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  • • Costovertebral angle/ flank pain

    • Pain may radiate to the ipsilateral lower abdominal quadrant

    • Hematuria

    • Nausea, vomiting, intestinal ileus

    • Radiographic evidence of renal or ureteral calculus

    • Fever, if proximal infection present

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Epidemiology

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  • • Many affected patients have history of prior renal calculi

    • -Roughly 50% chance of developing second stone within 5 years of the first calculi

    • Hypercalcuria is a metabolic risk factor for stone formation, seen in:

    • -Hyperparathyroidism

      -Excess calcium and vitamin D intake

      -Immobilization osteoporosis

      -Paget disease

      -Sarcoidosis

      -Dehydration

    • Urea-splitting bacteria create magnesium-ammonium phosphate (struvite) stones

    • Metabolic stones form from the hypersecretion of uric acid or cystine

    • Other metabolic risk factors include:

    • -Hyperuricosuria

      -Hypocitraturia

      -Hypomagnesuria

      -Hyperoxaluria

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Symptoms and Signs

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  • • Moderate to severe costovertebral angle/flank pain that does not improve with change in position

    • Pain may radiate to ipsilateral lower abdominal quadrant depending on location of calculus

    • Often nausea and vomiting, associated with an intestinal ileus

    • Gross hematuria occurs more often than microscopic

    • Symptoms of pyelonephritis with proximal infection (costovertebral angle tenderness, high fever, chills, dysuria)

    • Nonobstructive calculi are typically asymptomatic

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Laboratory Findings

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  • • Evidence of hematuria

    • Pyuria, bacturia, and leukocytosis with secondary infection

    • Urine pH > 7.6 suggests presence of urea-splitting organisms

    • Urine pH < 5.5 suggests metabolic stone formation (uric acid and cystine)

    • Hypercalcemia and hypophosphatemia consistent with hyperparathyroidism

    • Hyperchloremic metabolic acidosis consistent with renal tubular acidosis with secondary renal calcifications

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Imaging Findings

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  • • 90% of stones are radiopaque (calcium, cystine, and struvite) and seen on plain films

    • Uric acid stones are non-radiopaque, but can be seen on spiral CT

    • Spiral CT without contrast demonstrates entire urinary tract and can distinguish between stones, tumor, and blood clots

    • Excretory urography will verify stone location and provides qualitative information on renal function

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  • • Acute pyelonephritis

    • Renal adenocarcinoma (hematuria)

    • Transitional cell tumors (obstruction)

    • Renal papillary necrosis

    • Renal infarction

    • Acute pancreatitis

    • Psoas abscess

    • Symptomatic abdominal aortic aneurysm (AAA)

    • Acute appendicitis

    • Acute salpingitis

    • Herpes zoster

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Rule Out

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  • • Symptomatic/ruptured AAA

    • Proximal infection

    • Presence of a urologic neoplasm

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  • • CBC

    • Basic chemistries

    • UA

    • Urine culture and sensitivities

    • Qualitative urine cystine

    • Abdominal x-ray

    • Spiral CT without contrast ("stone protocol") diagnostic test of choice

    • Calculi composition analysis if recovered

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When to Admit

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  • • Fever and leukocytosis

    • Severe ureterorenal colic requiring parenteral analgesics

    • Inability to tolerate PO fluids or analgesia

    • Obstruction complicated by infection, requiring percutaneous nephrostomy tube or ureteral stent for drainage

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When to Refer

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  • • All patients should be managed by a urologist

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  • • 80% of ureteral stones pass spontaneously

    • -Passage depends on stone size and location—a 5 mm distally located ...

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