Nephrolithiasis Kidney stone, also known as renal calculi, a solid concretion or crystal aggregation formed in the kidneys from

dietary minerals in the urine. Kidney stones have many causes and can affect any part of your urinary tract from your kidneys to your bladder. Often, stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together.

Signs and Symptoms Severe pain in the side and back, below the ribs Pain that spreads to the lower abdomen and groin Pain that comes in waves and fluctuates in intensity Pain on urination Cloudy or foul-smelling urine Nausea and vomiting Urinary retention Fever and chills if an infection is present Renal colic Urinary urgency Restlessness Hematuria Diaphoresis

Types of calculi Calcium, most common substance and if found in up to 90% of stones. It usually composed of calcium phosphate or calcium oxalate. Some studies suggest people who take supplemental calcium have a higher risk of developing kidney stones, and these findings have been used as the basis for setting the recommended daily intake for calcium in adults. Struvite stones, form in response to an infection, such as a urinary tract infection. These stones can grow quickly and become quite large, sometimes with few symptoms or little warning.

Uric acid stones, can form in people who don't drink enough fluids or who lose too much fluid, those who eat a high-protein diet, and those who have gout. Certain genetic factors also may increase your risk of uric acid stones. Cystine stones. These stones form in people with a hereditary disorder that causes the kidneys to excrete too much of certain amino acids (cystinuria).

Diagnosis Diagnosis of kidney stones is made on the basis of information obtained from the history, physical examination, urinalysis, and radiographic studies. 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. Physical examination may reveal fever and tenderness at the costovertebral angle on the affected side.

Blood tests. Blood tests may reveal too much calcium or uric acid in your blood. Blood test results help monitor the health of your kidneys and may lead your doctor to check for other medical conditions.

Urine tests. Tests of your urine, such as the 24-hour urine collection, may show that you're excreting too many stone-forming minerals or too few stone-preventing substances.

Imaging tests. Imaging tests may show kidney stones in your urinary tract. Options range from simple abdominal X-rays, which can miss small kidney stones, to highspeed computerized tomography (CT) that may reveal even tiny stones. Other imaging options include an ultrasound, a noninvasive test, and intravenous pyelography, which involves injecting dye into your arm vein and taking X-rays as the dye travels through your kidneys and bladder.

Analysis of passed stones. You may be asked to urinate through a strainer to catch stones that you pass. Lab analysis will reveal the makeup of your kidney stones. Your doctor uses this information to determine what's causing your kidney stones and to form a plan to prevent more kidney stones.

Management

Medical Therapy NSAIDS Hoth baths, moist heat Increase fluid intake

Renal colic can cause excruciating pain; thus, pain control is a priority after the definitive diagnosis has been made. Nausea and vomiting often prevent the use of oral medication, so parenteral medication is typically required. Narcotics and parenteral nonsteroidal anti-inflammatory drugs (NSAIDs) have been demonstrated to be equally effective, and NSAIDs are preferred because of fewer side effects. However, the risk associated with parenteral NSAIDs needs to be kept in mind because it may be increased in the setting of dehydration, decreased renal function, or the use of radiocontrast. Alkalinization of urine may be effective for acutely treating ureteral uric acid stones, but these are not nearly as common as calcium-based stones. Intravenous fluids are routinely given in the hope that this will increase the likelihood of stone passage, but the status of hydration has little, if any, impact on stone passage. [5] A urologist should be involved in the following situations: infection, persistent or uncontrollable pain, inability to pass the stone, urinary extravasation detected by imaging, high-grade obstruction with a large stone, a solitary kidney, or pregnancy.

Surgical Therapy Ureteral stent Percutaneous nephrostolithotomy Cystoscopic stone removal Extracorporeal shock wave lithotripsy (ESWL)

The patient does not require admission if able to tolerate oral analgesics, but instructions should be given to return if fever or uncontrollable pain develops. Most urologists usually wait several days before intervening unless there is evidence of urinary tract infection, a low probability of spontaneous stone passage (e.g., stone >6 mm; anatomic abnormality), or intractable pain. Relief of the obstruction is the initial approach because this will relieve the symptoms. A ureteral stent may be placed

cystoscopically but anesthesia is required. Although the stent can be quite uncomfortable and may cause gross hematuria, it may help with stone passage. The approach to stone removal is dictated by stone size, location, and composition; urinary tract anatomy; availability of technology; and the experience of the urologist. The least invasive approach is ESWL, which can be used in the acute setting, but the success rate depends on the size, location, and composition of the stone. The results of studies of the effectiveness of all stone removal approaches must be compared with caution because of lack of agreement on the definition of success of treatment. Cystoscopic stone removal, both by basket extraction and by fragmentation, is more invasive than ESWL but has a higher stone-free success rate and can remove stones even in the kidney. Percutaneous nephrostolithotomy has the highest likelihood of making a patient stone free but is more invasive than cystoscopic methods. These newer endoscopic approaches have virtually eliminated the need for open surgical procedures such as ureterolithotomy and pyelolithotomy.