Senior Cleckship, School of Medicine, Medical Faculty of Sriwijaya University, Dr.Mohammad Hoesin General Hospital, Palembang2Department of Urology, School of Medicine, Medical Faculty of Sriwijaya University, Dr.Mohammad Hoesin General Hospital, Palembang
Background
Obstruction is one of the most important
abnormalities of the urinary tract, since it
eventually leads to decompensation of the muscular
conduits and reservoirs, back pressure, and atrophy
of the renal parenchyma. It also invites infection
and stone formation, which is cause additional
damage and can ultimately end in complete
unilateral or bilateral destruction of the kidneys.
Complete obstruction leads to rapid
decompensation of the system proximal to the site
of obstruction. Partial obstruction leads to gradual
progressive muscular hypertrophy followed by
dilatation, decompensation, and hydronephrotic
change.
Hydronephrosis is the swelling of a kidney
due to a build-up of urine. It happens when urine
cannot drain out from the kidney to the bladder
from a blockage or obstruction. Hydronephrosis
can occur in one or both kidneys. Hydronephrosis
(kidney swelling) occurs as the result of a disease.
It is not a disease itself. Conditions that are often
associated with unilateral hydronephrosis include:
Nephrolithiasis (kidney stones).
A kidney stone, also known as a renal
calculus, is a solid concretion or crystal
aggregation formed in the kidneys from dietary
minerals in the urine. Urinary stones are typically
classified by their location in the kidney
(nephrolithiasis), ureter (ureterolithiasis), or
bladder (cystolithiasis), or by their chemical
composition (calcium-containing, struvite, uric
acid, or other compounds). About 80% of those
with kidney stones are men.
Kidney stones typically leave the body by
passage in the urine stream, and many stones are
formed and passed without causing symptoms. If
stones grow to sufficient size (usually at least 3
millimeters (0.12 in)) they can cause obstruction of
the ureter. Ureteral obstruction causes postrenal
azotemia and hydronephrosis (distension and
dilation of the renal pelvis and calyces), as well as
spasm of the ureter. This leads to pain, most
commonly felt in the flank (the area between the
ribs and hip), lower abdomen, and groin (a
condition called renal colic). Renal colic can be
associated with nausea, vomiting, fever, blood in
the urine, pus in the urine, and painful urination.
Renal colic typically comes in waves lasting 20 to
60 minutes, beginning in the flank or lower back
and often radiating to the groin or genitals. The
diagnosis of kidney stones is made on the basis of
information obtained from the history, physical
examination, urinalysis, and radiographic studies.
Ultrasound examination and blood tests may also
aid in the diagnosis.
Clinical findings
A male patient 36 years old came to the
surgery polyclinic of Muhammad Hoesin General
Hospital in Palembang after being referred by AK
Gani Hospital with the chief complain sore at the
left waist. Based on auto anamnesis and allo
anamnesis of the present illness, about 1 and half
months ago, the patient complains he had a sore
waist. Before, he also felt the same, but he thought
it was just usual sore waist, but 1 and half month
ago, the pain became more serious, especially after
sat for long time and after lifted something heavy.
Then he went to the internal specialist at Muara
Enim Hospital to consult the pain, he had fever (-),
nausea (-), vomiting (-), loss weight (-), loss
strength (-), pallor (-), urinary dripping (-),
continuous urinary (-), urgency urinary (-), normal
urine color, hematuria (-) but the frequencies and
the quantity were lower than normal, normal stool.
At the specialist doctor, he done the kidney USG
and the result is kidney tone. Then at the other day,
he went to the hospital to do another examination.
At the hospital he had done blood test and BNO
IVP test. The blood test result was normal but the
BNO result saw that he got hydronephrosis grade II
at the left kidney due to obstruction by staghorn
calculi. So the doctor told him to take the surgery.
At the other day he went to the surgery department,
but the doctor said the stone was already big, so the
doctor referred the patient to the hospital at
Palembang.
±17 days before admission to the hospital,
the patient go to Palembang, he go to AK Gani
hospital, but AK Gani hospital does not has a
complete equipment to do the surgery, so the
hospital referred him to Mohammad Hoesin
hospital.
±10 days before admission, he came to
polyclinic Mohammad Hoesin Hospital to consult
pain at the waist area, pain became worsened,
especially after sat for long time and after lifted
something heavy, fever (-), nausea (-), vomiting (-),
loss weight (-), renal colic (+), pain at the rear side
(+), joint pain at legs (-), sore feet (-), numbness at
legs (-), urinary dripping (-), continuous urinary (-),
urgency urinary (-), normal urine color but the
frequencies and the quantity were lower than
normal, normal stool, edema (-), erithema (-).
History of past illness the patient had the
same complain at 2010, he just controlled once and
the doctor said that he had a kidney stone, the
doctor gave some drugs, and he never come back
for control. History of trauma (-), history of stroke
(-), history of use catheterization (-), history of
hypertension (-), history of diabetic (-). There is no
same complaint as the patient in the family.
From physical examinations, general
examination was normal. On local examination,
abdomen was within normal limit, there was
tenderness at CVA region at the left area and
enlarged kidney palpable. External genitalia
examination, from inspection there is no urethra
bloody discharge. On rectal touched examination
TSA good, upper boarder of prostate unpalpable,
rubbery consistency, flat surface, faces (-), blood
(-). Laboratory examination, revealed a increase in
erithrosit (8.14), increase calcium (113), and
creatinine (1.32).
From plain BNO examination of this
patient, the result shows the radio opaque at the
pelvic renalis (staghorn calculi) at the upper left
abdomen and the right abdomen, but the left one is
more bigger than the right one, from IVP test, from
the contrast ultravist there is no allergic reaction,
from the nephrogam the secresion and excresion
from both kidney are normal, pelvicocalics system
(PCS) right is normal and left is extacis grade II,
both left and right ureter are normal, bully-bully
size and shapes are normal, post miksi residu urine
little. Result suspect hydronephrosis grade II at the
left kidney due to staghorn stone obstruction.
(Figure 1 and Figure 2)
The patient is diagnosing as hydronephrosis
sinistra et causa partial staghorn stone obstruction
sinistra. Prognosis for this patient quo ad vitam and
quo ad functionam is bonam.
Figure 1
Figure 2
Figure 3
Discussion
Hydronephrosis is the swelling of a kidney
due to a build-up of urine. It happens when urine
cannot drain out from the kidney to the bladder
from a blockage or obstruction. Hydronephrosis
can occur in one or both kidneys. Hydronephrosis
(kidney swelling) occurs as the result of a disease.
It is not a disease itself. Conditions that are often
associated with unilateral hydronephrosis include:
Nephrolithiasis (kidney stones).
A kidney stone, also known as a renal
calculus, is a solid concretion or crystal
aggregation formed in the kidneys from dietary
minerals in the urine. Urinary stones are typically
classified by their location in the kidney
(nephrolithiasis), ureter (ureterolithiasis), or
bladder (cystolithiasis), or by their chemical
composition (calcium-containing, struvite, uric
acid, or other compounds). About 80% of those
with kidney stones are men.
When a stone causes no symptoms,
watchful waiting is a valid option. For symptomatic
stones, pain control is usually the first measure,
using medications such as nonsteroidal anti-
inflammatory drugs or opioids. More severe cases
may require surgical intervention. For example,
some stones can be shattered into smaller
fragments using extracorporeal shock wave
lithotripsy. Some cases require more invasive
forms of surgery. Examples of these are
cystoscopic procedures such as laser lithotripsy or
percutaneous techniques such as percutaneous
nephrolithotomy. Sometimes, a tube (ureteral stent)
may be placed in the ureter to bypass the
obstruction and alleviate the symptoms, as well as
to prevent ureteral stricture after ureteroscopic
stone removal.
This patient generally present with chief
complaint of sore at the left waist for the past 1 and
half month, especially after sat for long time and
after lifted something heavy, urinary dripping (-),
continuous urinary (-), force urinary (-), trauma (-),
history of operation (-), history of used
catheterization (-), normal urine color but the
frequencies and the quantity were lower than
normal. From all those symptoms indicated
obstruction at the upper urinary tract which is
commonly found in patient with supravesical
obstruction due to uretral stone.
On physical examination, when the upper
urinary tract abnormalities occurs, sometimes
kidney may be palpable and if pyelonephritis
happens it will be accompanied by pain and
percussion pain at the waist area.
In this patient, from the physical
examination on CVA region there was tenderness,
local examination of suprapubic region there was
no tenderness. From external genitalia examination,
from inspection the urine clear, no bloody urine,
and no continuous urinary. On the rectal
examination, no enlargement prostate, smooth
surface, no tenderness, blood (-), feces (-).
Evidence of urinary tract infection,
hematuria, or christalluria may be seen.
Leukocytosis is to be expected in the acute stage of
infection. Little if any elevation of the white blood
count accompanies a chronic stage. In the present
of significant bilateral hydronephrosis, urine flow
through the renal tubules is slowed. Thus, urea is
significantly reabsorbed but creatinine is not. Blood
chemistry therefore reveals a urea-creatinine ratio
well above the normal 10:1. BSS to find possibility
of diabetic that can cause neurological bladder. A
24-hour urine collection for calcium may reveal
hypercalciuria, which occurs with
hyperparathyroidism and idiopathic hypercalciuria.
A qualitative test for urinary cystine should be part
of the routine evaluation. Total renal function will
be impaired if the stones are bilateral and
particularly if chronic infection complicates the
clinical presentation. A pH of 7.6 or higher implies
the presence of urea-splitting organisms. A pH
consistently below 5.5 is compatible with the
formation of uric acid or cystic stone. If pH is fixed
between 6.0 and 7.0, renal tubular acidosis should
be considered as a cause of nephrocalcinosis.
In this patient, the laboratory results found
that increase in erithrosit (8.14), increase calcium
(113), and creatinine (1.32). From this result we
can take conclusion that there is a little bit blood at
the urine, and hypercalciuria.
The plain abdominal (BNO) examination is
used to look for the opaque stone in the urinary
tract, the presence of stone and sometimes may
show a shadow of bladder that filled with urine
which is the sign of a urinary retention. And also to
know the present of bone metastases of prostate
carcinoma. From IVP we can see the place of
obstruction and the obstruction degree. In this
patient, there are opaque stone in the left pelvic
area and there is sign of urinary retention because
there is no urethral catheter fixed in the patient.
After patient has been evaluated, they
should be informed of the various therapeutic
option for upper urinary tract obstruction. Specific
treatment recommendation can be offered for
certain groups of patients. On the other end of the
therapeutic spectrum, absolute surgical indications
include refractory urinary retention, recurrent
urinary tract infection from the job of the patient
and partial staghorn stone obstruction. From the
anamnesis, physical examination, laboratory, BNO
finding this patient has been diagnosed of
hydronephrosis sinistra e.c partial staghorn stone
obstruction sinistra. The most suitable treatment for
this patient is ureterorenoscopy URS sinistra and
pyeloletotomy sinistra. Beside medication and
surgery patient should also be given proper
education before surgery. Patient should be
educated about to change of lifestyle could
improving the quality of living. Firstly reeducation
of fluid intake at specific times, recommended total
daily fluid intake is 2L per day. Secondly, take
some exercise so that every part of the body can
work properly. Third, control to the doctor as the
scheduled.
Conclusion
This case report we found that the patient chief
complain was pain at the hip. From the anamnesis
we can conclude that he feel pain when he lifted a
heavy thing, after take a long sit, pain at the rear
side, pain radiate to the lower spine, done less
activity, less drink water, but there is no pain when
urination, no bleeding, no continuous urine. From
the physical examination i found that CVA region
there was tenderness, palpable enlargement of
kidney, but from the external genitalia theres no
abnormality. From the lab test there was slightly
increase at the erithrosit, calcium, and creatinine.
From the BNO we can see the opaque stone at the
left pelvic area. From the information it has
presented upper tract symptom along with physical
rectal examination and BNO which point to see the
obstruction that cause by staghorn stone at the renal
pelvic. Further investigation of pathology and
anatomy using BNO to confirm the diagnosis of the
hydronephrosis. Later to that, this patient had to
undergo nefrolitotomy. Following surgical
treatment, patients may be seen within 2 weeks to
discuss the histological findings and to identify
early post – operative morbidity. Long term follow
up should be scheduled at 3 months to determine
final outcome.
Reference
1. Preminger, GM (2007). "Chapter 148: Stones in the Urinary Tract". In Cutler, RE. The Merck Manual of Medical Information Home Edition (3rd ed.). Whitehouse Station, New Jersey: Merck Sharp and Dohme Corporation.
2. Wolf Jr. JS (2011). "Background". Nephrolithiasis. New York: WebMD. Retrieved 2011-07-27.
3. Purnomo, Basuki B (2009). Dasar-Dasar Urologi edisi II. Falkutas Kedokteran Universitas Brawijaya
4. Soeparman (1990). Ilmu Penyakit Dalam. Jilid II. FKUI. Jakarta
5. Purnomo, Basuki B (2012). Dasar-Dasar Urologi edisi II. Falkutas Kedokteran Universitas Brawijaya
6. Curhan, G. C.; Willett, W. C.; Rimm, E. B.; Spiegelman, D.; Stampfer, M. J. (Feb 1996). "Prospective study of beverage use and the risk of kidney stones". Am J Epidemiol 143 (3): 240–7. doi:10.1093/oxfordjournals.aje.a008734. PMID 8561157