CALCULI FORMATION

Bonifacio | Bueno | Burton | Busa | Cariaga

FEU NRMF Medicine 1-C

CALCULI

• An abnormal or pathologic

concretion or mass of

mineral salts that occur in

the body

• Precipitation or

crystallization of minerals

in organs such as the

kidneys or the gall bladder

CALCULI

FORMATION CALCULI

FORMATION

GALLSTONE FORMATION

FORMATION GALLSTONE FORMATION

CALCULI

GALLSTONES

• Cholesterol stones • Most common

• Form when amount of cholesterol exceeds or supersaturates capacity of bile

• Pigment stones

• From crystallization of calcium bilirubinate

• May indicate infection

• Black or brown

TYPES OF CALCULI

CALCULI

RENAL STONES

•Calcium stones

• Most common renal stones

• Contain Ca, PO4, oxalate

• Caused by excessive Ca in the body

• Hyperparathyroidism

TYPES OF CALCULI

CALCULI

•Uric acid

• Formed due to

• Low urine output

• High protein diet

• Increased alcohol

intake

•Struvite

• Affect more women

than men

• May accompany

renal infections

TYPES OF CALCULI

RENAL STONES

CALCULI

RENAL STONES

•Cystine

• Rare

• Typically occur in individuals with family

history of cystinuria

TYPES OF CALCULI

CALCULI

GALLSTONES: Cholesterol

• Supersaturation of bile with cholesterol

• Intestinal hypomotility

• Excess in pro-nucleation factors, deficiency of

anti-nucleation factors

• Hypersecretion of mucus in the gall bladder

PROMOTING FACTORS

CALCULI

GALLSTONES: Pigment

• Elevated levels of unconjugated bilirubin in the blood

• Hemolytic diseases

• Severe ileal dysfunction

• Intestinal hypomotility

• Infection of the biliary tree • Bacteria (E. coli)

• Parasite (Ascaris lumbricoides)

• Fungi (Ophiocordyceps sinensi)

PROMOTING FACTORS

CALCULI

RENAL STONES

•Slow urine flow

•Damaged urinary tract lining

•Absence of inhibitory proteins (nephrocalcin, Tamm-Horsfall protein, uropontin)

• Intake of medication

•Dehydration

PROMOTING FACTORS

CALCULI

RENAL STONES

•Urine pH

• Acidic pH: favour precipitation and formation

of uric acid stones and cystine stones

• Alkaline pH: CaPO4 stones and struvite

stones

PROMOTING FACTORS

CALCULI

RENAL STONES

•Sufficient consumption of water

•Decreased protein intake

•Reduced sodium consumption

•Frequent drinking of water

PREVENTIVE FACTORS

CALCULI

RENAL STONES

•Normal concentration of urine elements

•Normal urine parameters (volume, pH,

etc)

•Presence of inhibitory proteins (Tamm-

Horsfall protein, nephrocalcin, uropontin)

•Prevention of urine stasis (timely and

sufficient voiding)

PREVENTIVE FACTORS

CALCULI

GALLSTONES

•Normal composition of gall bladder

contents

•Low-fat, low-cholesterol diet

•High fiber intake

•Decreased sugar consumption

•Physical exertion/exercise

PREVENTIVE FACTORS

CALCULI

CHOLELITHIASIS UROLITHIASIS Increasing age Middle aged (35-45)

Female gender Male gender

Gall bladder stasis Urinary stasis

Pregnancy Geography

Diet, obesity, physical inactivity Diet, obesity

Ethnicity Nationality

Cirrhosis History of cystinuria

Family history Family history of nephrolithiasis

Ileal disease, ileal resection Chronic UTI

Medications Dehydration

Rapid weight loss

RISK FACTORS

CALCULI

•CLDN-14

•Polymorphisms occuring at:

•Calcium-sensing receptor (CSR)

•Vitamin D receptor (VDR)

•Osteopontin (OPN)

GENETIC BASIS OF PREDISPOSITION

CALCULI

GALLSTONES

• Pulsating, propagating pain that disappears

shortly after it begins

• Pain in the upper right portion of the abdomen

• Pain immediately below the area of the breast

• Pain in the right shoulder • Referred pain

CLINICAL MANIFESTATIONS

CALCULI

RENAL STONES

• Severe pain in the back and sides of the

abdomen, just below the ribs

• May spread to groin area

• In the case of an infection, symptoms include

nausea or vomiting, fever, and chills

CLINICAL MANIFESTATIONS

CALCULI

RENAL STONES

CLINICAL MANIFESTATIONS

• Painful urination

• Hematuria or pink, red, or

brown urine with a foul

odour

• Changes in the voiding

pattern

• Small amounts of urine

may be voided at a time.

CALCULI

RENAL STONES

• Severe renal obstruction and the possibility of

infection

• Kidney failure

GALLSTONES

• Gall bladder inflammation

• Common bile/pancreatic duct blockage

• Gall bladder cancer

COMPLICATIONS

CALCULI

RENAL STONES

• Urine examination

• Hematuria

• Pyuria

• BUN, creatinine, and electrolytes

• Abdominal ultrasound

• Intravenous pyelogram (IVP)

LAB DIAGNOSIS

CALCULI

GALLSTONES • Elevated serum aminotransferase, alkaline phosphatase, bilirubin and amylase

• Blood test: look for signs of infection, obstruction, pancreatitis, or jaundice.

• Oral cholecystogram

• Bile microscopy

• Cholescintigraphy

• Physical examination (Murphy’s technique)

• MRI, CT scan, ultrasound

LAB DIAGNOSIS

CALCULI

GALLSTONES

DIAGNOSIS

CALCULI

GALLSTONES

•Administration of Ursodiol

•Contact distribution therapy

•Use organic solvent methyl tert-butyl

ether (MTBE)

•Surgical removal

TREATMENT

CALCULI

RENAL STONES

•Extracorporal shockwave lithotripsy

(ESWL)

•Percutaneous nephrolithotomy

•Ureteroscopy

•Open surgery

•Medication

TREATMENT

CALCULI

RENAL STONES

TREATMENT

Etiology Intervention Dosage/Recommendation

URIC ACID

Normal 24-h uric acid

levels, but urine pH

<5.5

Alkali-citrate preparations

(preferred)

Potassium citrate:40-60 mEq

of citrate in 24 h (divided

doses)

Sodium-based preparations Sodium bicarbonate: 1, 300

mg bid

CYSTINE

Genetic:

Autosomal

Recessive

Restrict dietary methionine

(sulfur) intake

Limit meat, eggs dairy

products, legumes, grains

Alkali-citrate preparations Potassium citrate: 40-60 mEq

of citrate in 24h (divided

doses)

CALCULI

RENAL STONES

TREATMENT

Etiology Intervention Dosage/Recommendation

CYSTINE

Genetic:

Autosomal

Recessive

Sodium-based preparations Sodium bicarbonate: 1, 300mg

bid

Thiol-binders α-mercaptopropionylglycine

(tiopronin): 200-300md tid

(up to 1, 000mg in 24h)

D-penicillamine: 250mg qd;

gradually titrate to 2, 000mg

in 24h

Captopril: 50mg tid (not

preferred)

CALCULI

RENAL STONES

TREATMENT

STRUVITE

Urine pH >7;

Chronic infection of

genitourinary tract with

urease-producing

bacteria (Proteus,

Pseudomonas, or

Kiebsiella spp) or yeast

Surgical treatment (preferred) Ureteroscopy, percutaneous

nephrolithotomy

Urease inhibitors AHA; 250 mg tid-qid (up to 1,

500mg in24 h)

Hydroxyurea: 500mg qd

Antibitotics (short duration)

Ciprofloxacin: 250-500mg bid

Levofloxacin: 250-750mg qd

Ofloxacin: 200mg bid

Urine acidifiers Ammonium chloride: 1, 000mg

bid-tid

Methionine: 200-500mg qd-

tid

Betaine: 650mg tid with a

meal

Cranberry juice: > 16 oz in

24h

CALCULI FORMATION

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