IMAGE OF THE WEEK

WEEK 36

Nephroliathiasis is a common urological disorder in the world and in Brunei Darussalam it is one of the common causes of end stage renal failure. This disorder has afflicted humans for centuries, in fact renal and bladder calculi have been found in Egyptian mummies.

Clinical presentation is very typical with patient complaining of recurrent loin pain (renal calculi) or colicky loin pain which in most instances may radiate to the groin, particularly with ureteric calculi. The pain can be so severe that patient rolled around or move around  to ease the pain. There may be associated nausea and vomiting in 50% of patients. Urinary symptoms such as frequency and dysuria may also be present. Patient may also be proned to recurrent urinary tract infection.

Abdominal examination is usually unremarkable and peritonism is usually absent. Palpation of the loin may elicit pain particularly if hydronephrosis is present due to ureteric obstruction by a calculi. Urine microscopic examination is an important part of investigation if a suspicion of renal calculi is made and microscopic haematuria is usually present in 85% of cases.

Radiological investigations

Key radiological investigation is a plain KUB as 80% of urinary tract calculi are visible as calcified lesionthe one shown in Figure 1. The urinary tract including the renal outline, the renal pelvis at L2 and 1-2cm lateral to the spine, the ureter vertical downwards at the tips of the lumbar transverse processes down to the sacroiliac joint and laterally along the pelvic brim before coming medially to join the inferior bladder border. Urinary tract calculi are located  in the pelviureteric junction in 12.58%, 10.69% in the proximal ureter, 6.91% in the mid ureter, 28.93% in the distal ureter, and 40.88% in the pelviureteric junction.

 Renal ultrasound is also useful but reported sensitivity is low at 73% for detecting urinary tract calculi compare to CT KUB with a reported sensitivity of 97% and specificity of 96%. Because of the high sensitivity and specificity, CT KUB is becoming a popular imaging modality for investigating nephroliathiasis (Figure 2).

Treatment modality

Conservative with good hydration for small stones

Percutaneous nephrostomy for acute hydronephrosis in order to salvage renal function

ExtraCorporeal Shockwave Lithotripsy (ESWL)

Percutaneous Nephrostolithotomy

Open nephrostomy

Flexible uretroscopic extraction or DJ stent insertion

Images contributed and prepared by Mr William Chong, Department of General Surgery, RIPAS Hospital, Brunei Darussalam.

All images are copyrighted and property of RIPAS Hospital.