Types of diseases
Disease is a chronic course.
Pathogenesis:
Favor the creation of stone: hypercalciuria, alkaline urine, oliguria, creating core crystallization - of salt, the protein and polysaccharide compound called uromukoida.
Pathogenesis of calcium, phosphate or oxalate kamijenja not explained.
The stones of uric acid is often associated with gout, which points to the same etiological factor.Sometimes gout first appears, sometimes preceded by renal calculosis.
The influence of age: the majority of the above middle age, more than half of the first signs of the disease are between 31-50 years.
Male sick more often, especially since uratnog kamijenja. Legacy has a significant role in uratnog kamijenja.
It is not only expressed a preference for formation of painful kidney kamijenja, but kamijenja same chemical composition.
Increased incidence of renal kamijenja the workers who do hard labor in a sitting or standing position and Koti are exposed to the elements (the impact of orthostatic proteinuria).
Poor nutrition foods with vitamin "A", the food poor in milk and meat have aetiological significance.
Bladder stones in children is often in some of our provinces (Dalmatia, Sandzak).
Everywhere the increased number of patients with renal urate stones. It occurs in a stronger economic strata, with a diet richer in purines. Bladder stones often in poor layers with predominantly vegetarian diet.
Hydronephrosis, which occurred not more damage to the renal parenchyma, is to create favorable conditions kamijenja. The longer stay of urine in the renal pelvis allows the deposition of salts and create kamijenja.
Infection creates favorable conditions for the deposition of salt by changing the chemical reaction of urine, certain bacteria, its enzymes break down urea into ammonia and carbon dioxide. Reactions of urine then tend to alkaline, thereby reducing the solubility of phosphate. In addition, ammonia associated with the ammonium carbonate, which is the only one with phosphates and magnesium salts, forming insoluble magnesium ammonium phosphate (struvite).
In cases of pyelitis decreased urine output, and created a barrier to urine, swelling and inflammation of the dynamic origin of ureteral atony.
In cases of long-term immobilization - nerve diseases, bone fractures, tuberculosis of bones and joints, resulting increased calciuria and increased tendency to create kamijenja.
In diseases accompanied by excessive production of uric acid often produces urate stones: leukemia, polycytemia, lymphomas, particularly during treatment when it destroys a large number of cell nuclei nucleoprotein.
Topographic aspect
According to the reservoir rocks distinguish renal parenchyma, renal pelvis, ureter and bladder.
Parenchymatous stones orders in cups, pijelogenim cysts, in extended zjapovima tubules, and finally in the papillae.
Anatomical aspects:
Stone in the urinary tract may be performed by mechanical irritation, stop urinating on that side completely or partially. In the latter case will be developed enlargement of renal pelvis and patella - hydronephrosis. If a stone completely clog urethra perform renal atrophy. Along with the atrophy of the kidney and perirenal Perihilar grow fat and fibrous tissue. Hyperplastic indurirana fatty capsule is a characteristic finding in cases of renal kamijenja.
Incomplete obstruction of channels is a consequence of hydronephrosis. If this happens to adults then increased pressure will cause atrophy of the organ. However, in young people increased pressure will act as a stimulus of a rise in body, not just a stretch under pressure. The result will be a large renal pelvis, and the capacity to 1 liter, but with enough preserved parenchyma.
There are cases where the complete blockage of the channel does not cause drying of the kidney, but "hibernation" of a kidney after the removal of barriers being broken and the kidney is again capable of secretion.
Aseptically little stones with a smooth surface will not usually cause major reactions lining the renal pelvis. However, stones with rough surface, and larger stones will cause swelling and hyperemia of the mucous membranes, making infiltration of lymphocytes and plasma cells. I can create erosion and necrosis. Such ulcers are more common than in the ureters in the pelvis. One can break the wall and urethra, or cause strictures. In response zapaljenjskoj periureteralno being affected and surrounding tissue and fat tissue, so that finally creates fibroziranje ureteral wall with sclerosing periureteralnog tissue.
Finally, the stone can cause infection. When infection occurs join pyelonephritis, pyonephrosis, perinefritična phlegmon. Out the course and consequence of infection is ascendant interstitional nephritis.
Depending on the severity of infection, virulence of germs, of the conditions for the swelling of urine can occur all forms of pyelitis simplex and eksudativnih piogenih and shape to ulcerative pyelitis. With each infection, renal pelvis occurs and kidney tissue infections - pyelonephritis. The lining is difficult and in places devoid of the covering of the cell layer with ulceration, covered gnojavom deposits. The binder is suffused mucosal leukocytes. High blood pressure occurs in the renal card gnojave reflux of urine in the collecting ducts.
Pijelonefritična homes are spread out in the form of lines of the core to the kidney cortex, with the creation of small purulent foci under the capsule. By removing barriers, stone and liberation urine passes all these changes in renal parenchyma and renal pelvis may be withdrawn and to heal.
In cases of hydronephrosis with stones formed secondary pyonephrosis. It turns into a chronic stage and can not be cured.
These inflammatory processes are secondary, caused by the presence kamijenja. There kamijenja secondary nature, induced by inflammation and that has grown due to inflammation. Thus, for example. kamijenja most of apatite, apatite-struvite, and large coral rocks. Renal pelvic wall is thickened due to inflammation of the connective tissue and permeated; mucous membrane is thickened scar with fibrin gnojavo scum covered.
Renal parenchyma is first edematous because of inflammatory reaction, and later in some parts of the resulting disappearance of the parenchyma. The process is uneven in some parts hidronefrotična atrophy predominates, while in other pijelonefritičko scar contraction. The lower poles occurs creating an abscess.
The primary cause kalkulozna pyonephrosis supurous glass softening. The process of penetrating the renal papilla and the module from this gnojavo necrotizing nephritis resulting cavern in the parenchyma. The ureter is surrounded by a sclerotic fatty tissue (periureteritis fibroadiposa), and he turned into a scar tube.
The stones in the ureters causing their enlargement. Analogously promjenarna in the renal pelvis and ureters may occur ureteritis follicularis (multiplication of lymphoid tissue): ureteritis granularis, conversion occurs in the transition epitijela cylinder; ureteritis cystica (pyelitis) Reproduction Brunn's cell nests in the stratum proprium.
Uzuriranjem stone wall can cause its perforation followed by the creation or perinefritičnog periureteralnog abscess.
During chronic infection can create new layers to the already existing rocks. Thus arises coral rock forms that take the form of the renal pelvis.
Mechanical irritation caused by stones interstitional nephritis, with periglomerulitisom and proliferation of connective tissue. At the same time fatty capsule becomes thickened. The end result is a sclerotic kidney that can not be distinguished from pijelonefritičnog sclerotic kidney.
Age of patients usually ranges between 30-50 years. Kamijenja higher frequency in men.
The clinical aspect
Both sides of the stones in less than 15% of patients. Recurrent stones are more often not the same, but the opposite kidney. Relapses occur after surgical removal kamijenja during the first 4 years in 54%.
In clinical terms, there may be pain, hematuria or leukocyturia, signs of infection.
The pain is caused by outside influences - physical strain, earthquakes body, long standing or walking, stretching and bending of the body, fall, jump and so on. Have the characteristic radiation of pain in the bladder and sexual organs, rarely in the thigh.
The pain is often accompanied by the appearance of macroscopic or microscopic hematuria. During an attack of renal colic reflex caused by disorders of other organs: the pulse is small, fast, color of face pale, the patient feels the winter and sweating a lot, often vomit or have nausea: meteorism of the abdomen, often accompanied by oliguria, most of what, may occur and anuria - mostly to mutual mechanical barrier, or obstruction of a solitary kidney.
If the stone is lower in the ureter are the more frequent calls to urinate while eliminating only a few milliliters of urine.
Localization of pain: kidney stones cause pain in the pelvic flank foreface; ureteral stone causing pain to the abdomen and navel. Stones at the lower end of the ureter gives pain in the belly button height with radiation in the groin. What stops immediately as soon as the free passage of urine (a stone from the ureter into the renal pelvis back, or is dropped from the ureters into the bladder), and also the abdominal disorders. Often, the cessation of pain appears enhanced diuresis. Sometimes the patient after what izmokri stone.
Often there is an infection - septic type of temperature, with chills, sweating at the end of the attack, the appearance of leukocytes, and even pus in the urine.
In cases of long-term course there can be kidney failure.
Rarely, but one of the attacks of renal colic may go with anuria and life-threatening. The cause of anuria is a mechanical barrier of stone. The obstacle is the path of one kidney, anuria occurs if a second off the previous functions.
Etiologic aspects:
• The stones of calcium salts (phosphates, or oxalates) is caused by excessive excretion of calcium in the urine (various bone diseases, hiperparatireodizam, osteoporosis, prolonged treatment with corticotherapy, prolonged immobilization, vitamin D intoxication, excessive intake of milk, baking soda to treat gastro-intestinal is excellent).
• The phosphate rock (calcium acid phosphate - brimit, tricalcium phosphate - apatite, hydroxyapatite, calcium and magnesium hidroksifosfat, diammonium phosphate and calcium; magnezijumfosfati, and magnesium ammonium phosphate hexahydrate, calcium triphosphate, magnesium and ammonium - resulting in infections from germs ureolitičnim. Ureolitične germs (usually the B. proteus, B. Staphylococcus, infection associated with B. coli and Proteus), break down urea, relieving urinary alkalinizing ammonia precipitate of ammonium magnesium phosphate-calcium, which is undiluted in an alkaline environment. center stone is oxalate, urate, or other structure, and around it are made from layers triphosphate, which is characteristic of litogenu infection.
• Oxalate stones composed of pure calcium and dihydro monohidrooksilata or associated with phosphate dihydrate or uric acid. The etiology is unclear. Hiperoksialurija may have an impact on the formation of kamijenja, but it is certain that hiperoksialurija that occurs in the case of sugar diabetes, liver disease, intake of foods rich in oxalates has no etiologic role in the formation of oxalate kamijenja.
• Mixed calcium stones, oskalatno-urate, oxalate-phosphate. Moreover one of the same patient can have eg. first stone of kalcijumoksalata, then urate stones, or to okoprvobitno uratnog oxalate stones or later deposited phosphate layer under the influence of infection.
By creating alkaline urine, oliguria, the existence of core crystallization nuclei for the creation of stone, kalcifikovanje uromukoida, organic compounds of proteins and polysaccharides that can condense into tubules forming clot sizes, which can fill cups and even pijelum considered to have significance for the formation of calcium, phosphate and ksalatnog kamijenja, but can not be taken to the pathogenesis of calculosis proven.
Urate stones often associated with gout. often ill males. Heritage, constitution, ethnicity, have a certain importance. Not far there etiopathogenetic link between hyperuricemia and hiperurikurije with a penchant for creating uratnog kamijenja, except in cases of leucosis, lymphoma, polycythemia, treated with radiotherapy or cytotoxic drugs - you can create urate kidney stones.
• cystine stones - is created if the urine contains high concentrations of cystine, several hundred milligrams in 24 hours instead of normal 70-150 mg. It is an inborn disorder of tubules and family character which is reflected in the inability reapsorbovanja cystine, colonialism, arginine and ornithine, whereas the other amino acids reabsorbed normally.
Morphological aspects
• The stones of calcium oxalate is hard, or krvgavo malinastog looks, but with a sharp needle izdanicima, dirty white or gray, the surface impurities of hemoglobin can be brown to black. Do not miss X-ray beam. These stones are very hard and difficult. Can reach the size of an egg.
• The stones of uric acid is yellow, red or brown color. It may be breaches or the firm. Round or oval is shape, with a smooth surface. At the intersection of concentric layers visible. Large stones may look like corals and has a rough surface. There are also fine as sand.
• cystine stones are rare, a variety of sizes and can also be as big as pigeon's egg. Soft, can be cut into fingernail, it is easy to break, its surface is smooth or finely granulated. The color is yellowish, and standing in the air gets a greenish color. On cross-section can be discerned radijarna lumber.
• Phosphate rock is irregularly shaped, flat surface or sprayed with crystal beads, colored white or gray. It is easy to break and crumble.
• Calcium carbonate rocks (the crystal-chemical terms it is a carbonate apatite, a complex of calcium carbonate and calcium phosphate) is mostly fine.
• Stones of ammonium urate. When it is soft as a wet paste. Has a hardness of dry earth and easy to crumble into dust. The color is pale to dark yellow, mostly small and individually. More common in children.
Largest stones are highly variable, ranging from sand and grits to hundreds of grams difficult.
The speed with which enhances the stones is different. The slowest increases calcium oxalate stones, followed by urate. On the contrary, the stones and struvite apatiat increases rapidly. Thus, after surgical removal of recurrent stones can occur after only a few weeks.
In the most solitary stones (in 60%). In cases multipnog kamijenja, they can be hundreds, even over a thousand.
Functional aspects:
Kidney stones may occur in the kidneys that are functioning in a normal state.
Creating a barrier for swelling of urine stones can cause urine to a complete break or partial break. The degree of functional damage depends on how long things take.
When complete obstruction of the definitive kidney damage occurring after only a few days to two weeks. If the infection is associated with failure to establish a faster pace.
Characteristically, the lesions caused no evolutionary character: when the obstacle is removed, the existing functional impairment may be somewhat improved, or in the worst case is the same, but are not getting worse.
Diagnosis
Anamnesis
In many cases, attacks of severe pain (renal colic) are the initial sign of disease. Occur without apparent cause, and sometimes occur after an earthquake body (run, jump, fall). Pain in the groin, usually unilateral, sometimes the patient can not accurately determine the location of most pain. The pain radiates into the anus, the external genitalia, the thighs. Sometimes radiation is atypical, so that the patient has diffuse abdominal pain. The pain was very strong and always causing patient fear and discomfort to the patient can not point to remain motionless, and in one place.
There is often a reflex delay in bowel movement - delay chairs and winds, tension and abdominal meteorism. Join often vomiting, so the clinical picture resembles intestinal occlusion.
What takes several hours or days. Once the attack calm throwing stones with the urine. Usually then bloody urine.
Hematuria are common, usually along with attacks of pain but may also be painless. Microhematuria have a regular and permanent result.
Interruption of urination occurs when both channels are clogged, which is extremely, often one is clogged, and the other is excluded from the function normally due to a long calculi.
The infection is manifested high temperatures, sepsis, presence of pus in the urine.
Fever is not always evidence of infection. It may be a sign of a halt of urine.
Chills and high tempereature arise in cases clogging the channels. One stop as soon be rid of the passage of urine.
In cases of large coral kamijenja, with severe infections and abundant pyuria usually no temperature.Fever is more related to the arrest of urine, which may be restricted to only one cup.
Some of these patients have long been lying, motionless, for broken bones, diseases of the spine, joints, some with paraplegia due to spinal lesions (fractures of the spine, polio).
The clinical picture
The patient was pale, restless, sweating. Breathing is shallow because of the pain during deep breathing. Testis with the sick was raised high. There are a defense is the abdomen. Kostovertebralni angle is very sensitive to pressure and touch. Once the upper abdomen sensitive.
Palpatory kidney may be increased; lumbar contact exists in cases of hydronephrosis. Macroscopic and microscopic hematuria. Pyuria.
In some cases of intermittent hydronephrosis, period pain and stop urine palpated a large kidney.Tempereatura is increased. Urinaran findings can then be without pathological changes. When you open a passage, kidney tumor subsides, the temperature falls, the pain ceased, and the urine may contain pus. The quantity of urine rapidly increased.
In cases of nephrolithiasis resulting from hyperparathyroidism join the clinical signs of hypercalcemia and renal insufficiency: fatigue, muscle weakness, vomiting, dehydration, headache, persistent constipation, thirst, polyuria, izostenurija, and sometimes pain and anemia.
In some cases there is ulcer disease, pancreatitis, metastatic calcification in the muscles, calcium depots in front of the eye.
Radiographic findings
Nativan recording can detect Renal calculosis in cups, in the pelvis, the ureters, or bladder. Calculosis is often bilateral in cases hiperparatireoidiztna. Then there are changes in the bones.
Intravenous pyelogram may determine the localization of the shadows that reveal that native radiography. whether the projection of the kidneys and urinary tract. They can detect and urate stones, giving a negative shadow, because they miss the X-ray beam.
Pyelogram may show enlargement or narrowing of the urethra, enlargement of the pelvis. If the stone is completely clogged ureter pyelogram shows that it is a good match is off.
Phosphate stones do not miss X-ray beam and can be seen on the native image: it is large and can have a look koraliformni outlining the negative image of kidney and renal pelvis cup.
The examination of urine in cases of aseptic kamijenja is almost always acidic pH of urine, while in cases of secondary kamijenja of struvite, the reaction is alkaline.
In cases of infected calculi, especially in infections with germs volume reaction is amphoteric or weakly acidic, if the stones of phosphate.
Macro-and microhematuria is an important objective sign.
The massive pyuria is in cases of large kamijenja followed by infection. Not rarely it is the only sign that indicates the coral rocks.
Leukocyturia is found in cases of aseptic kamijenja.
Proteinuria in cases where there is developing next interstitional pyelitis and nephritis.
Laboratory
In cases of renal adenoma kamijenja the parathyroid glands often have increased levels of calcium in the blood and reduce phosphorus. However, if the renal failure occurred phosphorus levels can be increased.
The amount of calcium that is excreted via urine (normal 100 to 300 mg/24 hours) increased by more than 300 mg. They may be greater than the amount entered for food. If a failure occurs burežna calcium decreases.
Alkaline phosphate is normal (if there are no changes to the bones).
In the case of oxalate kamijenja can be increased excretion of oxalic acid through urine, by 29.5 mg in 24 hours. Increased oskalurija is not a constant finding.
Most patients with stones burežnim has crystals in urine oxalate, phosphate, uric acid or mixed. The crystals are not always the same chemical composition as well as kidney stones.
Kristalurija does not mean that it creates stones. Oksalurija example. often exists as an independent phenomenon, but in connection with the oxalate stones. It is known that there may be both true as much for the massive oksalurije uraturije (during leucosis).
From the nature of the crystal can be concluded about the nature of stone, which is especially true for the crystals of uric acid and urate: tripelfosfati found in cases of ammoniacal decomposition of urine, which allows for the creation of struvite stones.
In cases uratnog kamijenja reaction of urine is usually acidic and the pH is 5.5 and below, while in healthy controls from 5.2 to 6.6, in patients with oxalate stones approximately 5.9, in people with 3.6 phosphate stones or more . The acidity of the urine of patients with urate stones is rather constant phenomenon, and tends to disappear only in cases of secondary infection.
The urine sediment can be found crystals of uric acid, and quite often, and calcium oxalate. After a meal rich in purines can really increase the amount of urine urate (physiological amounts of uric acid which is excreted in urine 24 hours is 500-1000 mg in normal diet).
Uric acid levels may be elevated, but this is not a constant finding.
In cases cistinskog kamijenja, increased excretion through the urine, the normal maximum of 70 to 150 mg increasing to 200 mg to several grams.
Functional testing
Examination of the functional state of the parathyroid gland is necessary because hipenparatireoidizam (due to tumor, the endometrial glands) can cause changes of bone (osteitis fibrosa), hypercalcemia, nephrocalcinosis and kidney stones. It is the primary hyperparathyroidism.
There is also a secondary hyperplasia of the parathyroid glands in chronic renal failure is usually increased phosphorus levels, which occur secondary hyperplasia of the parathyroid glands.Consequence of the fibro-osteoklazija bones. In this case, no nephrocalcinosis.
All renal function may be reduced, especially if the infection in addition to renal kamijenja.
Characteristically, polyuria with hipostenurijom and often hiperazotemija. Was reduced glomerular filtration and renal plasma opticanje.
Elevated serum calcium and phosphorus is reduced. Alkaline phosphatase was elevated (cases of parathyroid gland hyperfunction). The urine and the elevated amount of calcium and phosphorus.
If there is renal insufficiency with azotemia and acidosis, then the concentration of phosphorus in the blood increases.
The sequence of signs, symptoms, according to the parameters of significance for the diagnosis
Anamnesis
Renal colic, caused by the earthquake of the body, with the characteristic radiation of pain, followed by the emergence of macro-or microhematuria, sometimes throwing stones.
High temperatures in the case of urinary tract infection. Sometimes they have a septic type.
Endoscopy of the bladder and in particular ureteral ostium may indicate the upper tract stones. Island, petechiae, bumps on the form of tumors, fibrin cloth protruding from the ureteral ostium, pyuria, hematuria from the ureteral stone, slow evacuation of the hromocistoskopiji colors, or even termination of excretion.
Ureteral catheterization, possibly with radiography at the same time can make a stone localization. If the stone is stuck, then the catheter is not retractable.
CT and radiographic findings
Visible stones. The negative image of stone in the cases of pure uratnog kamijenja.
Laboratory
Kristalurija, hematuria, pyuria once. Changes in the concentrations of calcium and phosphorus in the blood and urine.
Functional status:
It can perform the reduction of global function, glomerular function, renal plasma opticanja.
In cases of renal hyperparathyroidism due kamijenja phosphorus reabsorption index is lower than in cases of healthy people, in terms of the same intake of calcium and phosphorus.
Functional characteristics of
Kidney stones damage the kidneys, reducing all of its function, global function, glomerular filtration, tubular function.
Function impairment, even the most difficult - anuria may occur due to mechanical barriers, clogging the channel, which is the removal of loose stone.
In cases of primary hyperparathyroidism in the global phase-preserved renal function and glomerular filtration rate index decreased reabsorption of phosphorus.
Forecast
Nephrolithiasis is a difficult disease: poslijedične renal lesions may be an evolutionary karketer.
Evolution is faster and more severe prognosis in cases with urinary infection.
Prognosis is better in cases uratnog kamijenja kamijenja small size and because of the possibility of stone throwing in a natural way.
Evolution is a rapidly progressive cases of failure to koraliformnog and recidivišućeg kamijenja (after surgery).
Working conditions can worsen the situation as an example. work in the area with excessively high temperature.
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