Management of Nephrolithiasis, Essays (university) of Medicine

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NEPHROLITHIASIS

2.1.1 Definition Nephrolithiasis (kidney stones) is a condition where there are one or more stones in the pelvis or calyx of the kidney. Broadly speaking the formation of kidney stones is influenced by intrinsic and extrinsic factors. Intrinsic factors are age, sex, and heredity, while extrinsic factors are geographical conditions, climate, eating habits, substances contained in urine, occupation, and so on. 2.1.2 Epidemiology In Indonesia, the most common kidney disease is kidney failure and nephrolithiasis. The highest prevalence of nephrolithiasis was in the Special Region of Yogyakarta (1.2%), followed by Aceh (0.9%), West Java, Central Java and Central Sulawesi (0.8%) respectively.The prevalence of this disease is estimated at 7% in adult women and 13% in adult men. Four of the five patients were male, while the peak age was in the third to fourth decades. 2.1.3 Etiology Kidney stones (calculus) are stones that can be found anywhere in the urinary tract. The most common stones are composed of calcium crystals. There are several types of kidney stones and they can range in size from small to as large as staghorn stones that can damage the collecting system. Usually kidney stones consist of calcium salts (oxalate and phosphate) or magnesium phosphate and uric acid. The cause of kidney stones is idiopathic. However, there are predisposing factors such as the type of food consumed, Urinary Tract Infection (UTI), volume of water drunk, metabolic disorders, age, gender, genetics, activity, consumption of certain vitamins and drugs, and body weight. Kidney stones are usually composed of calcium oxalate. The formation of kidney stones is closely related to an increase in urine pH (in calcium bicarbonate stones), or conversely a decrease in urine pH (in uric acid stones). Anything that causes obstruction to the flow of urine and causes static urine (no movement in the urine) in any part of the urinary tract, increases the formation of stones because it

pooling of the next heaps so that the kidney stones found vary in each collecting duct. This deposition is thought to arise on the part of the epithelial cells that experience the lesion, and it is possible that this lesion is also caused by the crystals themselves. The presence of lesions in the urinary tract causes irritation of the mucous membranes of the tract and causes bleeding resulting in haematuria (urine along with blood). These lesions may also be caused by friction of the crystals against the mucous membranes of the ureters and/or the urethra. the heap will get bigger due to the pooling of the next heaps so that the kidney stones found vary in each collecting duct. This deposition is thought to arise on the part of the epithelial cells that experience the lesion, and it is possible that this lesion is also caused by the crystals themselves. The presence of lesions in the urinary tract causes irritation of the mucous membranes of the tract and causes bleeding resulting in haematuria (urine along with blood). These lesions may also be caused by friction of the crystals against the mucous membranes of the ureters and/or the urethra. The presence of lesions in the urinary tract causes irritation of the mucous membranes of the tract and causes bleeding resulting in haematuria (urine along with blood). These lesions may also be caused by friction of the crystals against the mucous membranes of the ureters and/or the urethra. The presence of lesions in the urinary tract causes irritation of the mucous membranes of the tract and causes bleeding resulting in haematuria (urine along with blood). These lesions may also be caused by friction of the crystals against the mucous membranes of the ureters and/or the urethra. Kidney stones are the most common cause of abnormalities, both in the kidneys and urinary tract. However, the cause of kidney stones is still idiopathic. Kidney stones are more common in men than women which may be affected by the size of the male urethra being longer than women. The several risk factors that are the main predisposing factors for kidney stones, are as follows.

1. Hypercalciuria: Increased levels of calcium in the urine. This can be caused by several factors, such as increased absorption of calcium from the intestinal lumen, or the breakdown of calcium from the bones, as well as abnormalities in calcium reabsorption in the kidney tubules.
2. Hypocitraturia: Decreased levels of citrate which acts as an inhibitor of calcium formation in the urine. Increased citrate reabsorption due to increased proximal acid

causes reduced citrate in the urine so that the calcium aggregation process runs easily. Calcium inhibitors besides citrate are also found in glycoproteins secreted by distal tubular epithelial cells such as nephrocalcin which can absorb crystal surfaces and trigger interactions between crystals.

3. Hyperuricosuria: Increased uric acid in the urine.
4. Hyperoxaluria: An increase in the level of oxalate that is excreted in the urine. A small increase in oxalate levels can have a greater effect on the formation of calcium oxalate crystals than an increase in calcium excretion. Decreased fluid intake. It is known that a large intake of water can inhibit the formation of larger crystals, so that small crystals can decay from the tubule walls and be carried by large amounts of urine to be eliminated. 2.1.5 Clinical Overview Kidney stones, especially very small ones, will not be detected or cause no significant symptoms. Signs of a new kidney stone can be felt when the stone is large and stuck in the kidney, moves into the ureter, or when an infection occurs. This condition causes severe pain which is called renal colic. Symptoms of kidney stones that often occur include:  Pain in the backthe lower part and sometimes felt up to the groin. Whereas in men, pain is also felt in the testicles and scrotum. The pain can last for a few minutes or a few hours.. When kidney stones move to other locations in the urinary tract, pain can increase.  Increased frequency of needing to urinate  Pain when urinating (dysuria)  Urinate in small amounts  Urine that is pink, red, or brown  Nausea and vomiting.  Feeling uneasy.  Fever or chills, if an infection occurs 2.1.6 Examination and Diagnosis

dyspareunia

• You can feel the mass on touch
• Ultrasound results showed a lesion in the adnexa Obstructive ileus - Abdominal distension, vomiting and constipation
• X-ray examination may show signs of obstructive ileus Acute pancreatitis - History of gallstones and or excessive use of alcoholic beverages
• Epigastric pain that radiates to the back
• CT scan shows inflammation in the pancreas
• Amylase and lipase increase Peptic ulcer - Pain related to food
• Endoscopy may reveal gastric ulcers and visualize bowel
• Photo of the chest chest can show the presence of free air under the diaphragm if a rupture has occurred Gastroenteritis - Abdominal pain without back pain
• Nausea, vomiting, diarrhea
• A complete stool examination may be found to be abnormal Abdominal aortic aneurysm
• Sudden pain that spreads to the back and can cause fainting
• Ultrasound shows dilated abdominal aorta pyelonephritis - Pain at the costovertebral angle
• There are symptoms of a urinary tract infection
• Back pain that spreads to the back

• Fever
• Positive urinal towards UTI
• It can also be caused by kidney stones Myalgia on the back - Pain may change on palpation 2.1.8 Management Treatment of kidney stones depends on the size and type of kidney stones the patient is experiencing. For small kidney stones with a diameter of less than 4 mm, treatment can be done at home so that the kidney stones can pass through the urine. Treatment for small kidney stones can include:  Drink 6-8 glasses of water every day.  Taking pain relievers, because passing kidney stones through the urine can cause pain or discomfort. Pain relievers that can be consumed are:paracetamol. Meanwhile, for kidney stones that are large or exceed 6 mm, which are difficult to pass or cause bleeding, kidney damage, and urinary tract infections, the doctor will suggest the following treatment methods:  Extracorporeal shock wave lithotripsy (ESWL). Urology doctorwill direct the toolESWLwhich emits high-frequency sound waves to the location of the kidney stone to break the stone into smaller pieces that are easily excreted in the urine.  Ureteroscopy. This procedure is performed to remove small stones that are in the ureters or kidneys with a ureteroscope. A tool in the form of a hose equipped with a camera is inserted into the ureter where the stone is located, to break it into smaller pieces so that it can be easily excreted through urine.  Percutaneous nephrolithotomy****. This procedure using a nephroscope is performed for larger stones with a diameter of about 2-3 cm, and cannot be resolved by the ESWL method. In addition, this procedure is also performed if there is an obstruction or infection that damages the kidneys, or the pain is severe and does not can be treated with medication. The nephroscope will be inserted into the kidney through the outer skin. After that, the kidney stones can be pulled out or broken into small pieces with laser energy.

5. Swelling of tissue cells. The tissue products that cause these reactions are histamine, bradykinin, serotonin, prostaglandins, various reaction products of the complement system, reaction products of the blood clotting system and various substances called lymphokines released by sensitized T cells. The macroscopic signs of inflammation are swelling ( tumor ), reddish (rubor), painful (dolor), warm (calor), and reduced mobility (function laesa).