Medical symptoms checker- Back pain cause - Stones in kidney

Arrow points to the stone
Arrow points to the stone

Stones in the kidney / renal stone or known as nephrolithiasis is a deposition of crystal within the urinary tract or kidney .Most cases remain unknown. However other causes includes metabolic causes such as hyperoxaluria, hyperuricaemia, hypercalciuria and hypercystinuria. Infection which leads to hyperuricaemia may also contributes to urinary tract calculi/ stones on the kidney. Hypercystinuria or hyperoxaluria which are associated with anatomical factor and drug such as indinavir may contributes to formation stones on the kidney.

Renal stone also associated with anatomical defect of the urinary tract such as medullary sponge kidney or horseshoe kidney and low fluid intake.

It is common affecting 2-3 % of the individual per year.It is more common in men than women ( 3:1). The lifetime risk is about 5-10% in female and 10-15% in male.Individual around the age 20-50 years are the most commonly affected with kidney stone/ renal stone.Stones in the bladder is most commonly present in patient in developing countries while deposition of stones in the urinary tract is common in industrialized countries.

Initially patient is symptomless, then when the pain is severe it will radiates from the loin to the groin ( flank region ) known as flank pain. The pain is accompanied with nausea and smoking Patient may also complains of urinary frequency, urgency , urinary retention and hematuria.

On examination, tenderness may be felt on the lower abdomen and loin region without signs of peritonism. In elderly men , leakage from abdominal aortic aneurysm need to be consider as one of the diagnosis. We need to worry about sepsis if signs of obstruction above the stone of and infection develop.

Stones/ calculi are forms by stone forming compound which cause supersaturation of the urine and allow crystallization at the point of infection, foreign bodies and tumor.

Calcium oxalate or 'mulberry' stones is the commonest type. It has sharp projection that will traumatized the surrounding region. The common type of stone is struvite which consists of ammonium, magnesium and phosphate. It is associated with urea splitting organism such as klebsiella, proteus and pseudomonas. It is dirty white in colour, smooth and able to form staghorn stones on the kidney .

The other stones include calcium phosphate and rare form of stones that are urate and cystine.Both are uncommon 5% and 2% . Urate mostly presently in acidic urine and it is brown faceted, hard and smooth.Cystine also present in the acidic urine. It is translucent and white.

The investigations require include blood test, urine test, KUB radiology, IVU, ultrasound, non- enhanced spiral CT scan and isotopes renography.

Blood test includes full blood count , urea and electrolytes, Ca2+, urate and PO4 3-. Full blood count - Raised in white cell count indicates infection. Urea and electrolytes to assess the function of the renal system. If Ca2+ , urate and PO4 3- , raised, further investigation is required.

Urine test includes dipstick, culture and sensitivity and 24 hr urine collection . Urine dipstick to detect the present of blood in the urine ( hematuria) . Culture and sensitivity for infection and 24 hr urine collection for measuring the level of calculi forming ion.

KUB radiology or kidney, urinary, bladder scan is able to detect stone. 80% of the stones are radio- opaque in color which can be visualizes on the plain radiograph of the pelvis or lower abdomen.

IVU ( intravenous urogram ) is used to visualize the ureter and kidney. If ureteric stone is detected, there will be a delay in a nephrogram phase and a standing column of contrast fluid is visualized above the sites of the stones with dilated pelvicaliceal system.

Ultrasound is useful to detect obstructive uropathy which present as hydronephrosis or dilated uretral. It is useful for patient whom IVU contrast is contraindicated. However , ultrasound unable to detect stone which is small in size.

Non- enhanced spiral CT - scan is rarely use to detect stones due to its high radiation level. In complex stone disease, isotopes renography is used to assess the function of the kidney. The isotopes are DMSA or DPTA.

Management includes, acute presentation, removal of stones, treatment of causes and advice.

In emergency case or acute presentation, patient requires bed rest, analgesic and fluid replacement via intravenous or oral. Urine is collected to retrieve stones that are passed with urine for further analysis. This treatment is suitable for stone that is less than 5 mm and not causing any obstruction.In cases where the stone is obstructing the kidney and it is infected, the emergency steps include placement of percutaneous nephrostomy unde radiological guidance , follow with antibiotics and supportive therapy.

Removal of the stone is required if the stone /calculi is obstructing the kidney and the patient suffers from pain and pyrexia. There are 4 methods to remove the stones that include urethroscopy, extracorporeal shock - wave and percutaneous nephrolitomy.

Stone is removed with urethroscope which is either flexible or rigid. The urethroscope is passed from the bladder and up to the ureter and any stone present is visualized. The stones present are broken down or removed with basket, grasper, laser ultrasound and other measures. A JJ stent is inserted in case if the stone is impacted on the wall of the urinary tract and difficult to remove. JJ stent will ensure urinary drainage.

A non invasive method to remove stone include extra corporal shock wave lithotripsy. It is suitable for stone that is less than 2cm which not causing any obstruction on urinary drainage. It involves the electromagnetic wave or pizoelectric shock waves that are directed to the stones and latter shatter it into small particles that will pass through the urine spontaneously.

Percutaneous nephrolithotomy is performed for stones that are large and complex such as staghorn stone from struvite stone in the kidney. It involves the creation of the nephrostomy tract follow by nephroscope which disintegrate and remove the stones. Later nephrostomy tube is inserted post -op for 1- 2 days. Nephrostogram test is performed to ensure clear urinary drainage and no stone presents. Besides that , open nephrolithotomy, pyelonephrolithotomy and uretrolithotomy are also performed for for complex and large stones. In a non functioning kidney, removal of the kidney or nephrectomy is performed.

Another form of management is the treatment of the causes. It involves restriction of calcium and oxalate diet, perform parathyroidectomy and takes allopurinol.Oral potassium citrate is useful in dissolving urate and cystine stones. ( To alkalinizes the acidic urine ).The patient is advice to increase fluid intake.

Complication of renal stones include complication from the stones such as septicemia, pyelonephritis ( urinary infection ) and urinary retention. Complication from ureteroscopy such as false passage and trauma as well as perforation. The complication from lithotripsy ( steinstrassess- that is obstruction of the ureter by fragment from the stone. ) Pain and hematuria.

The prognosis is good with 5 years recurrence rates

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