Medical and Medical/Urologic Approaches in Acute and Chronic Urologic Stone Disease
ABSTRACT Urinary stone disease is a condition with far-reaching implications. Patients with their initial instance of acute renal colic enter the health care system through 2 routes. Severe cases are generally seen in the emergency room, whereas more tolerable cases may be seen by primary care physicians. Patients with urinary stone disease are then managed in the long-term by a urologist. Timely and appropriate treatment of patients with urinary stone disease is essential to prevent the development of sepsis and progressive renal insufficiency. This article reviews the epidemiology, pathogenesis, presentation, and short- and long-term management of acute and chronic urinary stone disease.
SourceAvailable from: Gonzalo Garcia Casasola[Show abstract] [Hide abstract]
ABSTRACT: PURPOSES: Emergency physician-performed ultrasonography holds promise as a rapid and accurate method to diagnose multiple diseases in the emergency department (ED). Our objective was to assess the initial diagnostic accuracy (first 55 explorations) of emergency physician-performed ultrasonography for multiple categories of ultrasound use after a short training period. BASIC PROCEDURES: This was a prospective observational study conducted at an urban ED from June 2010 to March 2011 in patients with suspected cholecystitis, hydronephrosis, deep vein thrombosis, and different cardiovascular problems. Five physicians had a 10-hour training session before enrolling patients. The test characteristics of bedside ultrasonography were determined with the final radiologist/cardiologist interpretation. MAIN FINDINGS: A total of 275 ultrasonographic examinations were performed (78 abdominal explorations, 80 renal explorations, 76 2-point compression ultrasonographic examinations in patients with suspected deep vein thrombosis, and 41 echocardiograms in patients with different acute cardiovascular problems). Radiologists/cardiologists detected 28 cases of cholecystitis, 26 cases of deep vein thrombosis, 49 cases of hydronephrosis, and 15 cases of significant cardiovascular alterations. The overall diagnostic accuracy of ED ultrasonograms yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 92.6% (95% confidence interval [CI], 90%-99%), 89% (95% CI, 84%-94%), 86.2 % (95% CI, 82%-93%), and 94.2% (95% CI, 92%-99%), respectively. Nineteen (6.9%) false-positive results and 6 false-negative results (2.1%) were obtained. PRINCIPAL CONCLUSIONS: Emergency physicians in our institution attained reasonably high initial accuracy in the performance of ultrasonography for a variety of clinical problems after a 10-hour training period.The American journal of emergency medicine 07/2012; 30(9). DOI:10.1016/j.ajem.2012.04.015 · 1.15 Impact Factor
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ABSTRACT: Renal scintigraphy is a powerful imaging method that provides both functional and anatomic information, which is particularly useful in the acute care setting. In our institution, for the past 2 decades, we have used a 25-minute renal diuretic protocol, technetium-99m ((99m)Tc) mercaptoacetyltriglycine with simultaneous intravenous injection of furosemide, for all ages and indications, including both native and transplant kidneys. As such, this protocol has been widely used in the workup of acutely ill patients. In this setting, there are common clinical entities which affect patients with native and transplant kidneys. In adult patients with native kidneys one of the most frequent reasons for emergency room visits is renal colic due to urolithiasis. Although unenhanced computed tomography is useful to assess the anatomy in cases of renal colic, it does not provide functional information. Time zero furosemide renal scintigraphy can do both and we have shown that it can effectively stratify patients with renal colic. To this end, 4 characteristic patterns of scintirenography have been identified, standardized, and consistently applied: no obstruction, partial obstruction (mild vs high grade), complete obstruction, and stunned (postdecompressed) kidney. With the extensive use of this protocol over the past 2 decades, a pattern of "regional parenchymal dysfunction" indicative of acute pyelonephritis has also been delineated. This information has proved to be useful for patients presenting with urinary tract infection and suspected pyelonephritis, as well as for patients who were referred for workup of renal colic but were found to have acute pyelonephritis instead. In instances of abdominal trauma, renal scintigraphy is uniquely suited to identify urine leaks. This is also true in cases of suspected leak following renal transplant or from other iatrogenic/postsurgical causes. Patients presenting with acute renal failure can be evaluated with renal scintigraphy. A scintigraphic pattern of "relative preservation of flow as compared to function" has been identified as indicative of acute tubular necrosis, which is distinct from other potential causes of acute renal failure, such as nephrotoxicity and in the case of renal transplants, rejection.Seminars in nuclear medicine 03/2013; 43(2):114-28. DOI:10.1053/j.semnuclmed.2013.01.001 · 3.13 Impact Factor
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ABSTRACT: 1. Is this nephrolithiasis? Severe, acute flank pain points to an obstructive renal or ureteric stone, which can often be suspected based on clinical presentation. The classic presentation of nephrolithiasis includes acute, colicky, ipsi-lateral, costovertebral, or flank pain, which may radiate to the groin. Dysuria and uri-nary urgency and frequency are common, as are nausea and vomiting; however, patients may appear relatively asympto-matic depending on the size and location of the stone. The risk of kidney stones is increased by male gender, caucasian ances-try, a previous history of kidney stones, a positive family history, a high fat, protein, or salt diet, obesity, and dehydration. 2. Could it be something else? While Jeri presented with a fairly typical picture of nephrolithiasis, it is important to rule out several other conditions that account for up to 20% of renal colic-like presentations. 1 Jeri is a healthy 59-year-old female who presents to the ED with a one-hour-history of right flank pain that has begun to radiate to her groin. She describes the pain as a steady burning feeling with episodes of more intense, radiating pain. She finds it hard to get in a comfortable position due to the pain. She also feels like she needs to constantly void, though she is not passing much urine. She has nausea but no fever/chills or diarrhea. She has never had an episode of pain like this before. Her brother has a history of kidney stones. Upon examination, Jeri looks well but is in severe discomfort. She is pale and sweaty and begins to vomit. Her abdomen is soft and non-tender with quiet bowel sounds, although her right flank and costovertebral angle are quite tender to palpation.