泌尿系统疾病课件：Urinary stone

1、Urinary StoneOutline and objectives:General Consideration of Urinary Stone: Epidemiology and Etiology Pathology and PathophysiologyStone of Upper Urinary Tract: Clinical manifestation of Renal & Ureteral stone Diagnosis and differiential diagnosis Treatment of acute renal colic Principle for the cho

2、ice of therapuetic approachesStone of Lower Urinary tract: Clinical manifestation, diagnosis, treatment of Vesical stone & Uretheral stoneGeneral Consideration:Urinary lithiasis (Uroliths): Stone in any parts (upper or lower) of urinary tract. One of the most common disease of the urotract. Form pri

3、marily in kidney or bladder, and block the urinary passage (ureter or urethera) secondly. The epidemiology, etiology of stone in upper or lower urinary tract are different. Epidemiology: Incidence of urinary stone in recent 30 years: Renal stone , and vesical stone Geographyic difference Gender: mal

4、e/female, about 3:1 Age: Upper urinary stone: 20-50, peak: 25-40 additional peak 50-65 for femaleLower urinary stone: children, old patients. The relation of urolith incidence to heredity, climate, season, metabolism, lifestyle(diet, water intake), occupation, etc.Components of Urinary Stone:Crystal

5、: insoluble salts and acids in urine Calcium oxalate (most common, in 90% stone), Calcium phosphate (most are hydroxylapatite form) Magnesium ammonium phosphate (infective stone) Uric acid crystals ( or + NH4, Na, in 10% stone) Cystine, Xanthine, etc.Matrix: Organic matrix consists of amino acid and

6、 carbohydrates, form the frame of crystals precipitation. The major components of urinary stone are crystals. The most common crystals are oxalates and phosphates, and usually are their calcium salts. Especially are the mixture of Oxalates and Phosphates. Relation between component and localization

7、of stone:Upper urinary tract: CaOx+CaPLower urinary tract: CaOx, Struvite, Uric acid crystal.Components Analysis Results of Urinary Stone :Etiology: The cause of urinary stone: complicated, multi-factors. Multi-faceted theory & Risk factorsEnviroment:Climate, Season, the adaptive ability, etc.Indivi

8、dual:Heredity, Lifestyle (diet, Water Intake), Abnormal metabolism: Ox, Ca, P; disease; drug.Urinary system:Structural anomalies, obstruction, infection, foreign body, local lesion in urinary tract.Urine:urine volume: decrease, pH of urine: change Insoluble components: supersaturated. Inhibitator: d

9、ecrease & promotor: increase.Mechanism of Stone formation:The physic-chemical theory of urinary stone formation:1. Stone formed salts: supersaturated.2. Lack of inhibitors and/or Increase of promotors.3. Surface of tract & Drainage of urine: not normal.The process of urinary stone formation:1. Nucle

10、ation: Homogenous/Heterogenous;2. Growth; 3. Aggregation; 4. Phase transformation.Simple classification of stone formation:1. Stone related to metabolism.2. Stone related to local infection.Can we answer the previous questions:Why in recent 30 years the incidence of renal stone increase, but that of

11、 vesical stone decrease?Why women has another age peak of 5065 years old for urinary stone?Why the incidence of urinary stone in men is pretty much higher than that of women?National Center of Bioinformatics National Library of Medicine Nation Institute of HealthPathology:The position and size of st

12、one govern the secondary pathologic changes:Local mechanical damage, Obstruction,Infection, polypus or malignance formation. Stoneformationmechanical damageInfectionObstructionPathophysiology:The Pathophysiological changes is related to the position and severity of obstruction and infection: Severit

13、y of ObstructionAcute complete obstructionChronic uncomplete obstruction The complicated infection Position:CaliceshydrocalicosisPelvishydronephrosisUreterUreteral dilationlower tractUrine retention Clinical Manifestation of Upper Tract StoneSymptoms:1. Pain and hematuria related to movement: The se

14、verity is due to size, positon, movement and complications. Pain: local pain: dull flank pain and renal colic, referred pain (radiating pain) Hematuria: gross or microscopic hematuria2. Infective symptom: Vesical irritability, chills, high fever, etc.3. GI tract symptom: nausea, vomitting, abdominal

15、 distension, etc.Clinical Manifestation of Upper Tract Stone:Signs: also related to the severity of obstruction and infection, could be none or very obvious. Patients with acute renal colic is usually agony, pacing the floor rather than lying quietly in bed. Tenderness in the costovertebral angle an

16、d flank. Fist percussion posteriorly may cause pain. Spasm of abdominal muscles on the affected side. Other signs related to complications.Diagnosis of Upper Tract Stone:1. History collection:2. Physical examination:3. Laboratory exam: CBC, urinalysis, blood chemistry studies, renal function test.4.

17、 Image Diagnosis:B-ultrasonograhy:X-rays: Plain film, Excretory urogram, Retrograde urogram,CT, Radionuclide renography, renal imaging.5. Instrumental examination:Endoscopic technique: ureteroscopyB-Ultrasonography of Upper Tract Stone:Plain film of Upper Tract Stone:Intravenous pyelography of Upper

18、 Tract Stone:Diagnosis of Upper Tract Stone:Diagnostic purpose: is to identify Uni- or bi-lateral, position, size, number, shapeThe complication and secondery lesionThe potential causesDifferential Diagnosis: How to differentiate fromSeveral acute abdominal symptoms, andGynecological diseases.Treatm

19、ent of Upper Urinary Stone:Purpose of treatment:1. Remove stone, Control Complication2. Relieve obstruction, Resume drainage 3. Protect renal function, Prevent recurrenceThe option of therapuetic approaches:1. Conservative measures2. Extracorporeal shock wave lithotripsy, ESWL Percutaneous nephrolit

20、hotomy(PCN, or PNL) Transuretheral ureteroscopic lithotomy3. Operative surgeryIntroduction of ESWL: Improvement of ESWL Instrument:Localization systemTransduct Water sacShock Wave producerTreatment of Upper Urinary Stone:The basis for the choice of therapuetic strategy:1. General conditon of patient

21、s2. Sides, position, size, shape of stone3. Complications: Obstruction, infection4. Total renal function, unilateral renal function 5. Symptoms including non-urinary symptoms6. Trends of recurrence of stone7. Others: Health economic evaluation, etc.Treatment of acute renal colicky pain:1. Antispasmo

22、dics Atropine 0.5mg im prn, Progesterone 20mg im qdNifedipine 10mg p.o. prn 2. AnalgeticsDolantin 50-100mg im prn, Morphine 10mg im prn, Indomethacin 25mg tid 3. Antibiotics: sensitive & effective antibiotics 4. Fluid supplement: associated with antispasmodics5. Symptomatic treatment: fever, vomitti

23、ng, etc.Clinical Consideration of Vesical Stone:Vesical Stone: Primary vesical stone: malnourished children Secondary vesical stone: 95% Occurs in menPartial urine retention + Infection with urine splitting bacteriaPass through upper tract into bladderForeign body, Parasites, Medical material.Clinical Findings:Sudden interruption of the urinary stream with pain radiating down penis, need to change position for urination.Vesical irritability, d