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INTERACTIVE CASE DISCUSSION: CASE 11

INTERACTIVE CASE DISCUSSION: CASE 11. University of Santo Tomas Faculty of Medicine and Surgery Department of Radiology Clk. Alexander L. Gonzales II. CASE 11. 24/M: Right sided flank pain. Patient with flank pain. History and physical examination. Renal colic suspected.

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INTERACTIVE CASE DISCUSSION: CASE 11

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  1. INTERACTIVE CASE DISCUSSION:CASE 11 University of Santo Tomas Faculty of Medicine and Surgery Department of Radiology Clk. Alexander L. Gonzales II

  2. CASE 11

  3. 24/M: Right sided flank pain Patient with flank pain History and physical examination Renal colic suspected Diagnostic imaging ??? Patient is pregnant, or cholecystitis or gynecologic process is suspected Patient has history of radiopaque calculi All other patients

  4. 24/M: Right sided flank pain

  5. 24/M: Right sided flank pain

  6. 24/M: Right sided flank pain

  7. 24/M: Right sided flank pain Patient with flank pain History and physical examination Renal colic suspected Diagnostic imaging Patient is pregnant, or cholecystitis or gynecologic process is suspected Patient has history of radiopaque calculi All other patients

  8. Hepatic Veins Spleen Celiac axis Liver SMA Left kidney Right kidney Renal artery Renal vein AORTA IVC

  9. Medullary pyramids Kidney Anatomy Minor Calyx Renal artery Major Calyx Renal vein Sinus Ureter Medulla Renal capsule Cortex

  10. Ultrasound Examination Plain-film radiography Intravenous pyelography if CT is not available Noncontrast helical CT Stone detected Stone not detected Stone detected Stone not detected Clinical suspicion of urolithiasis

  11. Right Kidney Long Axis Anterior Superior Inferior Liver Sinus Cortex Diaphragm Posterior

  12. Left Kidney Long Axis Anterior Inferior Superior Rib Shadow Kidney Posterior Spleen

  13. 24/M: Right sided flank pain

  14. 24/M: Right sided flank pain Imaging modality Sensitivity (%) Specificity (%) Ultrasonography 19 97 Advantages Limitations Accessible Poor visualization of Good for diagnosing of ureteral stones Hydronephrosis and renal stones Requires no ionizing radiation

  15. Ultrasound Examination Plain-film radiography Intravenous pyelography if CT is not available Noncontrast helical CT Stone detected Stone not detected Stone detected Stone not detected Clinical suspicion of urolithiasis

  16. 24/M: Right sided flank pain NORMAL STUDY PATIENT

  17. 24/M: Right sided flank pain Imaging modality Sensitivity (%) Specificity (%) Plain radiography 45 to 59 71 to 77 Advantages Limitations Accessible Stones in middle section & inexpensive of ureter, phleboliths, radiolucent calculi, extraurinary calcifications and nongenitourinary conditions

  18. Ultrasound Examination Plain-film radiography Intravenous pyelography if CT is not available Noncontrast helical CT Stone detected Stone not detected Stone detected Stone not detected Clinical suspicion of urolithiasis

  19. 24/M: Right sided flank pain NORMAL STUDY

  20. 24/M: Right sided flank pain PRIOR TO IVP 1 MINUTE

  21. 24/M: Right sided flank pain 5 MINUTES 15 MINUTES

  22. 24/M: Right sided flank pain 40 MINUTES 45 MINUTES

  23. 24/M: Right sided flank pain FULL BLADDER POST VOID

  24. 24/M: Right sided flank pain Imaging modality Sensitivity (%) Specificity (%) Intravenous 64 to 87 92 to 94 pyelography Advantages Limitations Accessible Variable-quality imaging Provides information Requires bowel preparation on anatomy and & use of contrast media functioning of both Poor visualization of non- kidneys genitourinary conditions Delayed images required in high-grade obstruction

  25. Ultrasound Examination Plain-film radiography Intravenous pyelography if CT is not available Noncontrast helical CT Stone detected Stone not detected Stone detected Stone not detected Clinical suspicion of urolithiasis

  26. 24/M: Right sided flank pain AXIAL VIEW CORONAL VIEW

  27. 24/M: Right sided flank pain Imaging modality Sensitivity (%) Specificity (%) Noncontrast helical 95 to 100 94 to 96 computed tomography AdvantagesLimitations Most sensitive & specific Less accessible and radiologic test (i.e., facilitates relatively expensive fast, definitive diagnosis) No direct measure of Indirect signs of the degree of renal function. obstruction Provides information on non- genitourinary conditions

  28. 24/M: Right sided flank pain • IMPRESSION: • Obstructing Ureterolithiasis ®, with resultant hyrdroureter and hydronephrosis

  29. UROLITHIASIS DISCUSSION

  30. EPIDEMIOLOGY • 2-4% of general population • 2-3 x more common in males • Caucasian > Oriental > African American • Hot climates > temperate • Types of Stones: • Calcium Stones • Uric Acid Stones • Struvite Stones • Cystine Stones • Nephrolithiasis- stones in the kidney • Ureterolithiasis – stones in the ureter

  31. Calcium Stones • 75%-85% of all renal calculi • Consists of: • Calcium oxalate • Calcium phosphate • Calcium urate • Common in males, • 3rd decade of life • Recurrence rate 2 to 3 years • Familial • Associated with: • Idiopathic hypercalciuria - 50% • Hyperuricosuria – 20% • primary hyperparathyroidism - 5% • Idiopathic – 20%

  32. Struvite Stones • Magnesium ammonium phosphate • 10%-15% of all renal calculi • Dchronicurinary tract infections with gram-negative urease-producing bacteria • Chronic bladder catherization • Common in women • Organisms: • Proteus • Pseudomonas Klebsiellaspecies. • Visualized on radiograph calcium carbonate or calcium phosphate • Produces staghorn calculi

  33. Uric Acid Stones • 5%-8% of renal calculi • Radiolucent, • common in males • Familial • Occur primarily in patients in whom a persistently acid urine (pH<5.5) promotes uric acid precipitation • Example: gout patients that are uric acid overproducers • Also in states of chronic diarrhea

  34. CystineStones • Rare and account for approximately 1% of all renal calculi • Develop in patients with cystinuria due to the insolubility of cystine in the urine • Slightly radioopaque • Due to a hereditary metabolic defect resulting in proximal tubular and jejunal transport of the dibasic amino acids:

  35. RISK FACTORS • Male Gender • Age (to 65) • Low urine volume • Situational • Geography • Heredity • Diet • Medications

  36. Pathophysiology EXCRETE INSOLUBLE SUBSTANCE CONSERVE WATER

  37. Relationship of Stone Location to Symptoms

  38. Relationship of Stone Location to Symptoms Stone LocationCommon Symptom Kidney Vague Flank Pain, Hematuria

  39. Relationship of Stone Location to Symptoms Stone LocationCommon Symptom Proximal Ureter Renal colic, flank pain, upper abdominal pain

  40. Relationship of Stone Location to Symptoms Stone LocationCommon Symptom Middle section of Renal colic, anterior ureter abdominal pain, flank pain

  41. Relationship of Stone Location to Symptoms Stone LocationCommon Symptom Distal ureter Renal colic, dysuria, urinary frequency, anterior abdominal pain, flank pain

  42. PROBABILITY OF STONE PASSAGE

  43. Confirmed stone YES Urgent urologic consultation Emergency: UROSEPSIS, Anuria, Renal Failure NO YES Consider hospital admission: Urologic consultation Refractory pain, Refractory nausea, Extremes of age, Debillated condition NO Symptoms amenable to medical management Referral to urologic clinic Ureteral stone < 5 mm Renal stone or ureteral stone > 5 mm Trial of conservative management Weekly KUB radiographs Stone passes Stone fails to pass within 2-4 weeks TREATMENT

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