Symptoms and Sign at Presentation

8/16/2019 Symptoms and Sign at Presentation

1/87

Cynthia Tanuwijoyo 07120090023

Admiral C. Zega 07120090027

Tegar Hidayat Jati 07120040049

!"#$TH$A%$%&em'im'ing ( dr.#ut) *agu+,%-


2/87

*a/groundrinary Caluli hae -lagued man or enturie+,

eidene o 'ladder aluli ha+ 'een ound ingy-tian mummie+ -re+ered oer 7,000 yr+.

or many year+ it ha+ 'een at the oreront o

urology. Thi+ +ituation might hae hanged

with the adent o new, le++ina+ie a--roahe+ to themanagement o urinary aluli.


3/87

$ntrodutionrinary aluli( the third mo+t ommon

aition o the urinary trat

5omenlature%truite +tone+

Calium o6alate dihydrate

tiology( remain+ +-eulatie


4/87

Anatomi ginjal


5/87


6/87

!enal and reteral %tone+


7/87

tiologyrinary +tone+ ry+talloid 8 organi

matri6.

%tone ormation reuire+ +u-er+aturatedurine.

%u-er+aturation de-end+ onurinary -H

ioni +trength

+olute onentration, andom-le6ation.


8/87

tiology (cont’d) The nuleation theory The ry+tal inhi'itor theory

The supersaturation theory


9/87

rinary $on+CaliumA major ion -re+ent in urinary ry+tal+.

#e++ than 2: i+ e6reted in the urine.

;any ator+ in


10/87

rinary $on+ (cont’d)"6alateA normal wa+te -rodut= relatiely in+olu'le.

5ormally, a--ro6imately 10>1?: o o6alateound in the urine originate+ rom the diet.

The ontrol o o6alate in the urine -lay+ a-iotal role in the ormation o aliumo6alate aluli. 5ormal e6retion( rom 20 to4? mg@day.


11/87

rinary $on+ (cont’d)&ho+-hate&ho+-hate i+ an im-ortant 'uer and

om-le6e+ with alium in urine.

$t i+ a /ey om-onent in alium -ho+-hate

and magne+ium ammonium -ho+-hate+tone+.


12/87

rinary $on+ (cont’d)ri aidri aid i+ the 'yB-rodut o -urine

meta'oli+m.

The -a o uri aid i+ ?.7?.

&ure uri aid ry+tal+ and aluli arety-ially radioluent and may not 'eidenti)ed on -lain a'dominal )lm+.

Di+i'le on nonontra+t CT image+.


13/87

rinary $on+ (cont’d)%odium&lay+ an im-ortant role in regulating the

ry+talliEation o alium +alt+ in urine.

High urinary alium e6retion redue+ the

a'ility o urine to inhi'it alium o6alatery+tal agglomeration.


14/87

rinary $on+ (cont’d)CitrateCitrate i+ a /ey ator aeting the

deelo-ment o alium urinary +tone+.

A de)ieny ommonly i+ a++oiated with

+tone ormation.+trogen and al/alo+i+ inrea+e itrate

e6retion.


15/87

rinary $on+ (cont’d);agne+iumA om-onent o +truite aluli.

Fietary magne+ium de)ieny i+ a++oiatedwith an inrea+ed inidene o urinary +tone

di+ea+e.%ulaterinary +ulate+ may hel- -reent urinary

aluli= they an om-le6 with alium.


16/87

rinary $on+ (cont’d)"ther urinary +tone inhi'itor+rinary -rotein+

"ther maromoleule+( glyo+aminoglyan+,-yro-ho+-hate+, and uro-ontin.

luorideG


17/87

%tone Darietie+Calium aluliA'+or-tie hy-eraliuri ne-hrolithia+i+ Ty-e $

$nde-endent o diet.

Treatment( ellulo+e -ho+-hata+e 10B1? g &" in 3diided do+e+I or hydrohlorothiaEide+.

Ty-e $$

FietaryBde-endent, a ommon au+e o urinary +tonedi+ea+e.

#imit alium inta/e to 400B00 mg@day.

Ty-e $$$%eondary to a -ho+-hate renal lea/.

Treatment( ortho-ho+-hate 5eutraB&ho+I 2?0 mg 3B4time+ daily.


18/87

%tone Darietie+ (cont’d)

Calium aluli (cont’d)!e+or-tie hy-eraliuri ne-hrolithia+i+&arathyroid hormone( inrea+e+ urinary -ho+-horu+

and derea+e+ -la+ma -ho+-horu+ an inrea+e in

-la+ma alium and a derea+e in urinary alium.!enal damage +eondary to hy-eralemia limit+

the /idney.

The only eetie treatment( +urgial remoal o-arathyroid adenoma.


19/87


Calium aluli (cont’d)!enalBindued hy-eraliuri ne-hrolithia+i+Hy-eraliuria o renal origin i+ due to an intrin+i

renal tu'ular deet in alium e6retion.

!enal hy-eraliuria i+ eetiely treated withhydrohlorothiaEide+.


20/87


Calium aluli (cont’d)Hy-erurio+uri alium ne-hrolithia+i+Fue to either an e6e++ie dietary inta/e o -urine+

or an inrea+e in endogenou+ uri aid -rodution.

rinary uri aid leel+( K00mg@24 h in women andK7?0 mg@24 h in men= urinary -H on+i+tently K?.?.

Treatment( hange o diet= allo-urinol or -ota++iumitrate.


21/87


Calium aluli (cont’d)Hy-ero6aluri alium ne-hrolithia+i+%eondary to inrea+ed urinary o6alate leel+ K40

mg@24 hI.

reuently ound in -atient+ with in


22/87


Calium aluli (cont’d)Hy-oitraturi alium ne-hrolithia+i+Hy-oitraturi L320 mg@24 hI alium

ne-hrolithia+i+ i+ a++oiated ommonly with renal

tu'ular aido+i+ ty-e $ di+tal tu'uleI, thiaEidethera-y aom-anied 'y -ota++ium wa+tageI, andhroni diarrhea.

Treatment i+ +ue++ul with -ota++ium itrate+u--lementation 20>30 m two to three time+

dailyI.


23/87


5onalium aluli%truite

ri aid

Cy+tine

Manthine

$ndinair


24/87

%T"5%


25/87

;uiti-le /idney +tone+ om-o+ed o uriaid and a +mall amount o alium

o6alate.


26/87

%truite ry+tal magne+ium ammonium

-ho+-hate @ tri-le -ho+-hateII


27/87

Calium "6alate ry+tal+


28/87

%N;&T";% A5F %$O5 AT&!%5TAT$"5


29/87

&A$5

--er urinary trat +tone+ ( -ain de-end on theloation

2 ty-e+ o -ain originating rom the /idney (

1. !enal oli

+trething o the ureter due tourinary o'+trutionI

2. 5on oli/y renal di+tention o renal a-+ule

.Aute on+et o -ain ( due to aute o'+trution and

di+tention o the u--er urinary trat."n+et ( a'ru-t

.;ay awa/en -atient rom +lee-

.&atient reuently moe on+tantly into unu+ual-o+ition+ to reliee -ain


30/87

TH %D!$TN A5F #"CAT$"5 " TH &A$5

%tone +iEe%tone #oation

Fegree o o'+trution

Auity o o'+trutionDariation in indiidual anatomy $ntrarenal

+ e6trarenal -eli+I


31/87

retero-eli +tone (

%eere CDA -ain rom a-+ular

and -eli di+tentionAute renal and ureteral -ain (

hy-er-eri+tal+i+ o +moothmu+le o alye+, -eli+, and

ureter

radiating along theour+e o the ureter into thete+tile+, +ine the nere+u--ly to the /idney and te+ti+

i+ the +ameI


32/87

;idureteral +tone

%ame a+ a'oe, withmore -ain in the lower

a'dominal uadrant

#ow ureteral +tone


33/87

#ow ureteral +tone

%ame a+ a'oe, with -ainradiating into 'ladder,

ula, +rotum The +rotal wall i+

hy-ere+theti

Te+tiular +en+itiity i+

a'+ent%tone a--roahe+ the

'ladder ( urgeny andreueny with 'urning on

urination in


34/87

!5A# CA#NM;ay au+e o'+trution and renal oli

&ain (

. $ntermittent

. Fee-, dull ahe in the


35/87

!5A# CA#NM (...continued)

Calieal aluli ( +mall and numerou+ a--ear to 'e a'le to -a++ +-ontaneou+ly

&atient ontinue+ to om-lain o -ain (%P# Fiagno+i+ and treatmentI


36/87

!5A# &#D$%

F K1m ( o'+trut the uretero-eli juntion +eere -ain in the o+toerte'ral angle

. Full > e6ruiatingly +har-, on+tant, 'oring,

diQult to ignore. !adiate+ to the


37/87

&&! A5F ;$F!T!

%eere, +har- 'a/ CDAI@


38/87

F$%TA# !T!

&ain ( radiate+ to the groin @ te+tile+ maleI, #a'iamajora emale+I

Fiagno+i+ may 'e onu+ed with te+tiular tor+ionor e-ididymiti+.

%u-ra-u'i -ain, urinary reueny and urgeny,dy+uria, +tranguria, gro++ hematuria y+titi+,urethriti+@-ro+tratiti+I

$n women ( men+trual -ain, &$F, ru-tured@twi+ted

oarian y+t+


39/87

*#AFF!

$rritatie oiding +ym-tom+$ntermittent urinary +tream

T$

Hematuria

&eli -ain

A large -erentage o 'ladder +tone+ areradioluent uri aidI.

ltra+ound o the 'ladder identi)e+ the +tone withit+ harateri+ti +hadowing.

The +tone moe+ with hanging 'ody -o+ition.

%tone+ within a ureteroele do not moe with 'ody

-o+ition nono'+trutieI


40/87

!TH!A# R &!&C$A#

%ym-tom+ are +imilar to 'ladder aluli The +tone+ may -re+ent with dri''ling @

during aute urinary retention

&ain may 'e +eere, in men ( radiate to theti- o the -eni+


41/87

H;AT!$A

Com-lete urinaly+i+ ( a++e++ing hematuriaand ry+talluria and urinary -H

$ntermittent gro++ hematuria

"a+ional teaBolored urine old 'loodI

;irohematuria


42/87

$5CT$"5

;agne+ium ammonium -ho+-hate +truiteI +tone+are synonymous with inetion +tone+. Proteus,Pseudomonas, Providencia, Klebsiella, andStaphylococcus infections.

Calium -ho+-hate +tone+ with a urine -H L. are'ru+hite +tone+

$netiou+ a-atite +tone+ hae a urinary -H K..

CultureBdireted anti'ioti+ +hould 'e admini+tered'eore eletie interention.

$netion ( ontri'uting ator to -ain -ere-tion


43/87

A%%"C$ATF D!

%ign o linial +e-+i+ ( eer, tahyardia,hy-oten+ion and utaneou+ a+odilation

eer a++oiated with urinary trato'+trution reuire+ -rom-t deom-re++ion retrograde atheter dou'leBJI, iun+ue++ul ( in+ertion o a -erutaneou+ne-hro+tomy tu'e


44/87

5A%A A5F D";$T$5O

--er urinary trat o'+trution$ntraenou+


45/87

DA#AT$"5


46/87

F$!5T$A# F$AO5"%$%

Aute a--endiiti+

to-i and unreogniEed -regnanie+

Twi+ted oarian y+t+

Fiertiular di+ea+e*owel o'+trution

*iliary +tone+ with and without o'+trution

&F

Aute renal artery em'oli+m

A'dominal aorti aneury+m


47/87

H$%T"!N

The nature o the -ain on+et, harater,-otential radiation, atiitie+ thate6aer'ate@ea+e the -ainI

5au+ea and omiting

Oro++ hematuria

Hi+tory o +imilar -ain


48/87

!$% ACT"!%

Cry+talluria

!i+/ ator or +tone+

%tone ormer+ e+- ( Ca o6alate +tone+I ( e6rete

more a o6alate ry+tal+, larger than normalK12mm

Cry+tal -rodution i+ determined 'y the +aturationo eah +alt and the urinary onentration o

inhi'itor+ and -romoter+.uri aid ry+tal+ a--ear a+ amor-hou+ -owder

'eau+e the ry+tal+ are +o +mall=


49/87

!$% ACT"!%

%oioeonomi ator+Auent

$ndu+rialiEed ountrie+


50/87

!$% ACT"!%

Fiet

an inrea+e in +aturated and un+aturated attyaid+, an inrea+e in animal -rotein and +ugar, and

a derea+e in dietary )'er, egeta'le -rotein, andunre)ned ar'ohydrate+.

High +odium inta/e i+ a++oiated with inrea+edurinary +odium, alium, and -H, and a derea+ed

e6retion o itrate= thi+ inrea+e+ the li/elihood oalium +alt ry+talliEation the urinary +aturationo mono+odium urate and alium -ho+-hate'ru+hiteI i+ inrea+ed.


51/87

!$% ACT"!%

"u-ation &hy+iian+ and other whiteollar wor/er+

hae an inrea+ed inidene o +tone+ (-hy+ial atiity agitate urine and di+lodge

ry+tal aggregate+I


52/87

!$% ACT"!%

ClimateHot limate+ ( dehydration inrea+e

inidene o urinary +tone+ uri aidaluliI

6-o+e -eo-le to more ultraiolet light ($nrea+ing a and o6alate e6retion


53/87

!$% ACT"!%

amily hi+tory %-ou+e+ o -atient+ with alium o6alate

+tone+ hae an inrea+ed inidene o+tone+= thi+ may 'e related to

enironmental or dietary ator+.


54/87

!$% ACT"!%

;ediation The antihy-erten+ie mediation

triamterene FyaEideI urinary aluli withinrea+ing reueny.

#ongBterm u+e o antaid+ ontaining+ilia the deelo-ment o +iliate +tone+.

&rotea+e inhi'itor+ in immunoom-romi+ed-atient+ radioluent aluli.


55/87

&HN%$CA# MA;$5AT$"5


56/87

&HN%$CA# MA;

&atient+ in 'iEEare -o+ition+ dierentiate -atient+-eritoniti+ ( araid to moeI

Tahyardia, +weating, nau+ea

CDA tenderne++

A'dominal ma++ -al-a'leI ( -atient+ with long+tanding o'+trutie urinary aluli 8 +eerehydrone-hro+i+

eer, hy-oten+ion and utaneou+ a+odilation (

uro+e-+i+*ladder -al-ation ( 'eau+e urinary retention may

-re+ent with -ain +imilar to renal oli

!etal e6am ( to e6lude $narerated inguinal hernia,

e-ididymiti+, orhiti+


57/87

!AF$"#"O$C $5D%T$OAT$"5%


58/87

CT5on ontra+t +-iral

CT hel-+ whenthe diagno+i+ i+unertain


59/87

$D&

Can doument ne-hrolithia+i+and u--er trat anatomy

"'liue iew+ ea+ily

dierentiate gall+tone+ romright renal aluli.


60/87

T";"O!A&HN

To identiy aluli in the /idney when theo'liue iew+ are not hel-ul

$t i+ualiEe+ the /idney in a oronal -lane ata +et di+tane rom the to- o the 6Bray

ta'le.

* $#;% A5F F$!CTF


61/87

* $#;% A5F F$!CTF#T!A%"5"O!A&HN

The di+tal ureter i+ ea+ily i+ualiEed throughthe aou+ti window o a ull 'ladder.


62/87

!T!"O!AF &N#"O!A&HN

To delineate u--erBtrat anatomy andloaliEe +mall or radioluent oendingaluli.

The dierene i+ that in retrograde

-yelogra-hy the dye i+ injeted diretly intothe ureter+ rather than into a ein


63/87

$5T!D5T$"5


64/87

$nterention

Con+eratie o'+eration;o+t ureteral aluli -a++ and do not reuire

interention.

%-ontaneou+ -a++age de-end+ on +tone +iEe,

+ha-e, loation, and a++oiated ureteraledema.reteral aluli 4>? mm in +iEe hae a 40>?0:

hane.

reteral aluli di+oered in the di+tal ureter at the

time o -re+entation hae a ?0: hane.


65/87

$nterention (cont’d)

Fi++olution agent+etiene++ de-end+ on +tone +urae area,

+tone ty-e, olume o irrigant, and mode odeliery.

"ral al/aliniEing agent+( +odium @ -ota++ium'iar'onate and -ota++ium itrate.

$D al/aliniEation( oneB+i6th molar +odiumlatate.


66/87


Fi++olution agent+ (cont’d)$ntrarenal al/aliniEation( through a

-erutaneou+ ne-hro+tomy tu'e or ane6ternaliEed retrograde atheter. Agent+

inlude +odium 'iar'onate, 2>4 am-ule+ in1 # o normal +aline.


67/87


!elie o o'+trutionA -atient with o'+trutie urinary aluli with

eer and ineted urine reuire+ emergentdrainage.

!etrograde -yelogra-hy i+ logially ollowed'y retrograde -laement o a dou'leBJureteral +tent.


68/87


69/87


6traor-oreal +ho/ wae lithotri-+y&rini-le redi+oered 'y Fornier, a Oerman

airrat or-oration.

Human ;odel H;IB1, B2, and B3.

All lithotri-tor+ reuire an energy +oure toreate the +ho/ wae, a ou-lingmehani+m to tran+er the energy romout+ide to in+ide the 'ody, and either


70/87


71/87


72/87


73/87


74/87


6traor-oreal +ho/ wae lithotri-+y(cont’d)&reo-eratie ealuationDital +ign+, inluding *&.

*ody ha'itu+.&regnany R -atient+ with large a'dominal aorti

aneury+m+ or inorreta'le 'leeding di+order+.

Cardia -aema/er


75/87


6traor-oreal +ho/ wae lithotri-+y(cont’d)&o+to-eratie areOro++ hematuria

luid inta/eollowBu- or 2 wee/+.


76/87


retero+o-i +tone e6trationretero+o-i +tone e6tration i+ highly

eQaiou+ or lower ureteral aluli.

The u+e o +mallBali'er uretero+o-e+ and

the adent o 'alloon dilation or ureteralae++ +heath+ hae inrea+ed +toneBreerate+ dramatially.

A ariety o lithotrite+ an 'e -laed through

an uretero+o-e, inluding eletrohydrauli,+olid and hollowBore ultra+oni -ro'e+, la+er+y+tem+, and -neumati +y+tem+.


77/87


78/87


79/87


80/87


&erutaneou+ ne-hrolithotomy&erutaneou+ remoal o renal and -ro6imal

ureteral aluli i+ the treatment o hoie orlarge K2.? mI aluli= tho+e re+i+tant to

%P#= and +elet lower -ole alyeal +tone+.5eedle -unture i+ direted 'y


81/87


&yelolithotomy&yelolithotomy i+ eetie, e+-eially with an

e6trarenal -eli+.

$njeted into the renal -eli+, endogenou+

lotting ator+ re+ult in a JellyBli/e oagulumo the olleting +y+tem.

The ri+/+ o he-atiti+ and other iralinetion+ hae made thi+ methodunae-ta'le.


82/87


Anatro-hi ne-hrolithotomyAnatro-hi ne-hrolithotomy i+ u+ed with

om-le6 +taghorn aluli.


83/87


"ther renal -roedure+!adial ne-hrotomy

&artial ne-hretomy

$leal ureter +u'+titution

Autotran+-lantation with -yeloy+to+tomy


84/87


reterolithotomy$ndiation( longB+tanding ureteral aluli

tho+e inae++i'le with endo+o-y and tho+ere+i+tant to %P#I.


85/87

&!D5T$"5


86/87

&reention

reterolithotomy;eta'oli ealuation

"ral mediation+Al/aliniEing -H agent+

Oa+trointe+tinal a'+or-tion inhi'itor( ellulo+e-ho+-hata+e

&ho+-hate and alium +u--lementation

Fiureti+

ri aidBlowering mediation+

rea+e inhi'itor( aetohydro6ami aid&reention o y+tine aluli( -eniillamine


87/87

TERIMA KASIH

Symptoms and Sign at Presentation

Documents

Transcript of Symptoms and Sign at Presentation