Medical information portal "Vivmed". Methods for removing stones from kidney stones. Causes and prevention of kidney stones
Definition
Kidney stone disease (nephrolithiasis) is a common disease that tends to be endemic. At kidney stone disease Stones form in the kidney calyces and pelvis. They can also be in the downstream urinary tract.
Causes
The development of this process is facilitated by both local factors (impaired formation of colloids by renal cells, the phenomenon of secretory neurosis of the kidney, the presence additional vessels and anomalies that cause urination disorders, urinary tract infections, changes in urine pH), and general (dietary regimen, use of certain medications, composition drinking water, development of nephrolithiasis in osteopathy, long-term immobilization in case of bone injuries, etc.).
Factors contributing to the development of kidney stones are congenital and acquired changes in the urinary tract, which disrupt normal urination and cause urinary stasis; various neurogenic dyskinesias and infections urinary tract; metabolic disorders (urate, purine, oxalate and phosphorus-calcium diathesis). Undoubtedly, heredity plays some role. Almost every tenth patient had kidney stones in their parents. Nephrolithiasis is found together with other metabolic diseases ( diabetes mellitus, cholelithiasis, gout, obesity) in certain families. Great importance is attached to the nature of nutrition ( excess nutrition with eating foods containing a lot of calcium and little retinol), using too mineralized drinking water when it enters the body a large number of mineral salts. Climatic conditions are also of great importance. In areas with a hot, dry climate, increased fluid loss occurs, which causes a significant concentration of urine. The development of nephrolithiasis is facilitated by prolonged immobility, especially associated with bone fractures, tuberculosis of the bones and spine, which leads to an increase in calcium in the blood, and hypervitaminosis A contributes to the deposition of salts in the kidneys.
The endocrine system (pituitary gland, thyroid and especially the thyroid glands). With hyperfunction of the parathyroid glands, hypercalcemia, hypercapciuria, and hyperphosphaturia are observed, which can contribute to the formation of kidney stones. An increased concentration of calcium salts in the urine can contribute to the formation of oxalate and phosphate stones. This is also facilitated by a decrease in the content of protective hydrophilic colloids in the urine, as well as an increase in the content of mucopolysaccharides and mucoproteins. For the formation of urate stones great importance has increased concentration in urine uric acid and increased urine acidity. When there is an insufficient amount of protective colloids, several molecules group together and form mycelia, which become the basis for further stone formation. The formation of stones depends on the concentration of salts in the urine, the concentration of hydrogen ions and the composition of urinary colloids. The chemical composition of stones is different, it can be homogeneous or mixed. There are oxalate, urate, phosphate, carbonate, cystine, xanthine, cholesterol and mixed stones. When urine is acidic, urate stones are formed, and when urine is alkaline, phosphate stones are formed. Oxalate compounds can be formed under both alkaline and acid reactions. The presence of stones can cause secondary changes in the kidneys such as pyelonephritis, pyonephrosis, etc. The development of complications depends on the location of the stone, its size, mobility, and the length of time the stone remains in the kidney.
Symptoms
A characteristic manifestation of renal stone disease is an attack of renal colic, which is manifested by pain, hematuria, pyuria and spontaneous passage of stones during an attack. Pain in the form acute attacks causes migration of stones, disruption normal outflow urine and spastic contraction of the ureteral muscles. In the presence of large stones (staghorn), a constant dull pain occurs. Increased intrapelvic pressure and stretching of the kidney capsule, which is rich in nerve endings, also contribute to the appearance of pain. Renal colic is accompanied by fairly typical pain in the lower back, radiating along the ureters and into the genitals. The pain is accompanied by frequent painful urination, flatulence, vomiting, and agitation of the patient. An attack can occur without any noticeable cause, but is often preceded by shaking, driving, or physical overload. Sometimes reflex anuria occurs. The pain is often one-sided, but can radiate to the opposite side, there it can sometimes be more pronounced. Fever of the wrong type is quite often present, which is explained by the pyelovenous reflex. Sometimes the pain radiates extremely widely, covering the entire abdomen. The location of pain, its radiation and duration may be atypical. Typically, an attack of renal colic lasts no more than 1 day. It can be short-lived, and sometimes, on the contrary, long-term. After an attack, there may be no manifestations of the disease, but sometimes there may be a dull pain in the lower back, slight microhematuria. At objective examination During an attack, the patient experiences significant pain in the lumbar region, sharp pain on palpation of the kidney area and along the ureter, Pasternatsky’s symptom is positive.
An important symptom of the disease is the appearance in the urine, after an attack of the disease, of unchanged red blood cells, and sometimes macrohematuria. Hematuria is observed in almost all patients with nephrolithiasis (92%) at the end of the attack or immediately after its end. It is caused by damage to the mucous membrane of the urinary tract and small capillaries submucosa. Slight proteinuria and leukocyturia are detected in the urine. Pyuria is caused by an inflammatory process in the kidneys and urinary tract. IN peripheral blood During attacks, slight leukocytosis appears with a shift to the left leukocyte formula and a moderate increase in ESR. The intervals between attacks can vary; sometimes the period without attacks lasts for many years.
An asymptomatic course of the disease is observed in approximately every tenth patient, and then diagnosis is based on additional research methods, such as urography or ultrasound, or attention is paid to this when detecting hematuria. There is no parallelism between the size of the stones and clinical course diseases, but more often painful attacks occur in the presence of numerous small stones, and large stones are more common with pyelonephritis. The course of kidney stone disease is generally favorable. Sometimes, after a single attack of the disease, no relapses are observed.
Most a common complication The disease may be associated with an inflammatory process in the kidneys and urinary tract - chronic pyelonephritis with a corresponding clinical picture (fever, lower back pain, changes in urine, increased AT). Even more unfavorable is the addition of apostematous nephritis, and in the case of blockage of the ureter - the development of hydronephrosis and pyonephrosis.
With renal colic, acute oliguria and anuria can develop. Excretory anuria can occur with bilateral nephrolithiasis and bilateral occlusion. Bilateral stone formation can lead to the development of renal failure.
Classification
There are several types of stones located in different areas of the urinary system:
- Cystine stones: which are rare, are located mainly in the kidneys.
- Calcium oxalate stones: form and develop as a result of living in a certain area; it most often forms in people living in humid, hot climates. They develop in the urinary tract and kidneys.
- Uric acid stones: develop in the urethra and bladder as a result poor nutrition(diet).
Diagnostics
Diagnosis of kidney stones, in typical cases in the presence of attacks of renal colic, especially during discharge kidney stones, uncomplicated. They help a lot correct diagnosis such additional methods studies such as urography and ultrasound. Sometimes, in the case of an atypical course of an attack of colic, it is necessary to carry out a differential diagnosis with acute cholecystitis and acute appendicitis. It should be noted that with damage to the biliary tract there is a tendency for pain to irradiate upward - into the shoulder blade, neck, and with renal colic downward - into the genitals, more typical with dysuric phenomena. With appendicitis and cholecystitis, in contrast to renal colic, irritation of the peritoneum is observed. More complex is differential diagnosis with renal infarction.
In addition to survey urography, excretory urography and ultrasound examination, if it is not possible to diagnose the disease, retrograde pyslography, isotope renography, ultrasound scanning and computed tomography of the kidneys are used.
Prevention
Treatment of kidney stones includes treatment of an attack of renal colic and treatment in the period between attacks. Treatment during the acute period does not depend on the composition of the stones, but in the period between attacks it should be differentiated depending on the composition of the stones. The first priority during an attack of renal colic is pain relief.
If stone passage is impossible, surgical treatment is used. The latter is also shown when frequent attacks renal colic that does not respond to conservative treatment; kidney blockade caused by a stone; ureteral stones that do not migrate; stones in a single kidney.
During the interictal period, proper nutrition is important. With uric acid diathesis, you need to limit the consumption of foods rich in purine compounds (fried meat, broths). Patients are prescribed a dairy-vegetable diet. For oxaluria, products are recommended that remove oxalate salts and help increase alkalinity. For phosphaturia, it is recommended to consume meat products that increase the acidity of urine. If you have urate stones, limit the consumption of foods containing purines. The formation of stones is promoted by a disorder of calcium metabolism caused by adenoma of the parathyroid glands. In this case, surgical treatment of the adenoma is indicated.
All patients should drink more fluids (800-2000 ml per day).
To prevent stone formation, a number of herbal preparations, which contain soluble silicic acid compounds (field pine, common knotweed). Cystenal is widely used - complex drug, consisting of tincture of moraine rhizome, magnesium salicylate, essential oils, ethyl alcohol and olive oil. To eliminate an attack of renal colic, up to 20 drops of this drug with sugar are prescribed in the period between attacks.
Kidney stones are often complicated by a urinary tract infection. In this case, appropriate antiseptic therapy is used, as for pyelonephritis. Treatment at resorts is indicated for patients who have undergone surgery to remove stones, as well as for patients with small stones, when there is hope for the stones to pass on their own. Treatment in Truskavets with its low-mineralized water Naftusya, as well as in the resorts of Transcarpathia gives the best results.
Hello! There is no need to remove a kidney because of a 4 cm stone if it is functioning normally. But you need to get rid of the stone, because over time it will begin to impair the functions of the kidney. I do not recommend doing angiography. It would be much better to do a CT scan with contrast. This method is safer and more informative.
The diagnosis of kidney stones is established after complaints of attacks of constant dull pain in the lumbar region. But the main indicator for the doctor is the results of pyelography, ultrasound, radiography, and urine analysis, which reveals the presence of red blood cells in it.
This is due to the fact that kidney stones have a number of symptoms similar to those of other diseases that must be excluded. So it must be promptly distinguished from pyelonephritis, glomerulonephritis, polycystic disease and even osteochondrosis in lumbar region spine.
Dull pain in the kidney area may continue between attacks, intensify after hypothermia or physical work. The clinical manifestation of the disease is multivariate: it can be completely hidden, or it can be accompanied by unbearable colic.
Kidney stone disease is when stones are deposited in and in those parts of the urinary tract that are located at the top. Stones that are commonly found are urate, phosphate and oxalate. There are also combined deposits.
Urates are formed when there is an excess of purine compounds in food. An acidic environment is favorable for them.
To form phosphates you only need alkaline environment when the diet is rich in vegetables and fruits.
If abused sulfa drugs, especially if the urine reaction is acidic, stones with the same name appear.
Experience traditional medicine allows you to treat kidney stones without resorting to chemical medications and surgery. Here are the most common and effective remedies.
1. Melon seeds. One hundred grams of raw material should be poured into a liter of water and not boiled, but simply left overnight and a glass of liquid drunk throughout the day, dividing it into three doses before meals.
2. Pour 200 g of finely chopped onion with white wine (0.5 l), leave in the room for two weeks. Filter the liquid and drink a tablespoon after meals for three weeks. After a week or two break, repeat the course up to four times.
3. Take a glass three times a day Fresh Juice, squeezed from an onion. This recipe is contraindicated for those who suffer from gastritis with increased secretion or a stomach ulcer in the acute stage.
4. Since milk, which has an alkaline effect, is undesirable to consume, it is useful to take two glasses of whey per day.
5. Try not to miss the watermelon season in the summer, eat more of them.
6. Take one gram of carrot seed powder before meals.
7. During this time, take a glass of garlic tincture a day. It is prepared from a handful of chopped garlic, doused with vodka. It must be infused for 9 days in direct sunlight. Remember to shake the liquid before drinking it.
Treatment cannot be successful without following a diet. It is necessary to limit spices, salt, and spicy foods. Food should be fortified and varied.
If urates predominate in the urine sediment, foods containing purine compounds should be excluded from the diet: meat broths, kidneys, brains, liver. The diet should predominate fresh fruits and vegetables.
Phosphorus-calcium stones dissolve when the body’s environment is acidified with fish, meat, flour products, eggs, cottage cheese and vegetable oil. On the contrary, the consumption of fruits, vegetables and milk should be limited.
If available, unacceptable following products: sorrel, coffee, rhubarb, tea, spinach. It is worth eating less potatoes and tomatoes. Natural citric acid helps dissolve this type of stone.
Kidney stone disease will be defeated in six months to a year, provided integrated approach to treatment, including the use of medicinal herbs and diet.
The reasons for the development of kidney stones have not yet been fully elucidated, but doctors identify a number of factors that can provoke its onset and progression. These include:
- violations metabolic processes in organism;
- the predominance of any one product (milk, meat) in the diet;
- kidney diseases that lead to dysfunction of the organ;
- gout;
- increased calcium levels in the blood;
- genetic predisposition;
- long-term treatment with certain medications (sulfonamides).
Depending on the chemical composition of stones, they are distinguished: urates, oxalates, phosphates. consist of uric acid salts and are formed in patients suffering from gout or in people whose diet is dominated by meat dishes and legumes. Sometimes patients have stones with a mixed chemical composition; their formation requires certain conditions, for example, a violation of the outflow of urine or a urinary tract infection.
One of the predisposing factors for the formation of kidney stones is long-term use of medications, in particular drugs from the sulfonamide group.
According to statistics, in countries with hot climates the number of cases of kidney stones is much higher than in regions where it is more humid and cool. This is due increased sweating human, as a result of which the amount of urine decreases and the content of mineral salts in it increases significantly. Factors in the development of this pathology also include drinking chlorinated tap water or overusing water with a high content of minerals.
Most often, stones form in the kidneys, although they are often found in the ureters or bladder. Depending on the location of the stones, patients will experience slightly different symptoms. Their size can vary from a millimeter to several centimeters, they are located singly or merge with each other, forming coral-shaped growths.
Clinical picture
Symptoms may vary depending on the size of the stones. The most common manifestations of kidney stones are:
- Pain in the lumbar region of a dull, aching nature that bothers the patient constantly or with increasing physical activity, errors in diet, consumption of alcoholic beverages.
- Painful sensations and discomfort when emptying the bladder.
- Hyperthermia, chills, nausea, vomiting - these symptoms occur when a secondary bacterial infection or the development of renal colic.
- The appearance of blood in the urine, which is caused by damage to the mucous membrane by moving stones or “sand”.
Large stones located in the renal pelvis cause dull aching pain in patients, which intensifies with physical activity and subsides slightly at rest. As the disease progresses, the renal pelvis may stretch, which leads to deterioration of urine outflow, development of congestion and reproduction pathogenic bacteria, resulting in inflammatory processes.
One of the most characteristic signs of kidney stones is renal colic. The attack occurs suddenly and is manifested by acute pain in the lumbar region, radiating to the groin and upper abdomen. The patient reflexively develops severe nausea, chills, vomiting, urge to defecate, bloating. These symptoms, especially those that arise for the first time, often complicate the diagnosis and treatment of the disease, as they are similar to the clinic of an “acute” abdomen. During an attack of colic, the patient behaves restlessly, rushes about, and tries to take a forced body position. Most often, an attack of renal colic is caused by strangulation of a stone in the urinary tract, shaking when driving, increased physical activity, eating spicy foods and smoked meats. The duration of the attack can vary from several minutes to several hours or even days, weakening or intensifying. The pain stops as suddenly as it begins, which is usually associated with a change in the position of the stone. IN severe cases Treatment of an attack of colic is carried out in a hospital setting.
Diagnostic methods
The prognosis of the course of the disease largely depends on correct and timely diagnosis. In some cases, kidney stones are detected completely by accident, for example, during an X-ray examination of the gastrointestinal tract.
One of the ways to diagnose kidney stones is the Pasternatsky method, which consists of the following: the patient is palpated in the lumbar region, and tapping movements are made on the kidneys with the edge of the palm. Normally, a person should not experience painful sensations. If there are stones, the procedure is accompanied by discomfort or pain, and after tapping, blood may appear in the urine.
Kidney stone disease is diagnosed using abdominal ultrasound - a study that can help identify pathology in early stage. Most informative method diagnosis is fluoroscopy with the introduction contrast agent into a vein - this procedure allows you to detect even the smallest stones.
IN mandatory Patients are prescribed urine and blood tests - studies that can help determine the type of stones, which is very important when prescribing treatment.
Healing procedures
The main principle of treatment of kidney stones is the elimination of factors that provoke the progression of growth and formation of stones, and also cause attacks of renal colic. To eliminate them, the doctor prescribes analgesics to the patient in combination with antispasmodics, for example, Baralgin and No-shpa. In order for the medicine to act faster, it is best to give an injection.
If an infectious inflammatory process is detected in the kidneys or urinary tract, the patient is prescribed antibiotics. In case of metabolic disorders, as one of the provoking factors in the development of kidney stones, the basis of treatment is nutritional correction and getting rid of excess weight.
After examining the patient's x-ray, the doctor will tell you what the chances are for the stone to pass on its own. In some cases, the patient requires surgical intervention, especially if there is progression of the disease and impaired renal function.
Treatment of kidney pathology with stone formation is carried out by a urologist together with a nutritionist. If the outflow of urine is not impaired, then the patient is treated conservatively. It is important to monitor your drinking regime; the amount of fluid consumed during kidney stone disease should be at least 2 liters per day.
If the diameter of the stones does not exceed 5 mm, then the patient is prescribed special medications and procedures to dissolve them. In modern urology, small stones are crushed using laser beams, after which they are removed from the body naturally. The procedure is painless and has virtually no contraindications. As part of complex treatment, the patient is recommended to drink mineral waters, which not only help improve diuresis, but also help reduce the inflammatory process in the urinary tract. Mineral water should be selected by the attending physician, depending on the chemical composition of the stones and the pH of the urine. It is recommended to drink mineral water an hour before meals in an amount of 200 ml.
Therapeutic diet
Nutrition for kidney stones should be as varied as possible, fortified and balanced. Depending on the chemical composition of the stones, certain foods are limited in the diet.
If you have urate stones, the consumption of meat dishes, offal, and strong meat broths is prohibited; preference is given to dairy and plant products. If detected, limit the consumption of dairy products, eggs, oxalic acid, peas, beans, chickpeas, chocolate, and cocoa. When detected, the patient is prescribed a diet based on proteins and fats; the diet limits the consumption of foods of plant and dairy origin. When diagnosing stones with a mixed chemical composition, the diet for the patient is prescribed by the doctor in individually, depending on the characteristics of the organism.
Forecast
Kidney stone disease can occur in different ways, depending on the number of stones, their size, location and the presence of concomitant pathologies of the urinary tract. In most cases it is accompanied by dull pain in the lumbar region. Painful symptoms, sometimes intensify, sometimes decrease, depending on the movement of the stone. The clinical picture is complemented by dysuric phenomena and periodic attacks of renal colic. With timely diagnosis of the disease, the patient is prescribed supportive and symptomatic treatment, thanks to which it is possible to stop the progression of the pathology. For large stones that interfere with the flow of urine and the proper functioning of the organ, as well as if they cannot be treated conservatively, surgical intervention is indicated.
Prevention
Patients with a genetic predisposition to the formation of stones in the urinary system should be careful about their health. Maintaining an active lifestyle, balanced diet and compliance with the drinking regime allows you to avoid the development of this pathology.
In case of any inflammatory diseases of the urinary tract, a person should definitely consult a doctor. Treatment without consulting a specialist is unacceptable and can lead to the development of secondary pathology, including stone formation. If left untreated, kidney stones can lead to the development of severe renal failure.
Urolithiasis (kidney stones)- a disease associated with the formation of calculi (stones) in the renal calyces and pelvis and leading to various pathological processes in the kidneys and urinary system generally. It is one of the most common kidney diseases.
Etiology, pathogenesis
The leading role in the etiology belongs to metabolic disorders - uric acid, purine, calcium phosphate, oxalic acid diathesis. Disorders of the metabolism of calcium, phosphorus, purine bases and uric acid, oxalates can be either primary or secondary, associated with endocrine or other disorders.
Disorders of calcium and phosphorus metabolism are characteristic of hyperparathyroidism, hypervitaminosis D, some endocrinopathies, frequent and prolonged intake of calcium salts and highly mineralized water, diseases of the musculoskeletal system, extensive fractures. As a result, the kidneys lose their ability to normal excretion soluble calcium phosphate, and calcium and phosphorus are converted into an alkaline, slightly soluble compound. The urine pH level in this case corresponds to 7.0.
Disturbances in the metabolism of oxalic acid occur when it is excessively supplied or endogenously formed. For example, large doses of ascorbic acid are metabolized to form excess oxalic acid. The solubility of oxalates is lost at urine pH of about 5.5, as well as at increased levels. ionized calcium. On the contrary, when increased concentration magnesium ions, the solubility of oxalates increases.
Disturbances in the metabolism of purine bases and uric acid occur primarily in gout. Besides, important role plays a role in food intake increased amount purines (abuse of meat products, legumes, coffee), as well as diseases that are accompanied by a significant breakdown of their own protein.
In addition to metabolic disorders, urinary stasis at various levels of the outflow tract and the presence of infection play an important role. A certain importance is attached to the presence of vesicoureteropelvic reflux, as well as inflammatory diseases(pyelonephritis, cystitis, urethritis).
The process of stone formation occurs in several stages: the formation of a primary “micelle” (organic core) from exfoliating epithelium, blood clot, leukocytes, fibrin, bacteria; precipitation of salts on the organic matrix (with changes in urine pH and insufficient colloidal protection, which normally prevents the precipitation of salts and maintains them in a soluble form concentrated solution- urine).
The chemical composition of stones can be homogeneous or mixed. The most common are phosphates (slightly soluble calcium salts of phosphoric acid). Slightly less common are urates (uric acid salts), oxalates and carbonates. Stones may also include protein, cholesterol, cystine and sulfonamide stones. The latter are formed during prolonged treatment with sulfonamide drugs.
Stones of different nature have different structure and density. Phosphates are usually rough or smooth, white in color, and occur when the urine pH shifts to the alkaline side. Urates - smooth or grainy dense stones yellow color, are formed when pH acidifies. Oxalates are very dense stones with an uneven surface, gray-black in color, easily wounding the mucous membrane of the urinary tract, and can form in both acidic and alkaline pH urine. Cholesterol stones are extremely fragile.
Cystines have a dense consistency, usually colorless or whitish-yellow, with a smooth surface. Protein stones are predominantly fibrin mixed with salts and bacteria.
Kidney stones can be either single or multiple (from 20% to 50%). More often they are located in one of the kidneys, but in 15-20% of cases there is a bilateral location. Stones in the calyces are less common than stones in the pelvis. Even less often, stones are detected in the ureters, bladder, and urethra.
Sizes vary from extremely small to the size of a chicken egg, weight - from 1-2 g to 2 kg. Coral stones occupy the entire renal pelvis, and oval stones also form there. Cone-shaped or oblong stones form in the ureters, but the location of the stone is not always the site of its formation. Into the ureter bladder or urethra, stones most often come from the kidney.
Stones cause further disturbances in the urinary system. If the stone is an obstacle to the outflow of urine, hydronephrosis develops, followed by atrophy of the renal parenchyma. With further development of the infectious process, pyonephrosis, apostematous nephritis, purulent calculous pyelonephritis or purulent melting of the renal tissue may occur.
If a stone remains for a long time, for example, in the ureter, a bedsore may develop, followed by perforation of the ureter.
Complete obstruction of the lumen of the ureter by a stone leads to the development of the most serious complication - anuria, which causes the development of acute renal failure.
The transition of inflammation to the perinephric tissue leads to the appearance of a thick capsule of fatty, fibrous and granulation tissue that completely surrounds the kidney. In some cases, the kidney stops functioning and is replaced by fatty tissue.
Clinical picture
In some cases, the disease occurs without severe symptoms. Kidney stones become an x-ray finding during an examination for another reason. Sometimes kidney stones manifest as dull, mild pain in the lumbar region with large stones. However, most often it is accompanied by typical attacks of renal colic, and it is characteristic that colic most often occurs with small stones.
The frequency of attacks depends on various reasons and can range from several within a month to one every few years. An attack is provoked by long walking, riding in bumpy vehicles, or lifting heavy objects, but colic often occurs for no apparent reason. A typical attack of renal colic is characterized by a sudden onset in the form of sharp pain in the lumbar region. The pain is of significant intensity, cutting in nature, quickly intensifies to the point of unbearable. Patients are excited, moan, and rush about in bed, trying to find a position that will alleviate their suffering. In some cases, an attack of renal colic lasts a long time, with short remissions within a few days. Pain begins in the lumbar region, but then quickly spreads to the abdomen along the ureters, groin area, in men it is characterized by irradiation into the scrotum, into the head of the penis, in women - into the area of the labia majora, the inner surface of the thighs.
Often the intensity of pain is much higher in the abdomen and genital area than in the lumbar region. As a rule, an attack of colic is accompanied by dysuric phenomena: frequent urge to urinate, pain and pain when urinating. This is especially true when sand or stone comes out small size.
With renal colic, symptoms of peritoneal irritation are often observed: retention of stool and gas, bloating, nausea and vomiting, dizziness when changing body position. Sharp pain may cause a collapsed state. A prolonged attack causes an increase in blood pressure.
If renal colic occurs against the background of pyelonephritis, an increase in body temperature to febrile levels is typical. After an attack, macro- or microhematuria and leukocyturia are observed in the urine. Sometimes, with a temporary block of the kidney, there are no changes in the urine.
Leukocytosis and increased ESR usually develop in the blood. An objective examination reveals severe pain in the costovertebral angle on the side of the affected kidney. Pasternatsky's symptom cannot be determined due to severe pain. Most often, palpation of the kidney is also impossible.
During the interictal period, patients may complain of dull pain in the lower back, sometimes there are changes in urinary sediment (macro- and microhematuria, pyuria, salts in significant quantities) and the passage of sand or small stones. Often the interictal period is not accompanied by negative subjective sensations. A positive Pasternatsky symptom is almost always determined. Often, marbling of the skin is noted in the area of the affected kidney, which is associated with frequent use heating pads, which help relieve pain.
Hematuria is especially characteristic in the presence of oxalate stones, since their lumpy surface most severely injures the mucous membrane of the pelvis and ureters. However, its occurrence may also be associated with venous stasis in the veins of the renal sinus. Microhematuria usually worsens after walking and physical activity.
Prolonged hematuria and especially pyuria are characteristic of associated pyelonephritis, further development which is accompanied by the formation of new stones.
The disease is long lasting and is prone to frequent relapses. As a result of prolonged presence of kidney stones, organic changes increase, leading to the development of hydronephrosis, and with concomitant infection - to purulent complications.
In case of renal stone disease in combination with pyelonephritis, persistent secondary arterial hypertension is observed.
In 13-15% of patients, renal stone disease is asymptomatic, pyelonephritis is mild, and there are no functional changes.
Prognosis in the absence of organic and functional disorders favorable, in the presence of coral or multiple stones, especially in a single kidney, serious. Timely surgical removal of stones with appropriate anti-relapse treatment aimed at stopping the chronic inflammatory process and normalizing metabolic disorders makes the prognosis more favorable.
Complications
Purulent calculous pyelonephritis develops in the presence of pyogenic flora and often complicates the course of renal stone disease. Any disturbance in the passage of urine leads to the occurrence of feverish state, high leukocytosis with a neutrophil shift to the left, increasing ESR, which requires emergency hospitalization.
Excretory anuria, associated with blockage of one of the ureters by a stone, is another complication of kidney stones. When one of the ureters is obstructed, the other kidney stops secreting urine due to the reno-renal reflex. Anuria is usually preceded by an attack of renal colic, which facilitates diagnosis.
The patient stops having the urge to urinate. Over the next 1-3 days, symptoms of acute renal failure gradually appear, and the level of residual nitrogen in the blood plasma increases.
Hydronephrosis occurs as a result of disturbances in the passage of urine, which lead to dilation collecting system, profound changes in the interstitial tissue of the kidneys and subsequent atrophy of their parenchyma. Urinary stasis contributes to the development of urinary tract infections, and infected hydronephrosis develops. An increase in intrapelvic pressure leads to expansion of the nephron tubules and a decrease in the functional abilities of their epithelium. The interstitial tissue of the kidney is saturated with urine, as a result of which the sclerotic process is activated and the renal tissue is replaced by connective tissue. The lost functions of the renal parenchyma are not restored even after removing the obstacle to the outflow of urine. Clinically, hydronephrosis against the background of urolithiasis is difficult to identify. In the initial stages, the main symptom is attacks of renal colic, which are also characteristic of kidney stone disease. The severity of the process may be indicated by dull pain with preferential localization in the lumbar region. This is due to the replacement of the tissues of the pelvis and calyces with connective tissue when they lose the ability to contract.
Diagnostics, differential diagnosis
Diagnosis of kidney stone disease is not difficult if after typical attack renal colic, hematuria is determined, sand or stone comes out. In the interictal period, the diagnosis is based on X-ray contrast examination data.
Plain films of the kidneys reveal most stones. However, urate or soft protein stones are not visualized by X-ray methods. To identify them, tomography, excretory urography), and pneumopyelography are used. To clarify kidney function after survey images, patients are shown excretory urography. It allows you to most accurately determine the location of stones (calyx, pelvis, ureter) and identify the presence and nature of complications (hydronephrosis, excretory anuria).
In cases where the stone is not detected during excretory urography or it is contraindicated, use retrograde pyelography or pneumopyelography (using liquid contrast agent or oxygen). In such images, the calculus is identified as a filling defect or as a clear shadow against the background of oxygen. The ultrasound method is widely used to diagnose kidney stones. However, it cannot inform about the function of the kidney, so X-ray examination remains necessary, especially in the surgical treatment of urolithiasis.
Diagnosis of renal colic usually does not cause difficulties, since it is characterized by a typical anamnesis, restless behavior of the patient and dysuric phenomena. However, in some cases, diseases of anatomically close organs can give a similar picture, and therefore a differential diagnosis with acute appendicitis, cholecystitis, intestinal obstruction, pancreatitis, acute adnexitis, perforation of a gastric or duodenal ulcer,
as well as renal infarction. IN difficult cases use data from chromocystoscopy and excretory urography. With chromocystoscopy, the release of indigo carmine from the affected kidney is sharply slowed down or absent altogether. In some cases, you can see bullous edema in the area of the mouth of the ureter, hemorrhages in the mucous membrane or a stuck stone. Excretory urography allows you to clarify the diagnosis and differentiate renal colic from other acute diseases of the pelvic and abdominal organs.
Excretory anuria should first of all be differentiated from acute urinary retention. Usually, if the urethra is passable for the catheter, there are no difficulties. At acute delay urine, the bladder is full; with excretory anuria, on the contrary, it is empty. If there are difficulties with catheterization, anamnesis data is used. In any case, the patient must be immediately taken to a specialized hospital.
With hydronephrosis, hematuria always occurs, and microhematuria predominates (macrohematuria is observed in only 20% of patients). Dysuric phenomena usually occur only at the height of a painful attack. When performing excretory urography, there is a slowdown in the accumulation of radiopaque substance in the dilated pelvis and calyces. At severe violation kidney function, contrast can accumulate only within 1-2 hours, or the affected kidney is not capable of excreting it at all. To confirm and clarify the diagnosis, radioisotope scanning and renography methods are used. Together they make it possible to accurately determine the degree of expansion of the pyelocaliceal apparatus and the functionality of the kidney.
Treatment
Treatment of kidney stones in modern conditions most often complex, includes both conservative and surgical methods. Complex therapy Renal stone disease sets itself the following objectives: relief of attacks of renal colic, surgical removal of stones, treatment of infectious complications and prevention of relapses of stone formation.
To relieve attacks of renal colic, antispasmodics are widely used as first aid: noshpa 0.04 or papaverine 0.04 - up to 2 tablets per dose, baralgin - 1 tablet orally or up to 5 ml intramuscularly. In most patients good effect noted from thermal procedures - a hot bath (water at a temperature of 37-39 ° C) and a heating pad on the lumbar region. You can use terpene-containing preparations: Avisan 0.5-1 g, cystenal 10-20 drops. Subsequently, against the background of these measures, the patient is administered 1 ml of 0.1% atropine subcutaneously in combination with 1 ml of 2% promedol or 1 ml of 2% pantopon subcutaneously, 1 ml of 0.2% platyphylline subcutaneously. In some cases, intravenous (very slow!) administration of 5 ml of baralgin helps. If there is no effect from the listed measures emergency care, as well as in case of severe fever during an attack of renal colic, the patient should be hospitalized in a specialized urological or surgical hospital.
Surgical treatment of nephrolithiasis is indicated for infected stones, if the pain syndrome makes the patient unable to work, with obstruction of the urinary tract leading to impaired urine outflow and the formation of hydronephrosis, with persistent hematuria, as well as with a combination of these indications. Spontaneous passage is possible only if there is a smooth stone less than 1 cm in diameter.
To treat the inflammatory process, antibiotics, nitrofuran drugs, and less often sulfonamides are used, given their ability to also precipitate. In the interictal period, drugs that tonic the smooth muscles of the urinary tract are indicated: madder extract, Avisan, cystenal, enatin, uralite, etc. They have a slight antispasmodic and diuretic effect, contain terpenes - substances that cause contraction of the urinary tract, which favors the outcome stones.
Therapy with terpene-containing drugs is indicated for single stones of small size that are capable of spontaneous passage.
In addition to them, patients are recommended to take long walks, drink plenty of fluids and antispasmodics, which in some cases accelerates the passage of stones.
However, neither surgical removal of stones nor their spontaneous passage cures kidney stone disease. It is necessary to take measures to correct metabolic disorders.
Urolithiasis caused by dysfunction of the parathyroid glands is very severe and often recurs.
In the presence of an adenoma of these glands, its possible faster surgical removal is indicated, which somewhat improves the prognosis and course of nephrolithiasis.
Gout or uric acid diathesis require special diet therapy: foods rich in purine bases(fried meat, offal - liver, kidneys, brains; meat broths; anchovies, sardines, sprats; cheeses; coffee). The diet should contain predominantly dairy and plant foods.
At the same time, dairy products should not prevail, while fruits and vegetables (with the exception of lettuce, spinach, Brussels sprouts, and legumes) can be consumed in unlimited quantities.
For oxaluria, diet therapy should be aimed at eliminating foods rich in oxalic and ascorbic acids, as well as calcium salts. These include lettuce, sorrel, spinach, beets, rhubarb, parsley, legumes, grapes, plums, strawberries, gooseberries, tea, cocoa, chocolate.
With phosphaturia, the diet, on the contrary, should shift the pH of the urine to the acidic side. In addition, foods containing large amounts of calcium salts (milk and dairy products, vegetables, fruits, herbs) are excluded. Meat food is shown, vegetables - peas, pumpkin, Brussels sprouts, asparagus, flour dishes in all types.
Can be assigned ascorbic acid 0.5-1 g per day, methionine 3-4 g per day. Magnesium oxide 0.15 g per day has a beneficial effect in case of phosphaturia and oxaluria, and after surgical intervention- methylene blue.
In order to prevent recurrent stone formation, patients with kidney stones are prescribed to drink plenty of fluids. Mineral waters are used depending on the type metabolic disorders.
For uraturia, alkaline solutions are recommended mineral water Zheleznovodsk, Truskavets, Borjomi, Essentuki (Essentuki No. 4 and No. 17). For phosphaturia - acidic mineral waters of Kislovodsk, Truskavets, Zheleznovodsk (Naftusya, Arzni). Oxaluria requires the appointment of alkaline mineral waters (Essentuki No. 20, Naftusya). For other metabolic disorders leading to stone formation, mineral waters are used, focusing on the reaction of urine: if it is acidic, mineral waters are used (Essentuki, Borjomi, Pyatigorsk), if alkaline - acidic (Kislovodsk, Truskavets, Zheleznovodsk). Currently, the lithotripsy method is successfully used to treat renal stone disease - crushing kidney and ureteral stones using ultrasound, then small fragments of stones are excreted in the urine on their own.
What type of kidney stones? Description:
The types of kidney stones depend on the location (oval or coral-shaped stones in the renal pelvis, oblong, cone-shaped stones in the ureters, etc.). Phosphates are more often found - calcium and magnesium salts of phosphoric acid. Less common are stones consisting of salts of oxalic acid - oxalates, uric acid - urates, carbonic acid - carbonates.In addition, cystine, cholesterol, xanthine, protein and sulfonamide stones are detected. The latter are formed when long-term treatment sulfonamides. There are stones of mixed composition.
Phosphate stones are grayish-white in color and have a rough surface; oxalates - very dense, with a bumpy surface; easily injure the mucous membrane; urates - yellow in color, hard in consistency, with a smooth or granular surface, cystine stones are colorless, have a dense consistency; cholesterol stones are fragile; xanthines have a reddish color and a smooth surface.
What is renal nephrolithiasis?
Nephrolithiasis, or otherwise urolithiasis, is one of the most common urological diseases, for which it is necessary to provide assistance not only to urologists, but also to a wide range of doctors, primarily surgeons and therapists.About 35% of all kidney surgeries are performed for stones. In many areas of the world, the disease is endemic (hot, dry climate, in areas where drinking water is rich in calcium salts). Mostly people aged 20 to 50 years are affected, with a slight predominance of men. Stones are somewhat more often localized in right kidney. Bilateral nephrolithiasis occurs on average in 15–20% of patients. From 20 to 50% are multiple kidney stones. More often, stones are located in the renal pelvis, less often - in the calyces or simultaneously in the pelvis and calyces.
Etiology and pathogenesis:
The causes of urolithiasis and the mechanism of its development are not yet clear enough, although numerous theories have been developed to explain them. It has been established that the formation of stones is facilitated by urinary tract infection, stagnation of urine, kidney injury, hemorrhage in the kidney tissue, vitamin deficiencies (A, B, D), disorders mineral metabolism, changes acid-base balance and urine pH; drinking water rich in calcium salts, as well as increased secretion with urine uric acid (with gout).Kidney stones form more easily in people who are bedridden for a long time.
A significant role in the origin of nephrolithiasis belongs to hereditary factors. In most cases, the release of salts from the urine and the formation of calculi occur around the organic “core,” which may include exfoliated cells of the pelvic epithelium, blood clots, accumulations of leukocytes, etc. Precipitation of salts occurs when their concentration in the urine increases or their solubility decreases. This can occur as a result of a change in the pH of the urine and a decrease in the content of protective colloids (physiological colloidal stabilizers) in it, which retain salts in solution and in its supersaturated state.
Pathological picture:
The pathological anatomy of nephrolithiasis is extremely diverse and depends on the location of the stones, their size, the duration of the process, the presence of infection, etc. If the stone is located in the pelvis and disrupts the outflow of urine, pyelectasia and hydronephrosis develop with atrophy of the renal parenchyma. When the calculus is localized in the calyx, a violation of the outflow of urine from it leads to expansion of the calyx and atrophy of only part of the renal parenchyma.When a ureteral stone obstructs its lumen, a picture of hydroureteronephrosis is observed (expansion of the pelvis and lumen of the ureter above the site of obstruction). In this case, urethritis often develops, followed by narrowing of the lumen of the ureter. A bedsore may form at the site of obstruction, followed by perforation of the ureter. When infected, a pathological morphological picture of pyonephrosis, pyelonephritis, pustular nephritis, purulent melting of the kidney parenchyma is added. When the inflammatory process moves to the perinephric tissue, the kidney becomes immured in a thick capsule of granulation, adipose and fibrous tissue, and sometimes is completely replaced by sclerotic fatty tissue.
Symptoms:
Urolithiasis may be asymptomatic and kidney stones may be discovered incidentally during an X-ray examination of the kidneys. However, more often the disease occurs with severe pain syndrome renal colic type - intense pain in the lower back, upper abdomen, radiating to the groin area, inner thigh and external genitalia. In this case, the patient’s motor agitation is often observed: he rushes about in bed, changes his body position, thus trying to relieve the pain.It can be so intense that the patient cannot restrain his moans and screams. A sharp pain attack can provoke the development of collapse. The attack is often accompanied by nausea, vomiting, retention of stool and gas, frequent, sometimes painful urination. The patient's face is hyperemic, breathing is rapid.
Blood pressure may increase. An attack of renal colic usually occurs as a result of the passage of a stone through the ureter. It usually starts suddenly, often after a bumpy ride or long walk. The duration of an attack is often measured in hours; Less commonly, an attack lasts more than a day. Objective research patients allows you to determine pain in the lumbar region and along the ureters. Rarely happens positive symptom Pasternatsky on the sore side: palpation of the kidney is impossible due to pain.
Urine output may decrease to the point of anuria, as a result of reflex inhibition of the function of the second kidney. Red blood cells and protein are usually found in urine. Most often, the cause of renal colic is strangulation of a stone in the ureter, as a result of which the outflow of urine becomes difficult or stops, which, in turn, leads to acute expansion renal pelvis and sharp increase intrarenal pressure.
The attack stops when the stone passes into the bladder. Sometimes the stone passes through urethra and stands out. The frequency of attacks varies: from several within one month to one over several years.
It should be remembered that when hepatic colic pain radiates to the right shoulder, scapula, and may be accompanied by jaundice; in addition, there are no dysuric phenomena. A responsible and important task is to differentiate an attack of renal colic from acute surgical diseases: acute appendicitis, perforated ulcer stomach and duodenum, intestinal obstruction, purulent perforated cholecystitis. In this case, X-ray and ultrasound examinations play an extremely important role.
In the diagnosis of urolithiasis outside of an attack, ultrasound, radioisotope and X-ray examination(general radiography, intravenous urography, pneumopyelography, tomography, etc.). On pyelograms, shadows of stones can be detected and their localization can be established. Oxalates, phosphates and carbonates are also visible during plain radiography of the kidneys. Urates and cystine stones may not be visible on a kidney x-ray. They are detected by retrograde or intravenous urography.
Pyelography also makes it possible to identify kidney diseases that accompany or complicate nephrolithiasis: pyelonephritis, pyelectasia, hydro- and pyelonephrosis. Ultrasonography reveals deformations of the renal calyces and pelvis, as well as an uneven decrease in the size of the kidneys. Scanning the kidneys in an advanced stage of nephrolithiasis can reveal a decrease in the size of the kidneys due to their shrinkage. In the final stage of the disease, with pronounced symptoms of urolithiasis, all functional tests of the kidneys are sharply impaired.
Course and complications of urolithiasis:
The disease has a chronic, relapsing course. The long-term existence of stones in the urinary system leads to the development of pyelonephritis, hydro- and pyonephrosis. Sometimes sepsis occurs, especially with the development of pyonephrosis and purulent melting of the kidney.Nephrolithiasis leads to functional and anatomical disorders in the urinary tract. In parallel with inflammatory and degenerative changes is growing functional impairment kidneys, up to the development of uremia.
A serious complication of urolithiasis is anuria with the subsequent development of necronephrosis. Urolithiasis is often accompanied by arterial hypertension, mainly in cases complicated by chronic pyelonephritis, less often - with the development of hydro- and pyonephrosis.
Forecast:
The prognosis is not always favorable due to the tendency of the disease to relapse. Most the prognosis is serious with coral or multiple stones of both kidneys or a single kidney, complicated by chronic renal failure. The death of the patient may occur due to uremia, sepsis, purulent melting of the kidney. Timely removal of the stone and subsequent systematic treatment of pyelonephritis to prevent re-formation of stones makes the prognosis more favorable. Attacks of renal colic in the presence of a small stone (no more than 1 cm in diameter) can end with its spontaneous passage or after instrumental interventions. At large sizes stones, obstruction of the lumen of the ureter and difficulty in the outflow of urine require surgical treatment of urolithiasis.Treatment:
During the interictal period, patients are advised to drink plenty of fluids. Alkaline mineral waters are useful for urates: Borjomi, Essentuki No. 4 and No. 17; for oxalates - Essentuki No. 20, naftusya; with phosphates - naftusya and arzni.The diet has features depending on the composition of the stones. In case of uric acid stones, it is necessary to limit the consumption of liver, kidneys, brains, and meat broths; for phosphates - milk, vegetables, fruits; for oxalates - spinach, sorrel, green salad, beans, tomatoes and other foods containing oxalic acid. Important point in the treatment of urolithiasis these are folk remedies. For small stones, attempts are made to speed up their passage. For this purpose, the patient is recommended to take long walks, drink plenty of fluids, and prescribe antispasmodics and drugs containing essential oils(enatin, cystenal, etc.).
In case of pyelonephritis, treatment is carried out with antibiotics and nitrofurans. Good results are obtained by using the lithotripsy method - crushing stones using ultrasound. In this case, small fragments of kidney stones are excreted in the urine. Large infected stones and stones that have caused obstruction of the ureter must be surgically removed. However, this does not eliminate the cause of the disease, and a relapse may occur.
To relieve an attack of renal colic, heating pads are used on the lumbar region, hot baths, as well as antispasmodics and narcotics. The patient is injected intramuscularly or intravenously (very slowly) with 5 ml of baralgin solution, 1 ml of 0.1% atropine solution with 1 ml of 1–2% promedol solution is injected subcutaneously; 1 ml of 0.2% platyphylline solution is injected subcutaneously. If emergency measures are ineffective, the patient should be hospitalized in a urological or surgical hospital for treatment. specialized assistance (novocaine blockades, ureteral catheterization, stone removal, drainage of the upper urinary tract).
