The following is the knowledge about stones, have a look.
lithangiuria
Urinary calculi refer to the abnormal aggregation of some crystalline substances (such as calcium, oxalic acid, uric acid, cystine, etc.). ) and organic substrates (such as matrix A, TammHorsfall protein, acidic mucopolysaccharide, etc. ) in the urinary system. It is one of the common diseases in urinary system. There are more men than women, about 4.5∶ 1. The formation mechanism has not been fully clarified, and the recurrence rate is high. Most stones have no ideal prevention method. The incidence of urolithiasis is regional. In China, it is more common in the south of the Yangtze River, and the incidence rate is higher in Guangdong, Shandong, Jiangsu, Anhui, Hebei, Shaanxi, Xiangjiang, Guangxi, Sichuan and Guizhou. It is rare in the north. In the past 30 years, the incidence of upper urinary tract (kidney, ureter) stones has increased significantly in China, and lower urinary tract (bladder) stones have become less and less common. Among bladder stones, primary stones are obviously less than secondary stones. In recent ten years, the treatment of urinary calculi has developed rapidly, and about 90% of urinary calculi can no longer be treated by traditional open surgery.
Formation mechanism of urinary calculi
It is considered that the basic formation process of urinary calculi is that some abnormal weight factors lead to the increase or decrease of the concentration of crystal substances in urine, which is supersaturated, and crystals form crystal nuclei with organic substances, then crystals grow and gather locally, and finally stones are formed. There are significant differences between upper urinary calculi and lower urinary calculi in formation mechanism, etiology, stone composition and epidemiology. Most upper urinary tract stones are calcium oxalate stones. Magnesium ammonium phosphate stones are more common in bladder stones than in upper urinary tract. Although some kidney calculi have definite etiology, such as hyperparathyroidism, renal tubular acidosis, spongy kidney, gout, foreign body, long-term bed rest, obstruction, infection, etc., at present, the etiology of most calcium stones cannot be completely explained. Nucleation, stone matrix and crystal inhibitor are the three basic theories of stone formation. According to the different formation mechanism of upper urinary tract stones, some people divide them into stones related to metabolic factors and infectious stones. Metabolic calculus is caused by metabolic disorder, such as hyperparathyroidism, hypercalciuria, hyperuricemia and hyperoxaluria caused by various reasons. High concentrations of chemical components damage renal tubules, increase matrix substances in urine, precipitate salts and form stones. Infectious stones are deposited by bacteria that produce urease to decompose urea in urine to produce ammonia, which makes urine alkaline and phosphate and ammonium urate in urine relatively saturated. Bacteria, infection products and necrotic tissue are also the core of stone formation. The distribution of stones in renal pelvis is the most common, followed by renal calices, and renal parenchyma is rare. Calculi in renal calices are mostly located in the lower renal calices, and the bilateral kidney calculi is less than 65,438 00%. Stones can cause injury, infection and obstruction of renal pelvis and calyx, which lead to ulcers before epithelial shedding and finally form scars. Obstruction caused by stones is mostly incomplete. Urine can flow into the ureter around stones, but there may be renal pelvis enlargement, renal pelvis wall hypertrophy and fibrosis. If stones are embedded in the junction of renal pelvis and ureter or in ureter, hydronephrosis, renal pelvis malformation and renal pelvis enlargement will occur, which will seriously cause renal cortex atrophy and damage, leading to renal failure.
Factors affecting the formation of urinary calculi
Many factors affect the formation of urinary calculi. The salts that form stone crystals in urine are supersaturated, and the lack of substances that inhibit crystal formation in urine and the existence of nuclear matrix are the main factors that form stones.
Epidemiological factors
Including age, sex, occupation, socio-economic status, diet composition and structure, water consumption, climate, metabolism and heredity. Upper urinary calculi are common in 20 ~ 50 years old. There are more men than women. The peak age of male onset is 35 years old. There are two peaks for women, 30 and 55. During the Second World War, the incidence of upper urinary calculi decreased, but it rose sharply during the intermission and nearly forty years, suggesting that it was related to the changes in economic income and diet structure. Experiments show that the increase of animal protein and refined sugar in diet and the decrease of cellulose promote the formation of upper urinary calculi. Drinking more water can dilute urine and reduce the formation of crystals in urine. The same high temperature environment and reduced activity are also influencing factors, but occupation and climate are not the only decisive factors.
(2) Urine factors
1. Excessive excretion of calculus-forming substances: increased excretion of calcium, oxalic acid and uric acid in urine. Long-term bed rest, hyperparathyroidism (absorbable hypercalcemia), idiopathic hypercalcemia (absorbable hypercalcemia-increased intestinal calcium absorption or renal hypercalcemia-decreased renal tubular calcium absorption), other metabolic abnormalities and renal tubular acidosis all increase urinary calcium excretion. Gout, persistent urine acidity, chronic diarrhea and thiazide diuretics all increase uric acid excretion. Increased endogenous oxalic acid synthesis or intestinal absorption can cause hyperoxaluria.
2. Uric acid decreases and pH increases.
3. Decreased urine volume will increase the concentration of salt and organic matter.
4. The content of substances that inhibit crystal formation in urine is reduced, such as citric acid, pyrophosphate, magnesium, acidic mucopolysaccharide and some trace elements.
(3) Abnormal anatomical structure, such as urinary tract obstruction, leads to the deposition of crystals or matrix at the site with poor drainage, and urinary retention leads to urinary tract infection, which is beneficial to the formation of stones.
(4) urinary tract infection
The cause of most calcium oxalate stones is unknown. Calcium phosphate and magnesium ammonium phosphate stones are related to infection and obstruction. Uric acid stones are related to gout. Cystine calculus is a rare family hereditary disease, which is caused by the excretion of a large amount of cystine in urine.
Composition and properties of urinary calculi
Calcium oxalate stones are hard, rough and irregular, often mulberry-shaped and brown. Calcium phosphate and magnesium ammonium phosphate stones are fragile, with rough and irregular surfaces, grayish white, yellow or brown, and X-ray films show stratification, often forming staghorn stones. Uric acid stones are hard, smooth or irregular, often multiple, yellow or reddish brown, and pure uric acid stones are not shown by X-ray. Cystine stones are smooth, yellow to yellowish brown, and have a waxy appearance.
physiopathology
Pathological and Physiological Changes Caused by Urinary Calculi Renal calices can be in situ without enlargement. It can also expand and develop into the renal pelvis. When the neck of renal calices is obstructed, it will lead to the accumulation of hydrops or pus in renal calices, which will lead to renal parenchymal infection, scar formation and even perirenal infection. Calyx stones can also enter the renal pelvis or ureter. Stones can be discharged naturally or left in a certain part of the urinary tract. When stones block the ureteropelvic junction or ureter, they can cause acute complete obstruction or chronic incomplete obstruction. There was no renal damage after the obstruction of the former was relieved in time. Chronic incomplete obstruction leads to hydronephrosis, which gradually damages renal parenchyma and affects renal function. Larger renal pelvis stones have slight damage to renal parenchyma and function. Stones can damage urinary tract mucosa, leading to bleeding and infection. Infection is more likely to occur when there is obstruction. Infection and obstruction can also promote the rapid growth or re-formation of stones. Stones in the renal pelvis or bladder occasionally lead to malignant transformation. Stones gradually grow in the kidney, filling the renal pelvis and part or all of the renal calices, forming staghorn stones. It can be secondary to infection or without any symptoms. After the stones enter the ureter, they often stay or incarcerate at the physiological stricture, that is, the junction of renal pelvis and ureter, and the junction of ureter crossing iliac vessels and ureter and bladder. Because the inner diameter of ureter becomes thinner from top to bottom, stones are most common under ureter 1/3.
clinical picture
First of all, symptoms
It mainly depends on the size, shape and location of stones, as well as the irritation, obstruction and secondary infection of stones to urinary tract. Kidney calculi's and ureteral calculi often present as pain in the waist or abdomen. It is mild to feel pain or discomfort in the waist, and severe to have a knife pain. This kind of pain seems to be unbearable for few people, and doctors call it renal colic. Often sudden attacks, pain often radiates to the lower abdomen, groin and inner thigh, while women radiate to the labia. When colic attacks, patients often have abnormal painful expressions, press their hands on their abdomen and waist, curl up in bed, and even roll on the bed, groan and sweat. The attack usually lasts for several hours, but it can also relieve itself within a few minutes. Accompanied by nausea, vomiting and hematuria. Bladder calculus, urethral calculus. Their symptoms are different. (1) Bladder stones are often manifested as urination interruption and pain. The pain is dull pain in the lower abdomen and perineum, and can also be obvious or severe pain. The pain at the end of urination is aggravated, which may be accompanied by end-stage hematuria. Patients often want to lie down to relieve pain. If stones are embedded in the bladder neck, there will be obvious dysuria, or urination interruption or acute urinary retention. The patient must change his position or shake his body to continue urinating. At this time, there will be sudden severe pain, which can radiate to the penis, penis head and perineum. Children with bladder stones often have symptoms such as unbearable pain, sweating, crying loudly, pulling or rubbing penis with hands or grasping perineum with hands, and changing various postures to relieve pain. ② Urethral calculi are characterized by dysuria, dripping water, and sometimes urinary flow interruption and urinary retention. There is obvious pain when urinating, and it radiates to the penis head. Pain in perineum and scrotum due to posterior urethral calculi. Penile stones can be felt in the painful part, and forced urination can sometimes discharge stones. There is purulent secretion in the urethra of the infected person. Female urethral diverticulum stones often have frequent urination, urgency, dysuria, pyuria and hematuria; Sexual pain is a prominent symptom. Male urethral calculi not only have urethral secretions and dysuria, but also have gradually enlarged and hard masses under the penis, with obvious tenderness, but no symptoms of urinary tract obstruction.
1, asymptomatic calculus kidney calculi can be completely asymptomatic, even when it causes obstruction, but it can be unexpectedly found by X-ray abdominal photos or B-ultrasound for other reasons. Some cases may have microscopic hematuria. In some cases, stones are found because of primary diseases (hyperparathyroidism or gout).
2, pain kidney calculi migration and obstruction in the ureteropelvic junction, or into the ureter, can occur typical renal colic, often at night or early in the morning suddenly attack, pain began in the rib ridge angle of dull pain, gradually strengthened to severe pain, along the side of the ureter, radiation to the vulva and vulva, often accompanied by nausea and vomiting. But sometimes the pain is not necessarily typical renal colic, but only low back pain or abdominal pain, which is easily misdiagnosed as acute abdomen. Sometimes stones can migrate to the ureter asymptomatic, and they can show chronic dull pain in the renal pelvis or calyx. The downward movement of the pain point often means that the stone moves to the lower end of the ureter, and the pain of stone discharge can disappear.
3, hematuria Renal colic is often accompanied by gross hematuria or microscopic hematuria, asymptomatic stones are mostly mild microscopic hematuria, and stone movement is significant hematuria.
4. Patients with urinary tract obstruction and infected stones are prone to urinary tract infection, because it may cause urinary tract obstruction, which may be asymptomatic bacterial urine or obvious symptoms of urinary tract infection. Obstruction and infection will soon lead to renal parenchyma damage and renal insufficiency. It should be noted that if stones cannot migrate outside the ureter in the bladder, frequent urination, urgency and dysuria may occur, which is easily confused with urinary tract infection.
5. Acute renal failure stones block the healthy ureters of patients with solitary nephropathy, causing acute urethral obstruction, such as blocking bilateral ureters, which can cause acute renal failure.
Second, the sign
There may be percussion pain in the kidney area, tenderness at the rib waist point or rib ridge angle, and tenderness along the ureter.
Third, common complications.
Common complications of urinary calculi include urinary tract infection, urinary tract obstruction, obstructive nephropathy and acute or chronic renal failure.
Treatment includes symptomatic treatment, traditional Chinese medicine treatment, extracorporeal shock wave lithotripsy, endoscopic lithotripsy and surgical lithotripsy.
(1) Symptomatic treatment: mainly to control renal colic. After a definite diagnosis, atropine 0.5 mg and dolantin 50 mg can be injected intramuscularly. The painful part can also be hot compress or acupuncture, and the sensitive part of the waist can be closed with subcutaneous procaine (skin test first). You can also plug the anus with propranolol or indomethacin.
(2) Chinese medicine lithotripsy: It is suitable for stones with a diameter less than 1cm, oval shape, smooth surface and no hydronephrosis in pyelography. Therapeutic drugs: clearing away heat and promoting diuresis, such as Lysimachia christinae and Lygodium japonicum. Clearing away heat and toxic materials, such as Cortex Phellodendri, Flos Lonicerae and Fructus Forsythiae. Promoting blood circulation and removing blood stasis, softening and resolving dampness, such as Rhizoma Sparganii and Rhizoma Curcumae. Tonify kidney such as cinnamon, aconite, cistanche deserticola, etc. Tonify qi and blood, such as Dangshen and Huangqi. There are also various stone-discharging particles, which are convenient to use.
(3) Extracorporeal shock wave lithotripsy: X-ray-oriented Dornier machine was used to treat upper ureteral calculi, which extended to the middle and lower ureteral calculi. The upper ureteral calculi should be in oblique semi-recumbent position, and the stones in the overlapping part of iliac wing should be in prone position. Semi-sitting position can be used in the lower section, and a certain success rate can be achieved by increasing the voltage. Although stones in all parts of the ureter can be crushed by extracorporeal shock waves, patients with small stones and high fat sometimes have problems such as difficult positioning, deep location and high energy consumption. Compared with crushing kidney calculi, it is relatively difficult to crush ureteral calculi, and the overall effect is not as good as that of kidney calculi. Therefore, it is necessary to strengthen the accuracy of positioning during shock wave. If it is difficult, it is necessary to do excretory urography or cystoscopy retrograde intubation and angiography at the same time to assist positioning. It is ideal if the stone can be pushed into the renal pelvis and then subjected to shock wave. Contrast agents can pass through stones and are usually easily broken and discharged. On the contrary, even if the stone is not big, there is obvious water accumulation on it, especially with periureteritis, or the retrograde intubation can not reach below the stone, so the effect of shock wave lithotripsy is often poor. For smaller stones in the lower ureter, ureterectasis, stone insertion and incision can be performed through cystoscope. In recent years, although it is reported that the success rate of ureteroscopic lithotripsy or laser and ultrasonic lithotripsy is 40 ~ 78%, it is worth noting that serious complications such as perforation and tearing can be caused during operation.
(4) Surgical incision and lithotomy: Indications: ① Ureteral stenosis; ② Urodynia caused by incarcerated infection of bilateral or unilateral ureteral stones; ③ Patients with large stones, severe hydronephrosis and poor renal function; ④ Extracorporeal shock wave cannot be located or the shock wave fails; ⑤ Tumor or tuberculosis cannot be ruled out clinically; ⑥ Economic factors. Urinary plain film should be taken 2 hours before operation to locate. If it is a large stone in the lower ureter of a woman, sometimes the stone is felt through vaginal vault examination and discharged by massage.
Several problems in the treatment of urinary calculi with combination of traditional Chinese and western medicine
1. About the problem of diagnosis (identification of the nature of stones) The diagnosis of urinary stones is not difficult, but there is also a problem of the nature of stones, mainly calcium or urate crystals. Understanding its composition plays a vital role in analyzing the condition and deciding the treatment plan (whether to operate or not). The patient can be identified by another x-ray examination or radiography. If the X-ray film has obvious stone shadow, it should be mainly urate crystals or mixed stones.
2. Stones lead to hydronephrosis complicated with infection. Hydronephrosis often occurs in patients with ureteral stones and obstruction. Once the stones are embedded in the upper, middle and lower strictures of a section of ureter, the ureter above the obstruction will expand and complicated with hydronephrosis. After a long time, it will be complicated with infection, such as frequent urination, urgency, dysuria, chills and fever, which will cause renal parenchyma damage, impaired renal function and anuria or nephromegaly. At this time, in addition to timely anti-infection treatment, surgical consultation is also required, otherwise the consequences will be unimaginable.
3. Screening effective litholytic drugs is the basis of treating urinary calculi. How to screen more effective drugs for dissolving calculus on the premise of syndrome differentiation and treatment is the key to treat lithiasis. The author thinks that all diuretic drugs have the effect of removing stones. Lysimachia christinae, pyrrosia, Lygodium japonicum and chicken's gizzard-membrane have better dissolution effect. Some traditional Chinese medicines that do not enter the kidney meridian and bladder meridian also have good litholytic effect, such as Yujin and Yinchen. The compatibility of Herba Artemisiae Scopariae and Radix Curcumae with Herba Lysimachiae Christinae, Folium Pyrrosiae, Endothelium Corneum Gigeriae Galli and Spora Lygodii has a more remarkable clinical effect.
4. The role of promoting blood circulation, promoting diuresis, relieving pain and removing stones is guided by the general principle of promoting diuresis and treating stranguria. In the process of stone extraction, patients sometimes suffer from renal colic, mainly due to diuresis, which makes the stones move down, causing severe pain, spontaneous reflex vomiting, and at the same time turning blue, sweating and moaning. Based on the basic prescription for treating kidney calculi, the author added some drugs for promoting blood circulation and promoting diuresis, such as Radix Aucklandiae, Fructus Aurantii, Rhizoma Corydalis, Radix Paeoniae Alba, Radix et Rhizoma Rhei, etc. To increase ureteral peristalsis and discharge stones. After taking the medicine for half an hour, intramuscular injection of 1 progesterone or atropine was used to relieve spasm and pain.
5. About hematuria In the process of treating urinary calculi, patients often have hematuria. The main reason is that in the process of effective stone removal, stones rub the ureter intima and produce hematuria. When using hemostatic drugs such as Anluoxue and Zhixuemin, Cortex Moutan, Herba et Gemma Agrimoniae, Lalang Grass Rhizome, Sanguisorba officinalis, Cirsium japonicum, Radix Rubiae, Radix Notoginseng or Yunnan Baiyao should be added to Paishi Decoction. These drugs can stop the bleeding.
6. As for surgical treatment and drug treatment, it is effective to take surgical treatment for stones with calcium salt as the main content above 1.5 cm. Calculi mainly composed of urate crystals, regardless of size, should be treated conservatively by internal medicine. Patients can avoid the pain of surgery. Generally, it is advisable to lay stones or combine with extracorporeal ultrasonic lithotripsy, and then take traditional Chinese medicine to consolidate the curative effect. Patients with hydronephrosis, after 1 month and a half of treatment, can't lay stones and should be treated surgically.