Kidney stones

It is estimated that every year 10,000 people arrive in hospital for kidney stones. Following the introduction of the DRG criteria, namely the classification system of admissions into force in Italy, after the U.S., this type of condition is not considered "proper", ie a condition that does not require hospitalization and even would be inappropriate for someone to admit that right! For this reason, unless the medical emergency department has other ideas about the pain that made (aneurysm, heart failure, cancer, pleurisy, appendicitis, salpingitis or other) you will send back home therapy (NSAIDs and antispasmodics) .


We see in particular such substances may be the calculation?

In the U.S., most kidney stones are made from the calcium, so much so that in 90% of cases the calculations are visible direct radiation survey of the kidneys. While the calculations result radiolucent uric acid. There are also calculations mold, consisting of triple phosphate and magnesium that are the result of urinary tract infections, by microorganisms that metabolize urea. Two-thirds of kidney stones, however, consist of calcium oxalate, 15-20% of magnesium ammonium phosphate, about 10% of uric acid and cystine and the rest by some rare compounds (xanthine, silicates and protein material).

. Causes of stones.

Fortunately, the calculations are not formed in all subjects but only in patients who have:

Excessive excretion of crystalline substances

Alteration of urine pH with urinary stasis and other factors that allow the formation of stones.


In the first patients are a good 50-70% of patients is the excessive excretion of calcium at the base of nephrolithiasis. But there are conditions such as:

Hyperparathyroidism with hypercalciuria of

renal tubular acidosis,

hypothyroidism,

sarcoidosis, some

malignancies

Idiopathic hypercalciuria syndrome that frequently are associated with kidney stones.

Among the metabolic diseases we have:

hypercalciuria by intestinal absorption of calcium for postprandial suppression of PTH and renal calcium reabsorption

hypercalciuria renal failure caused by inadequate absorption of calcium and secondary hyperparathyroidism

hypercalciuria with reduced serum phosphate, in which an apparent loss of renal phosphate stimulates the production of 1.25-DHCC, the absorption of calcium and its elimination via the urine. The stone formation also contribute to the increased excretion of oxalate and uric acid and greater production of ammonia in patients with urinary tract infection. The stones may also occur in patients where there is an obstacle to normal urinary crystalloid excretion in urine and changes in pH and stagnation, even the absence of inhibitors of the formation of urinary crystals (pyrophosphate and some glycoproteins).
History.

The patient often presents with colic pieloureterale ureteral obstruction and even urinary infection with fever, chills, sweating, sudden vomiting, tachycardia, and severe pain that some impairment from the balcony and down along the course of the ureter to radiate to the testicle or vagina in women (see picture). We must determine whether the calculator is recurrent, in 50-60% of these episodes are part of a chronic disease process that requires more extensive investigations.

Urinary tract infections and episodes of flank pain with hematuria, and feeling remove stones from the urinary tract are signs of a previous kidney stones, even if the patient does not report a clear history of nephrolithiasis. Given the hereditary nature of certain diseases that cause kidney stone formation (Hyperuricemia and cystinuria and hyperoxaluria, family history can be important. Also look for the conditions of hyperparathyroidism and hyperthyroidism and sarcoidosis and malignancies, it is very important for diagnosis. Inspection and acupressure spaces costovertebrali helps to understand if there is ureteral obstruction.


Investigations following physical examination include a urine test to search for chemical and physical sediment, the urine culture to exclude infections, direct radiography of the abdomen, not women who think they're pregnant! The simplest ultrasonography of the urinary tract, including the study of bladder and prostate in humans may already be sufficient to classify the patient and provide information about the presence of hydronephrosis and / or ureteroidronefrosi the condition that where there is a block the ureter with urine suffering upstream and, therefore, acute urinary retention. Also from the collection of blood can draw other useful information: uric acid, blood urea nitrogen and creatinine with creatinine clearance we can provide ideas about renal excretory function and the blood count can give us more valuable information about an infected status and neutrophilic leukocytosis we can oriented forms infectious bacterial and cos' well give us any idea of anemia secondary to renal failure (very frequent in the elderly).

The urinary tract infection have already been treated and we refer to these links:

Infections of the urine, Part I

Urine infections, Part II

Infections of the urine: the defense in the nature of the blueberry!

Therapy.

On the treatment of ureteral pieloureterale has said a lot but has not arrived at a unanimous choice of treatment. Some authors, for example, the university Catanese, is inclined to use the fans, to the good because im diclofenac that seems the most effective way to combat the pain of colic, followed by the antispasmodics (N-butylbromide and 1,3,5 hyoscin trihydroxybenzene trihydrate, ie Buscopan, spasmex etc..): Not everyone agrees on the need to moisturize the patient in the early stages of colic, especially if there is hydronephrosis, because you run the risk of worsening the picture. It 'can also use drugs called "urinary disinfectants and of real and specific antibiotics. Who writes long bangs with the case of an elderly, diabetic and bedridden, bearer of indwelling urinary catheter for neurogenic bladder and suffered recurrent infections of the worst kind of Pseudomonas aeruginosa to antibiotics pluriresistenti! The same patient has met with ureteral stenosis and had to undergo surgery for ureteral stenting replacing every 8 months or so! Even the use of uricosuric is always indicated nell'iperuricemia and gout (see diet for gout). Finally, remember that the treatment with mineral waters are always great indications in the treatment of kidney stones (see source of Venus).
 

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