Open the Flood Gates Urinary Obstruction and Kidney Stones. Dr. Jeffrey Rosenberg Dr. Emilio Lastarria Dr. Richard Kasulke

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Open the Flood Gates Open the Flood Gates –– Urinary Obstruction and Urinary Obstruction and

Kidney Stones Kidney Stones

Dr. Jeffrey Rosenberg Dr. Jeffrey Rosenberg

Dr. Emilio

Dr. Emilio LastarriaLastarria Dr. Richard

Dr. Richard KasulkeKasulke

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Nephrology vs. Urology Nephrology vs. Urology

NephrologistNephrologist a a physphysician who has been trained ician who has been trained in the diagnosis and management of

in the diagnosis and management of kidney kidney disease

disease, , blood pressureblood pressure, regulating , regulating electrolyteselectrolytes, , balancing fluids in the body, and administering balancing fluids in the body, and administering

dialysis dialysis..

Nephrology is a subspecialty of Nephrology is a subspecialty of internal internal medicine

medicine. .

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Conditions requiring a Conditions requiring a NephrologistNephrologist::

Acute Kidney failure (a sudden loss of kidney function)Acute Kidney failure (a sudden loss of kidney function)

Chronic Kidney Disease (declining kidney function over Chronic Kidney Disease (declining kidney function over months/years)

months/years)

Hematuria/ProteinuriaHematuria/Proteinuria (blood and protein in the urine)(blood and protein in the urine)

Kidney stones (recurrent stone formers)Kidney stones (recurrent stone formers)

Hypertension managementHypertension management

Electrolyte and acid/base disordersElectrolyte and acid/base disorders

Dialysis and renal transplant patientsDialysis and renal transplant patients

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Urologist Urologist a physician who is a a physician who is a surgicalsurgical specialist of specialist of the the urinary tracturinary tract and is usually involved in kidney and is usually involved in kidney

diseases that might be amenable to a procedural diseases that might be amenable to a procedural

intervention.

intervention.

Conditions requiring a Urologist Conditions requiring a Urologist

Disorders involving the kidneysDisorders involving the kidneys, , adrenal glandsadrenal glands, , uretersureters, , urinary bladder

urinary bladder, , urethraurethra, and the male reproductive organs , and the male reproductive organs

i.e. Recurrent urinary tract infectionsi.e. Recurrent urinary tract infections, , benign prostatic benign prostatic hyperplasia

hyperplasia (BPH), cancers, the correction of congenital (BPH), cancers, the correction of congenital abnormalities, correcting

abnormalities, correcting stress incontinencestress incontinence and urinary tract and urinary tract obstructions.

obstructions.

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Urinary Tract Anatomy Urinary Tract Anatomy

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Urinary Tract Obstruction Urinary Tract Obstruction

Can occur anywhere along the path of the Can occur anywhere along the path of the urinary tract.

urinary tract.

Can be acute or chronic in nature.Can be acute or chronic in nature.

Can have either a complete or partial blockageCan have either a complete or partial blockage

Can be unilateral (one kidney) or bilateral (both Can be unilateral (one kidney) or bilateral (both kidneys).

kidneys).

Numerous causesNumerous causes

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The major causes of UTO vary with the age of The major causes of UTO vary with the age of the patient:

the patient:

Anatomic abnormalities account for the majority of Anatomic abnormalities account for the majority of cases in children.

cases in children.

Calculi (kidney stones) are most common in young Calculi (kidney stones) are most common in young adults

adults

Prostatic hypertrophy (BPH) or carcinoma, other Prostatic hypertrophy (BPH) or carcinoma, other abdominal cancers or scarring, and calculi are the abdominal cancers or scarring, and calculi are the primary causes in older patients

primary causes in older patients

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Symptoms and Signs Symptoms and Signs

The clinical manifestations of UTO vary with the site, The clinical manifestations of UTO vary with the site, degree, and rapidity of onset of the obstruction

degree, and rapidity of onset of the obstruction

Pain (variable) -Pain (variable) - Upper ureteralUpper ureteral or intra-or intra-renal lesions lead to renal lesions lead to flank pain or tenderness, whereas lower

flank pain or tenderness, whereas lower ureteralureteral obstruction obstruction causes pain that may often radiate to the

causes pain that may often radiate to the ipsilateralipsilateral groin or groin or bladder region.

bladder region.

Kidney failure –Kidney failure often manifested as decreased urinary often manifested as decreased urinary output.

output.

Hypertension -Hypertension - variablevariable

Laboratory abnormalities –Laboratory abnormalities often high potassium and acidosisoften high potassium and acidosis

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Diagnosis Diagnosis

Early diagnosis of UTO is important, since most Early diagnosis of UTO is important, since most cases can be corrected and a delay in therapy can cases can be corrected and a delay in therapy can

lead to irreversible kidney injury.

lead to irreversible kidney injury.

If suspected If suspected urinary catheter.urinary catheter.

Radiology examinations:Radiology examinations:

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Renal Ultrasound Renal Ultrasound -- test of choicetest of choice

CT scan CT scan

IVP (Intravenous IVP (Intravenous pyelogrampyelogram))

MRI MRI very rarely very rarely

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Magnetic resonance

Magnetic resonance urogramurogram clearly showing right-clearly showing right-sided sided hydronephrosishydronephrosisand the full course and the full course of the right

of the right ureterureter. The left renal tract has a normal appearance.. The left renal tract has a normal appearance.

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Treatment Treatment

As per Dr.As per Dr.s s LastarriaLastarria and and KasulkeKasulke

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Kidney stones (

Kidney stones (NephrolithiasisNephrolithiasis))

Very commonVery common

Often present with the classic symptoms of Often present with the classic symptoms of renal colic (pain) and

renal colic (pain) and hematuriahematuria..

Asymptomatic or have atypical symptoms:Asymptomatic or have atypical symptoms:

vague abdominal painvague abdominal pain

NauseaNausea

Urinary urgency, frequency, or difficulty urinatingUrinary urgency, frequency, or difficulty urinating

Penile or testicular pain. Penile or testicular pain.

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Etiology Etiology

80% are calcium80% are calcium--based stones.based stones.

Remainder include uric acid, Remainder include uric acid, struvitestruvite (chronic (chronic urinary infection), and

urinary infection), and cystinecystine stones.stones.

Several theories on stone formation, however Several theories on stone formation, however urinary

urinary supersaturationsupersaturation is at the center of all!is at the center of all!

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Risk factors Risk factors

Dietary:Dietary:

LowLow calcium intake, high oxalate intake (spinach), high calcium intake, high oxalate intake (spinach), high animal protein intake, high sodium intake,

animal protein intake, high sodium intake, low fluid intakelow fluid intake, , and increased intake of Vitamin C.

and increased intake of Vitamin C.

Prior kidney stonesPrior kidney stones

Family history of stonesFamily history of stones

Enhanced intestinal oxalate absorption (gastric bypass Enhanced intestinal oxalate absorption (gastric bypass procedures, bariatric surgery, short bowel syndrome procedures, bariatric surgery, short bowel syndrome

Hypertension, diabetes, obesity, gout, primary Hypertension, diabetes, obesity, gout, primary hyperparathyroidism, and

hyperparathyroidism, and excessiveexcessive physical exercise physical exercise

Certain medicationsCertain medications

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Clinical Manifestations Clinical Manifestations

Pain (often intermittent)Pain (often intermittent)

HematuriaHematuria (blood in urine)(blood in urine)

Nausea, vomiting, pain on urination, urgencyNausea, vomiting, pain on urination, urgency

Passed stone or Passed stone or gravelgravel

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Evaluation Evaluation

ImagingImaging

Kidney UltrasoundKidney Ultrasound

CT scanCT scan

Others: IVP, Plain film (XrayOthers: IVP, Plain film (Xray))

Stone analysisStone analysis

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Laboratory studies:Laboratory studies:

24 hour urine collection for Stone risk analysis 24 hour urine collection for Stone risk analysis

(volume, electrolytes, oxalate, citrate, uric acid, etc.) (volume, electrolytes, oxalate, citrate, uric acid, etc.)

Blood tests –Blood tests rule out possible endocrine cause or rule out possible endocrine cause or electrolyte abnormalities

electrolyte abnormalities

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Treatment Treatment

Medical Medical Preventative in naturePreventative in nature

Based on results of 24 hour urine collection, stone Based on results of 24 hour urine collection, stone analysis, blood tests

analysis, blood tests

Increased fluid intake (>1/2 gallon per day)Increased fluid intake (>1/2 gallon per day)

Decreased salt, oxalate, animal protein, etc.Decreased salt, oxalate, animal protein, etc.

Occasionally medications (Occasionally medications (thiazidethiazide diuretics, diuretics, allopurinol

allopurinol, , KcitrateKcitrate))

Avoid becoming dehydrated!Avoid becoming dehydrated!

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Surgical Surgical per Dr.per Dr.s s LastarriaLastarria and and KasulkeKasulke!!

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