Kidney Stones

.Kidney stones (ureterolithiasis) result from stones or renal calculi (from Latin ren, renes, "kidney" and
calculi, "pebbles")[1] in the ureter. The stones are solid concretions or calculi (crystal aggregations)
formed in the kidneys from dissolved urinary minerals. Nephrolithiasis (from Greek νεφρός (nephros,
"kidney") and λιθoς (lithos, "stone")) refers to the condition of having kidney stones. Urolithiasis refers
to the condition of having calculi in the urinary tract (which also includes the kidneys), which may form
or pass into the urinary bladder. Ureterolithiasis is the condition of having a calculus in the ureter, the
tube connecting the kidneys and the bladder. The term bladder stones usually applies to urolithiasis of
the bladder in non-human animals such as dogs and cats.

Calyceal calculi (or caliceal calculi) refer to aggregations in either the minor or major calyx,
parts of the kidney which pass urine into the ureter.

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 before passage
(usually at least 2-3 millimeters), they can cause obstruction of the ureter. The resulting
obstruction causes dilation or stretching of the upper ureter and renal pelvis (the part of the
kidney where the urine collects before entering the ureter) as well as muscle spasm of the ureter,
trying to move the stone. This leads to pain, most commonly felt in the flank, lower abdomen
and groin (a condition called renal colic). Renal colic can be associated with nausea and
vomiting. There can be blood in the urine, visible with the naked eye or under the microscope
(macroscopic or microscopic hematuria) due to damage to the lining of the urinary tract.

There are several types of kidney stones based on the type of crystals of which they consist. The
majority are calcium oxalate stones, followed by calcium phosphate stones. More rarely, struvite
stones are produced by urea-splitting bacteria in people with urinary tract infections, and people
with certain metabolic abnormalities may produce uric acid stones or cystine stones.

The diagnosis of a kidney stone can be confirmed by radiological studies and/or ultrasound
examination; urine tests and blood tests are also commonly performed. When a stone causes no
symptoms, watchful waiting is a valid option. In other cases, pain control is the first measure,
using for example non-steroidal anti-inflammatory drugs or opioids. Using soundwaves, some
stones can be shattered into smaller fragments (this is called extracorporeal shock wave
lithotripsy). Sometimes a procedure is required, which can be through a tube into the urethra,
bladder and ureter (ureteroscopy), or a keyhole or open surgical approach from the kidney's side.
Sometimes, a tube may be left in the ureter (a ureteric stent) to prevent the recurrence of pain.
Preventive and structive measures are often advised such as drinking sufficient amounts of water
and milk although the effect of many dietary interventions has not been rigorously studied.

Signs and Symptoms

Symptoms of kidney stones include:[2][3]
Localization of kidney stone pain

 Colicky pain: "loin XX to groin". Often described as "the worst pain [...] ever experienced." This
can also occur in the lower back.[4] The pain is elicited by contractions of the ureter in response
to the stone, causing severe, crampy pain in the flank or lower back, often radiating to the groin
or, in men, to the testes.[5] The pain typically comes in waves, with a typical wave lasting 20 to 60
minutes.[5]
 Nausea/vomiting: embryological link with intestine– stimulates the vomiting center.
 Hematuria: blood in the urine, due to minor damage to inside wall of kidney, ureter and/or
urethra.
 Pyuria: pus in the urine.
 Dysuria: burning on urination when passing stones (rare). More typical of infection.
 Oliguria: reduced urinary volume caused by obstruction of the bladder or urethra by stone, or
extremely rarely, simultaneous obstruction of both ureters by a stone.
 Postrenal azotemia: the blockage of urine flow through a ureter.[6]
 Hydronephrosis:[7] the distension and dilation of the renal pelvis and calyces.

Causes
Kidney stones do not have single, well-defined cause, but are the result of a combination of
factors. A stone is created when the urine does not have the correct balance of fluid and a
combination of minerals and acids. When the urine contains more crystal-forming substances
than the fluid can dilute, crystals can form. Normally the urine contains components that prevent
these crystals from attaching to each other. However, when these substances fall below their
normal proportions, stones can form out of an accumulation of crystals.[8]

Kidney stones or calcium oxalate crystals in the kidney can be due to underlying metabolic
conditions, such as renal tubular acidosis,[9] Dent's disease,[10] hyperparathyroidism,[11] primary
hyperoxaluria[12] and medullary sponge kidney.[13] Kidney stones are also more common in
patients with Crohn's disease.[14] Patients with recurrent kidney stones should be screened for
these disorders. This is typically done with a 24 hour urine collection that is chemically analyzed
for deficiencies and excesses that promote stone formation.[15]
There has been some evidence that water fluoridation may increase the risk of kidney stone
formation. In one study, patients with symptoms of skeletal fluorosis were 4.6 times as likely to
develop kidney stones.[16]

A 1998 paper in the Archives of Internal Medicine examined the sources of a widely-held belief
in the medical community that vitamin C can cause kidney stones, and found it to be based on
several circular references, ultimately attributing the belief to a wider pattern of skepticism
regarding efficacy of vitamin supplements.[17] A more recent study suggested a causal
relationship may exist, but it was not conclusive.[18]

The American Urological Association has projected that increasing global temperatures will lead
to greater future prevalence of kidney stones, notably by expanding the "kidney stone belt" of the
southern United States.[19] Astronauts seem to show a higher risk of developing kidney stones
during or after long duration space flights.[20]

Calcium oxalate stones

The most common type of kidney stone is composed of calcium oxalate crystals, occurring in
about 75 to 80% of cases,[9] and the factors that promote the precipitation of crystals in the urine
are associated with the development of these stones.

Perhaps counter-intuitively, current evidence suggests that the consumption of diets low in
calcium is associated with a higher overall risk for the development of kidney stones.[2] This is
perhaps related to the role of calcium in binding ingested oxalate in the gastrointestinal tract. As
the amount of calcium intake decreases, the amount of oxalate available for absorption into the
bloodstream increases; this oxalate is then excreted in greater amounts into the urine by the
kidneys. In the urine, oxalate is a very strong promoter of calcium oxalate precipitation, about 15
times stronger than calcium.

Uric acid (urate)

About 5–10% of all stones are formed from uric acid.[9] A risk factor is obesity.[21] Uric acid
stones form in association with conditions that cause hyperuricosuria with or without high blood
serum uric acid levels (hyperuricemia); and with acid/base metabolism disorders where the urine
is excessively acidic (low pH) resulting in uric acid precipitation. A diagnosis of uric acid
nephrolithiasis is supported if there is a radiolucent stone, a persistent undue urine acidity, and
uric acid crystals in fresh urine samples.[22]

Other types

Other types of kidney stones are composed of struvite (magnesium, ammonium and phosphate);
calcium phosphate; and cystine. Struvite stones are also known as infection stones, urease or
triple-phosphate stones. About 10–15% of urinary calculi consist of struvite stones.[23] The
formation of struvite stones is associated with the presence of urea-splitting bacteria,[24] most
commonly Proteus mirabilis (but also Klebsiella, Serratia, Providencia species). These
organisms are capable of splitting urea into ammonia, decreasing the acidity of the urine and
resulting in favorable conditions for the formation of struvite stones. Struvite stones are always
associated with urinary tract infections.[23] The formation of calcium phosphate stones is
associated with conditions such as hyperparathyroidism and renal tubular acidosis. Formation of
cystine stones is uniquely associated with people suffering from cystinuria, who accumulate
cystine in their urine. Cystinuria can be caused by Fanconi's syndrome. Urolithiasis has also been
noted to occur in the setting of therapeutic drug use, with crystals of drug forming within the
renal tract in some patients currently being treated with Indinavir, Sulfadiazine or Triamterene.
[citation needed]

Diagnosis
Clinical diagnosis is usually made on the basis of the location and severity of the pain, which is
typically colicky in nature (comes and goes in spasmodic waves). Pain in the back occurs when
calculi produce an obstruction in the kidney.[3]

Imaging is used to confirm the diagnosis and a number of other tests can be undertaken to help
establish both the possible cause and consequences of the stone.

X-rays

The relatively dense calcium renders these stones radio-opaque and they can be detected by a
traditional X-ray of the abdomen that includes the kidneys, ureters and bladder—KUB.[25] This
may be followed by an IVP (intravenous pyelogram—intravenous urogram (IVU) is the same
test by another name) which requires about 50 ml of a special dye to be injected into the
bloodstream that is excreted by the kidneys and by its density helps outline any stone on a
repeated X-ray. These can also be detected by a retrograde pyelogram where similar "dye" is
injected directly into the ureteral opening in the bladder by a surgeon, usually a urologist.

About 10% of stones do not have enough calcium to be seen on standard X-rays (radiolucent
stones).

Computed tomography

Computed tomography without contrast is considered the gold standard diagnostic test for the
detection of kidney stones. All stones are detectable by CT except very rare stones composed of
certain drug residues in the urine.[25] If positive for stones, a single standard X-ray of the
abdomen (KUB) is recommended. This gives a clearer idea of the exact size and shape of the
stone as well as its surgical orientation. Further, it makes it simple to follow the progress of the
stone by doing another X-ray in the future.

Drawbacks of CT scans include radiation exposure and cost.

Ultrasound
Ultrasound imaging is useful as it gives details about the presence of hydronephrosis (swelling of
the kidney—suggesting the stone is blocking the outflow of urine).[25] It can also be used to
detect stones during pregnancy when x-rays or CT are discouraged. Radiolucent stones may
show up on ultrasound however they are also typically seen on CT scans.

Some recommend that US be used as the primary diagnostic technique with CT being reserved
for those with negative US result and continued suspicion of a kidney stone. This is due to its
lesser cost and avoidance of radiation.[26]

Other

Other investigations typically carried out include:[25]

 Microscopic study of urine, which may show proteins, red blood cells, bacteria, cellular casts and
crystals.
 Culture of a urine sample to exclude urine infection (either as a differential cause of the
patient's pain, or secondary to the presence of a stone).
 Blood tests: Full blood count for the presence of a raised white cell count (Neutrophilia)
suggestive of infection, a check of renal function and to look for abnormally high blood calcium
blood levels (hypercalcaemia).
 24 hour urine collection to measure total daily urinary volume, magnesium, sodium, uric acid,
calcium, citrate, oxalate and phosphate.
 Catching of passed stones at home (usually by urinating through a tea strainer or stonescreen)
for later examination and evaluation by a doctor. [27][28]


 Staghorn calculus

Multiple kidney stones composed of uric acid and a small amount of calcium oxalate.

Star-shaped bladder urolith on an X-ray of the pelvis.

Bilateral kidney stones on abdominal X-ray. Not to be confused with phleboliths seen in
the pelvis.

CT of abdomen without contrast showing right proximal ureteric stone causing mild
obstruction and hydronephrosis (marked by an arrow).
 

A kidney stone at the tip of an ultrasonic instrument.

Three-dimensional reconstructed CT scan image of a ureteral stent in the left kidney

(indicated by yellow arrow). There is a kidney stone in the pyelum of the lower pole of
the kidney (highest red arrow) and one in the ureter beside the stent (lower red arrow).

Prevention
Preventive strategies may include dietary modifications and medication with the goal of reducing
excretory load on the kidneys:[2][29]

 Drinking enough water to make 2 to 2.5 liters of urine per day. A failure to intake sufficient
liquids will mean the urine is concentrated and the substances that create kidney stones are
more likely to clump together.
 A diet low in protein, nitrogen and sodium intake. The National Institutes of Health website
disputes the notion that specific foods can cause formation of kidney stones in everyone,
although "in some people, a diet high in protein may lead to kidney stones because extra
protein causes calcium to be excreted from the body, raising calcium levels in the urine." [30]

People with urinary tract infections, kidney disorders such as cystic kidney diseases, and certain
rare, inherited metabolic disorders are also more likely to develop kidney stones. In some of
these susceptible people, the foods they eat can have an influence on the development of their
kidney stones. Prevention strategies include:

 Restriction of oxalate-rich foods, or consumption of more calcium

 Taking drugs such as thiazides, potassium citrate, magnesium citrate and allopurinol, depending
on the cause of stone formation.
 Some fruit juices, such as orange, blackcurrant, and cranberry, may be useful for lowering the
risk factors for specific types of stones. Orange juice may help prevent calcium oxalate stone
formation, blackcurrant may help prevent uric acid stones, and cranberry may help with UTI-
caused stones.[31][32] Lemons have the highest concentration of citrate of any citrus fruit, and
daily consumption of lemonade has been shown to decrease the rate of stone formation. [33] Beer
is also recommended, but grapefruit juice has been known to increase the risk of stones. [34]
 One study indicated that intake of caffeinated beverages[35] increases risk of kidney stones, a
finding which was soon taken up in the popular press. [36] While it may be advised to avoid cola
beverages, whether artificially sweetened or not [37][38] because of their high phosphate content,
this does not include coffee or tea. Prospective cohort studies of coffee and tea actually indicate
that they may prevent kidney stones, while apple juice and grapefruit juice may cause them. [39]
 Avoiding large doses of vitamin C.[40]
 In South Asia, there is a popular cultural belief that spinach should not be cooked along with
tomatoes, since spinach is rich in calcium and oxalates, and reacts with the chemicals in
 tomatoes, causing deposits in those prone to kidney stone formation. However, this theory is
not scientifically proven and is controversial. [citation needed]

For those patients interested in optimizing their kidney stone prevention options, a 24 hour urine
test can be a useful diagnostic.[citation needed]

Oxalate and calcium balance

Since oxalates form the basis of one type of kidney stone, one prevention strategy is to restrict
consumption of oxalate-rich foods such as chocolate, nuts, soybeans,[41] rhubarb, and spinach.[42]
(See oxalate for a list.) However, this is only helpful in those patients who are absorbing excess
oxalate - a minority of patients as most oxalate excreted in the urine is actually made by the liver.
[citation needed]

Stones are formed when oxalates bind with calcium, but calcium plays a vital role in body
chemistry and limiting calcium may be unhealthy. Recent research has actually shown that a diet
that includes recommended calcium levels prevents kidney stones in men better than a low-
calcium diet appears to.[30] Since calcium in the intestinal tract will bind with available oxalate,
thereby preventing its absorption into the blood stream, some nephrologists and urologists
recommend chewing calcium tablets during meals containing oxalate foods. Calcium citrate
should be taken with food if dietary calcium cannot be increased.[34]

Diuretics

Although it has been claimed that the diuretic effects of alcohol can result in dehydration, which
is important for kidney stone sufferers to avoid, there are no conclusive data demonstrating any
cause and effect regarding kidney stones. However, some have theorized that frequent and binge
drinkers create situations that set up dehydration: alcohol consumption, hangovers, and poor
sleep and stress habits. In this view, it is not the alcohol that creates a kidney stone but it is the
alcohol drinker's associated behavior that sets it up.[43]

One of the recognized medical therapies for prevention of stones is thiazides, a class of drugs
usually thought of as diuretics. These drugs prevent calcium stones through an effect
independent of their diuretic properties: they reduce urinary calcium excretion. Nonetheless,
their diuretic property does not preclude their efficacy as stone preventive. Sodium restriction is
necessary for clinical effect of thiazides, as sodium excess promotes calcium excretion.
Thiazides work best for renal leak hypercalciuria - a condition in which the high urinary calcium
levels are from a primary kidney defect. They work well initially for absorptive hypercalciuria -
a condition in which high urinary calcium is a result of excess absorption from the GI tract. With
this condition they lose effectiveness over time, typically around 2 years, and patients need a
period off treatment to regain effectiveness. Thiazides will cause hypokalemia and reduced
urinary citrate levels so should be given with supplements for each, usually as a potassium citrate
preparation.

Allopurinol
Allopurinol (Zyloprim) is another drug with proven benefits in some calcium kidney stone
formers. Allopurinol interferes with the liver's production of uric acid. Hyperuricosuria, too
much uric acid in the urine, is a risk factor for calcium stones. Allopurinol reduces calcium stone
formation in such patients. The drug is also used in patients with gout or hyperuricemia.[44]
However, hyperuricemia is not the critical feature of uric acid stones, which can occur in the
presence of hypouricemia. Uric acid stones are more often caused by a combination of high urine
uric acid and low urine pH.[45] Even relatively high uric acid excretion will not be associated with
uric acid stone formation if the urine pH is alkaline. Therefore prevention of uric acid stones
relies on alkalinization of the urine with citrate (in the form of Shohl's solution (sodium citrate),
sodium bicarbonate, potassium citrate, potassium bicarbonate or acetazolamide, a carbonic
anhydrase inhibitor).

Allopurinol is reserved for patients in whom alkalinization is difficult. For patients with
increased uric acid levels and calcium stones, allopurinol is one of the few treatments that has
been shown in double-blinded placebo controlled studies to actually reduce kidney stone
recurrences. Dosage is adjusted to maintain a reduced urinary excretion of uric acid. Serum uric
acid level at or below 6 mg/dL is often the goal of the drug's use in patients with gout or
hyperuricemia.

Decreased-protein diet

American diets typically contain more animal protein than the body can use, and the excess is
broken down into uric acid and excreted, increasing the risk of uric acid stones.[citation needed] Red
meat also contains acids that need to be excreted and these acids constitute another risk factor for
kidney stones[21] because the body will balance urinary pH by leaching calcium from the bones
and this free calcium is subject to combining with any available oxalate to form stones.[citation needed]

Other modifications

Potassium citrate is also used in kidney stone prevention. This is available as both a tablet and
liquid preparation. The medication increases urinary pH (makes it more alkaline), as well as
increases the urinary citrate level, which helps reduce calcium oxalate crystal aggregation.
Optimal 24 hour urine levels of citrate are thought to be over 320 mg/liter of urine or over
600 mg per day. There are urinary dipsticks available that allow patients to monitor and measure
urinary pH so patients can optimize their urinary citrate level.

Though caffeine does acutely increase urinary calcium excretion, several independent
epidemiologic studies have shown that coffee intake overall is protective against the formation of
stones.[39]

Measurements of food oxalate content have been difficult and issues remain about the proportion
of oxalate that is bio-available, versus a proportion that is not absorbed by the intestine. Oxalate-
rich foods are usually restricted to some degree, particularly in patients with high urinary oxalate
levels, but no randomized controlled trial of oxalate restriction has been performed to test that
hypotheses.
Calgranulin

Crystallization of calcium oxalate (CaOx) appears to be reduced by molecules in the urine that
retard the formation, growth, aggregation, and renal cell adherence of calcium oxalate. By
purifying urine using salt precipitation, preparative isoelectric focusing, and sizing
chromatography, some researchers have found that the molecule calgranulin is able to inhibit
calcium oxalate crystal growth.[46] Calgranulin is a protein formed in the kidney. Given the large
amounts of calcium oxalate in the urine, and considering its potency, calgranulin could become
an important contribution to the normal urinary inhibition of crystal growth and aggregation. If
so, it will be an important tool in the renal defense against kidney stones.

Medical management

There has been some debate regarding the usefulness of medical management overall in the
treatment of stone forming patients. Despite this debate, it is clear that repeat stone formers do
benefit from more intense management, including proper hydration and use of certain
medications. Additionally, it is also clear that careful surveillance is required in order to
maximize the clinical course for patients who are unlucky enough to be stone formers.[47][48]

Management
Conservative

85% of the time, it is possible to pass the stone with urination. Usually this will occur within 72
hours of the start of symptoms.[49] Stones larger than 6 mm will almost always require some form
of intervention, however.[50] There are various measures that can be used to encourage the
passage of a stone. These can include increased hydration.[citation needed]

Straining the urine allows collection of the stone when it passes and analysis of the stone can
help establish preventative options.

In most cases, interventions are not needed especially for smaller stones, unless a month goes by
and the stone has not moved.[2] Prompt surgery may nonetheless be required with persons who
have only one working kidney, bilateral obstructing stones, a urinary tract infection and thus
presumably an infected kidney, or intractable pain.

Analgesia

Management of pain often requires intravenous administration of NSAIDS or opioids in an

emergency room setting. Orally-administered medications are often effective for less severe
discomfort (NSAIDs or opioids). Intravenous acetaminophen also appears to be effective.[51]

After treatment, the pain may return if the stone moves but re-obstructs in another location.

Alpha adrenergic blockers

Alpha adrenergic blockers such as tamsulosin (Flomax) may increase the spontaneous passage of
the stone by 30%. Recent studies have, however, questioned this claim, finding no benefit from
these medications.[52][53]

Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) was the most common form of intervention in
1990s and 2000s and is still very common for stones that are 10 mm or smaller as it is the least
invasive form of intervention. This involves breaking up the stone by projecting sonic waves into
the area.

A single retrospective study at the Mayo Clinic suggested that lithotripsy may increase
subsequent incidence of diabetes and hypertension,[54] but the clinic did not believe the treatment
should be abandoned.[55] Although shock wave lithotripsy may involve some bruising and
provoke internal bleeding, the benefits of SWL outweigh the risk for many patients. A shock
wave firing rate of 60 waves per minute represents a lower risk of renal injury than 120 per
minute.[56]

Surgery

Percutaneous nephrolithotomy or, rarely, open surgery may ultimately be necessary for large or
complicated stones or stones which fail other less invasive attempts at treatment. Surgery is
typically done from the back, through the ureter.

Ureteral stents

One modern medical technique uses a ureteral stent (a small tube between the bladder and the
inside of the kidney) to provide immediate relief of a blocked kidney. This is especially useful in
saving a failing kidney due to swelling and infection from the stone. Ureteral stents vary in
length and width but most have the same shape usually called a "double-J" or "double pigtail",
because of the curl at both ends. They are designed to allow urine to drain around any stone or
obstruction. They can be retained for some length of time as infections recede and as stones are
dissolved or fragmented with ESWL or other treatment. The stents will gently dilate or stretch
the ureters which can facilitate instrumentation and they will also provide a clear landmark to
help surgeons see the stones on x-ray. Most stents can be removed easily during a final office
visit. Discomfort levels from stents typically range from minimal associated pain to moderate
discomfort. However, it isn't uncommon for patients to experience severe discomfort too,
especially upon removal of said stent.

The use of ureteral stents is of particular significance in the treatment of ureteral stones. Their
use, non use, and circumstances peculiar to stents should be well understood in order to
maximize the benefits.[57]

Ureteroscopy
Ureteroscopy has become increasingly popular as ureteroscopes have gotten smaller. Typically, a
ureteroscope will use a laser to destroy or at least fragment encountered stones.

Epidemiology
Within the United States, about 12% of men and 7% of women will be diagnosed with a kidney
stone,[21][58] and the total cost for treating this condition was US$2 billion in 2003.[25] The
incidence rate increases to 20–25% in the Middle East, because of increased risk of dehydration
in hot climates (the typical Middle Eastern diet is also 50% lower in calcium and 250% higher in
oxalates compared to Western diets, increasing the net risk).[59] Recurrence rates are estimated at
about 10% per year, totalling 50% over a 5–10 year period and 75% over 20 years.[9] Recent
evidence has shown an increase in pediatric cases.[60]

History
See also: List of kidney stone formers

The existence of kidney stones has been recorded since the beginning of civilization, and
lithotomy for the removal of stones is one of the earliest known surgical procedures.[61] In 1901, a
stone was discovered in the pelvis of an ancient Egyptian mummy, and was dated to 4,800 BC.
Medical text from ancient Mesopotamia, India, China, Persia, Greece and Rome all mentioned
calculous disease. Part of the Hippocratic oath suggests that there were practicing surgeons in
Ancient Greece to whom physicians should defer for lithotomies. The Roman medical treatise
De Medicina by Cornelius Celsus contained a description of lithotomy, and this work served as
the basis for this procedure up until the 18th century.[62]

Among the famous leaders who were kidney stone formers are Emperor Napoleon Bonaparte,
Emperor Napoleon III, Peter the Great, Louis XIV, George IV, Oliver Cromwell, and former
U.S. President Lyndon B. Johnson. Other notable individuals who endured stones include
Benjamin Franklin, the philosophers Michel de Montaigne and Sir Francis Bacon, the scientist
Sir Isaac Newton, the civil servant and diarist Samuel Pepys, the physicians William Harvey and
Herman Boerhaave, and the anatomist Antonio Scarpa.[63] Interestingly, astronauts seem to have
a higher risk of developing kidney stones during or after long duration space flights.[64]

New techniques in lithotomy began to emerge starting in 1520, but the operation remained risky.
It was only after Henry Jacob Bigelow popularized the technique of litholapaxy in 1878 that the
mortality rate dropped from about 24% down to 2.4%. However, other treatment techniques were
developed that continued to produce a high level of mortality, especially among inexperienced
urologists.[62][63] In 1980, Dornier MedTech introduced extracorporeal shock wave lithotripsy for
breaking up stones via acoustical pulses, and this technique has come into widespread use.[65]

Kidney stones were once referred to as gravel or gravel disease during the 1800s in the United
States. One such example is documented in the Oak Ridge Cemetery records for Charles Muir
Campbell who died 13 Oct 1874 in Springfield, Sangamon, Illinois, USA.[citation needed]
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Urolithiasis
From Wikipedia, the free encyclopedia

Jump to: navigation, search

Urolithiasis

Classification and external resources

KUB stone

ICD-10 N20.0-N22.0

ICD-9 592

DiseasesDB 11346

eMedicine ped/2371

MeSH D052878
Bladder stones incidentally found in a bladder diverticulum during transvesical prostatectomy (removal
of the prostate via an incision in the bladder).

Urolithiasis (from Greek oûron, "urine" and lithos, "stone") is the condition where urinary
calculi are formed[1] in the urinary tract.[2][3]

The term kidney stone (or "renal calculus") is sometimes used to refer to urolithiasis in any part
of the urinary tract, however it is more properly reserved for stones that are actually in the
collecting duct of the kidney itself.[4][5][6]

The term nephrolithiasis can be used to describe the condition of having kidney stones,[7] and
ureterolithiasis can be used to describe the condition of having stones in the ureter.[8]

Obstruction of the ureter by the kidney stones causes a renal colic attack which is why intense
pain is felt in groin and back.

The term bladder stone is more frequently associated with veterinary science.

Contents
[hide]

 1 Composition
 2 Pathology
 3 Causes
 4 Diagnosis
 5 Treatment
 6 Surgery
 7 Prevention
 8 References

[edit] Composition
Urinary stones may be composed of the following substances:[9]

 Calcium oxalate monohydrate (whewellite)

 Calcium oxalate dihydrate (weddellite)
 Calcium phosphate
 Magnesium phosphate
 Ammonium phosphate
 Ammonium magnesium phosphate (struvite)
 Calcium hydroxyphosphate (apatite)
 Uric acid and its salts (urates)
 Cystine
 Xanthine
 Indigotin (rare)
 Urostealith (rare)
 Sulphonamide (rare)

[edit] Pathology
Bladder stones are small particles that can form in the bladder. In most cases bladder stones
develop when the urine becomes very concentrated or when one is dehydrated. This allows for
the minerals like calcium or magnesium to crystallize and form stones. Bladder stones vary in
number size and consistency. In some cases bladder stones do not cause any symptoms of signs
and are discovered as an incidental finding on a plain x ray. However, when symptoms do occur
these may include severe lower abdominal and back pain, difficult urination, frequent urination
at night, fever, painful urination and blood in the urine. The majority of individuals who are
symptomatic will complain of pain which comes in waves. The pain may also be associated with
nausea, vomiting and chills.[10]

Bladder stones vary in their size, shape and texture- some are small, hard and smooth whereas
others are huge, spiked and very soft. One can have one or multiple stones. Bladder stones are
somewhat more common in men who have prostate enlargement. The large prostate presses on
the urethra and makes it difficult to pass urine. Over time stagnant urine collects in the bladder
and minerals like calcium start to precipitate. Other individuals who develop bladder stones
include those who have had spinal cord injury, paralysis or some type of nerve damage. When
nerves to the back are damaged, the bladder cannot empty and stagnant urine results.[11]

[edit] Causes
Bladder stones can occur if kidney(s), the bladder or urinal tracts get inflamed. Another reason is
if a patient has frequent insertion of urinary catheters. Some people who are paralyzed and
unable to pass urine require small plastic tubes (catheters) placed in the bladder. These tubes are
prone to infection which irritates the bladder resulting in stone formation. Finally kidney stones
can travel down the ureter into the bladder and grow in to bladder stones. There is some evidence
indicating that chronic irritation of the bladder by retained stones may increase the chance of
bladder cancer.
[edit] Diagnosis
The diagnosis of bladder stone includes urine analysis, ultrasound, x rays or cystoscopy
(inserting a small thin camera into the urethra and viewing the bladder). In the past a study called
the intravenous pyelogram was frequently used to assess the presence of kidney stones. This test
involves injecting a dye which is passed slowly into the urinary system. X ray images are then
obtained every few minutes to determine if there is any obstruction to the dye as it is excreted
into the bladder. Today, Intravenous Pyelogram has been replaced at most rural health centers by
Ct scans. CT scans are more sensitive and can identify very small stones not seen by other tests.
[12]

[edit] Treatment
The treatment of bladder stones is simple. One needs to start drinking a lot of fluids. While any
fluids can be consumed, water is considered to be the ideal solution. Excess fluid can help pass
the small stones. Large stones or those that fail to pass may require other methods of treatment.
[13]

Breaking up of bladder stones is also done with a camera (cystoscope) which is inserted into the
bladder. The surgeon visualizes the stone and use ultrasound or another mechanical device to
break the stones into small pieces which are then flushed out. The procedure does require some
type of anesthesia and may require admission to a hospital for several days. Complications of
this treatment include infections, small tear of the bladder or bleeding in the urine.[14]

[edit] Surgery
Sometimes stones are just too large and may need open surgery. In such a case, the bladder is
opened and the stones are removed. Surgery is usually the last step and is considered a major
procedure.

[edit] Prevention
The best way to prevent bladder stones is to prevent them in the first place. This means drinking
plenty of liquids. If you sweat a lot, exercise intensely or live in a hot environment, drink 6-10
glasses of water on a daily basis. One should avoid drinking excess tea as there is evidence that
this beverage can stimulate formation of bladder stones. If one does develop bladder irritation or
urgency to urinate, drink lemon juice because it has been shown to prevent development of small
stones. Finally men who have difficulty with urination and are found to have prostatic
hypertrophy should seek treatment.[15]

[edit] References
 Wikimedia Commons has media related to: Kidney stone

1. ^ urolithiasis at Dorland's Medical Dictionary

2. ^ "Case Study: Urolithiasis". Hole's Human Anatomy & Physiology. http://highered.mcgraw-
hill.com/sites/0070272468/student_view0/chapter20/case_studies.html.
3. ^ Urolithiasis at eMedicine Dictionary
4. ^ "Kidney Calculi". Mesh. http://www.nlm.nih.gov/cgi/mesh/2008/MB_cgi?
field=uid&term=D007669.
5. ^ "Dorlands Medical Dictionary:kidney stone".
http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?
pg=/ppdocs/us/common/dorlands/dorland/nine/20113223.htm.
6. ^ renal+calculus at eMedicine Dictionary
7. ^ nephrolithiasis at Dorland's Medical Dictionary
8. ^ ureterolithiasis at Dorland's Medical Dictionary
9. ^ S. Materazzi, R. Curini, G. D'Ascenzo, and A. D. Magri (1995), TG-FTIR coupled analysis applied
to the studies in urolithiasis: chracterization of human renal calculi. Termochimica Acta, volume
264, 75--93.
10. ^ Bladder Stones General Overview, Retrieved on 2010-01-19.
11. ^ Bladder Stones Prevention, Retrieved on 2010-01-19.
12. ^ Bladder Stones: eMedicine Urology, Retrieved on 2010-01-19.
13. ^ Bladder Stones: NY Times Health Information, Retrieved on 2010-01-19.
14. ^ Bladder Stones Overview: University of Maryland Medical Center, Retrieved on 2010-01-19.
15. ^ Bladder Stones: Prevention, Retrieved on 2010-01-19.

Extracorporeal shock wave lithotripsy

From Wikipedia, the free encyclopedia

Jump to: navigation, search

This article's citation style may be unclear. The references used may be made clearer with a
different or consistent style of citation, footnoting, or external linking. Citations are not inline
and do not use standard Cite templates. (May 2010)

Extracorporeal shock wave lithotripsy (ESWL) is the non-invasive treatment of kidney stones
(urinary calculosis) and biliary calculi (stones in the gallbladder or in the liver) using an acoustic
pulse. Lithotripsy and the lithotriptor were developed in the early 1980s in Germany by
Dornier Medizintechnik GmbH (now known as Dornier MedTech Systems GmbH)[1], and came
into widespread use with the introduction of the HM-3 lithotriptor in 1983. Within a few years,
ESWL became a standard treatment of calculosis.

It is estimated that more than one million patients are treated annually with ESWL in the USA
alone.[citation needed]
[edit] How it works
The lithotriptor attempts to break up the stone with minimal collateral damage by using an
externally-applied, focused, high-intensity acoustic pulse. The sedated or anesthetized patient
lies down in the apparatus' bed, with the back supported by a water-filled coupling device placed
at the level of kidneys. A fluoroscopic x-ray imaging system or an ultrasound imaging system is
used to locate the stone and aim the treatment. The first generation lithotriptor known as the
HM3, has a half ellipsoid-shaped piece that opens toward the patient. The acoustic pulse is
generated at the ellipsoidal focal point that is furthest from the patient and the stone positioned at
the opposite focal point receives the focused shock wave. The treatment usually starts at the
equipment's lowest power level, with a long gap between pulses, in order to accustom the patient
to the sensation. The length of gap between pulses is also controlled to allow cavitation bubbles
to disperse minimizing tissue damage. Second and later generation machines use an acoustic lens
to focus the shock wave. This functions much like an optical lens, focusing the shock wave at the
desired loci. The frequency of pulses are currently left at a slow rate for more effective
comminution of the stone and to minimize morbidity while the power levels are then gradually
increased, so as to break up the stone. The final power level usually depends on the patient's pain
threshold and the obsevered success of stone breakage. If the stone is positioned near a bone
(usually a rib in the case of kidney stones), this treatment may be more uncomfortable because
the shock waves can cause a mild resonance in the bone which can be felt by the patient. The
sensation of the treatment is likened to an elastic band twanging off the skin. Alternately the
patient may be sedated during the procedure. This allows the power levels to be brought up more
quickly and a much higher pulse frequency, often up to 120 shocks per minute.

The successive shock wave pressure pulses result in direct shearing forces, as well as cavitation
bubbles surrounding the stone, which fragment the stones into smaller pieces that then can easily
pass through the ureters or the cystic duct. The process takes about an hour. A ureteral stent (a
kind of expandable hollow tube) may be used at the discretion of the urologist. The stent allows
for easier passage of the stone by relieving obstruction and through passive dilatation of the
ureter.
Some of the passed fragments of a 1-cm calcium oxalate stone that was smashed using lithotripsy.

Extracorporeal lithotripsy works best with stones between 4 mm and 2 cm in diameter that are
still located in the kidney. It can be used to break up stones which are located in a ureter too, but
with less success.

The patients undergoing this procedure can, in some cases, see for themselves the progress of
their treatment. If allowed to view the ultrasound or x-ray monitor, they may be able to see their
stones change from a distinct bright point (or dark spot depending on whether the fluoro unit is
set up in native or bones white) to a fuzzy cloud as the stone is disintegrated into a fine powder.

ESWL is the least invasive of the commonplace modalities for definitive stone treatment, but
provides a lower stone-free rate than other more invasive treatment methods, such as
ureteroscopic manipulation with laser lithotripsy or percutaneous nephrolithotomy (PCNL). The
passage of stone fragments may take a few days or a week and may cause mild pain. Patients
may be instructed to drink as much water as practical during this time. Patients are also advised
to void through a stone screen in order to capture stone fragments for analysis.

ESWL is not without risks. The shock waves themselves, as well as cavitation bubbles formed
by the agitation of the urine medium, can lead to capillary damage, renal parenchymal or
subcapsular hemorrhage. This can lead to long-term consequences such as renal failure and
hypertension. Overall complication rates of ESWL range from 5–20%.