Discussion Author: Jeremiah R Long
Nephrolithiasis classically presents with renal colic and hematuria. Stones within the renal collecting system typically obstruct at one of three locations: the ureteropelvic junction, the pelvic brim, or the ureterovessicular junction. Occasionally obstructing stones may also lodge at the bladder outlet. When acute in onset, many patients with obstructing stone disease will present to the emergency department with acute flank pain. The differential diagnosis consideration for such presentations can often include appendicitis, pyelonephritis, pelvic inflammatory disease, ectopic pregnancy, tubo-ovarian abscess, and inflammatory bowel disease. For this reason imaging typically plays an important role in diagnosis. A study from Radiology in 2000 looking at the detection of ureteral calculi in emergency room patients determined that the sensitivity for stone detection by CT was 96%, and by ultrasound was 61% (both with specificities of 100%).
It is estimated that somewhere between 3 and 12 percent of individuals in the United States will experience symptomatic renal stones at some point in their lives. The majority of stones (eighty percent) are composed of calcium (typically calcium oxalate and less often calcium phosphate). The main other types include include uric acid, struvite (magnesium ammonium phosphate), and cystine stones. Generalized risk factors for forming stones include low water intake, high protein intake, family history, urinary tract infection with a urease splitting organism (e.g. Proteus or Klebsiella), and disease states resulting in hypercalciuria, hyperuricosuria, or hypocitriuria. Treatment of ureteral stones in the acute setting begins with adequate pain control. Once an obstructing stone has been identified within the collecting system, location and size of the stone plays a major role in determining management with stone size of 5mm typically representing the threshold for interventionâ€”with stones smaller than 5mm being managed conservatively (pain control, oral hydration, and urine straining for spontaneous passage), and stones greater than or equal to 5mm being managed with some sort of intervention (e.g. lithotripsy, cystoscopy, etc).
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