Case report VI

VESICOLITHIASIS



Compiled by :
FAISAL D BRAWIDYA 1102009104
MUHAMMAD ARDYANSYAH PRATAMA 1102009179

PRECEPTOR:

Dr. H. Herry Setya Yudha Utama, Sp.B, MHKes, FInaCs


CLINICAL SURGICAL
Hospital Arjawinangun Yarsi


IDENTITY

Name: Mr. M
Age: 65 years
Gender: Male
Occupation: Wiraswasta
Address: majalengka

HISTORY TAKING (ALLOANAMNESIS)

Main complaints: Pain when urinating
Additional complaints: -
History Disease Now:
The patient came to the hospital emergency room complaining of pain
Arjawinangun because when pee grievances felt since 2 weeks ago. Perceived pain
disappear and appear and progressively worse. Red pee, Pee was not satisfied, no
nausea and vomiting.
Past history of disease:
Deny patients had diabetes mellitus, hypertension.
Family history of disease:
Patients admitted in my family no one has ever experienced the same thing as the
patient.

PHYSICAL EXAMINATION
Status generalist
General Condition : Moderate Pain
Awareness : Compos mentis
Vital Signs : BP: 120/80 mmHg
N: 82 x / min
S: 36.6 C
R: 24 x / min
Head : Normocephal
Eyes : Conjunctiva anemis - / -
Sclera jaundice - / -


Pupillary reflex - / -
Neck : The thyroid was not palpable enlarged, the KGB was not palpable enlarged
thoracic:
I cast: iktus cordis is not visible
Q: iktus cordis palpable on ICS V line midclavikula
Q: cardiac borders easily assessed
A: BJ regular I-II, murmurs (-), gallop (-)
Pulmo
I: symmetrical piston movement in a static state and dynamic
Q: vocal fremitus at the right and left hemithorax
P: resonant to both lung field
A: Vesicular, rhonki - / -, wheezing - / -
abdomen
I: convex, symmetric, surgical wound (-)
A: Bowel (+) normal
Q: Timpani whole abdominal field
Q: soft, tenderness (+)
extremity
Left Right Superior: edema (-), warm akral
Right inferior Left: edema (-), warm akral



EXAMINATION SUPPORT
Routine blood

LAB RESULT FLAGS UNIT NORMAL
WBC 18.0 10^3/ 4.0-12.0
LYM 1.8 10^3/ 1.0-5.0
MON 0.4 10^3/ 0.1-1.0
GRANUL 10.3 10^3/ 2.0-8.0
LYM % 8.9 % 25.0-50.0
MON% 4.4 % 2.0-10.0
GRANUL% 86.9 % 50.0-80.0
RBC 4.89 10^6/ 4.0-6.20
HGB 15.4 g/dl 11.0-17.0
HCT 43.5 % 35.0-55.0
MCV 89.0 80.0-100.0
MCH 31.5 Pg 26.0-34.0
MCHC 35.4 g/dl 31.0-35.0
RDW 12.4 % 10.0-16.0
PLT 170 10^3/ 150.0-400.0
MPV 7.0 7.0-11.0
PCT 0.193 % 0.200-0.50
POW 13.4 % 10.0-18.0
Thorax X-Ray:
Cast not enlarged, normal diaphragm
Pulmo : normal Hili
Increased lung pattern
Roomy hard looking stains on the middle left and bottom right field
Software does not seem rickshaw


USG Result:
Vesicolithiasis
DIFFERENTIAL DIAGNOSTIC
Tumor buli-buli
Nephrolithiasis
PROPOSED EXAMINATION SUPPORT
1. Laboratory examination:
Culture and urine sediment
2. Radiological examination:
Plain abdominal.
Cystogram.
BNO-IVP.
THERAPY
Conservative therapy: waiting for the results of the investigation
1. dilution
2. Force diuresis
3. Giving Antibiotics and Analgesics
Operative therapy
Vesicolitectomy
PROGNOSIS
Dubia ad bonam.



Review Of The Literature

A. DEFINITION
Urolithiasis is a disease that is symptomatic of the formation of stones in the urinary
tract. Suspected urinary tract stone formation related to urine flow disorders, metabolic
disorders, urinary tract infection, dehydration, and other circumstances that remain unclear
(idiopathic).
Epidemiologically, there are several factors that facilitate the occurrence of urinary tract
stones at someone. These factors are intrinsic factor which is the state that comes from one's
body and extrinsic factors that influence comes from the surrounding environment.

Intrinsic factors such as:
A. Hereditary (hereditary). The disease is thought to be derived from his parents.
2. Age. The disease is most often obtained at the age of 30-50 years.
3. Gender. The number of male patients are three times more than the number of female
patients.
Several extrinsic factors such as:
1. Geography. In some areas show the incidence of urinary tract stones are higher than other
areas and became known as the stone belt (belt rocks), while the Bantu in South Africa
found almost no urinary tract stone disease.
2. Climate and temperature.
3. Water intake. Lack of water intake and high levels of calcium in mineral water
consumption can increase the incidence of urinary tract stones.


4. Diet. Many purine diet, oxalate, and calcium facilitate the occurrence of urinary tract stone
disease.
5. Job. The disease is often found in people who are sedentary or less pekerjannya activity or
sedentary life style.

B. THEORY OF THE FORMATION OF STONE TRACT.
The theory of the formation of stones:
A. The theory of the core (nucleus); crystals and foreign body is where the deposition of
crystals in the urine which have had a supersaturasi.
2. Matrix theory; organic matrix derived from serum or urine protein-protein offers the
possibility of precipitation of crystals.
3. The theory of crystallization inhibitors; some substance in the urine to inhibit the
crystallization, the low concentration or absence of this substance allows the crystallization.

C. Etiology TRACT STONES:
A. Idiopathic.
2. Disorders of urine flow.
- Phimosis.
- Stricture meatus.
- Hypertrophy of the prostate.
- Vesicoureteral reflux.
- Ureterokele.
- Constriction associated with ureteropelvik.
3. Metabolic disorders.
- Hyperparathyroidism.
- Hiperuresemia.
- Hypercalciuria.
4. Urinary tract infections by microorganisms that can make a urease (Proteus mirabilis).
5. Dehydration.
6. Foreign objects.
7. Tissue death (necrosis papil).
8. Multifactorial.
- Children in developing countries.
- Patients multitrauma.


Theoretically can form stones in the entire urinary tract, especially in places that are
experiencing barriers to the flow of urine (urinary stasis), namely the system of renal calices
or jar. Congenital abnormalities in pelvikalises (uretero-pelvic stenosis), diverticular, chronic
obstructive infravesika as in benign prostate hyperplasia, stricture, and neurogenic bladder is
a condition that facilitates the formation of stones.
A rock composed of crystals composed of organic and inorganic materials dissolved in the
urine. The crystals remain in a metastable state (remains dissolved) in the urine in the absence
of particular circumstances which caused the precipitation of crystals. Precipitation of
crystals held together to form a rock core (nucleation) which would then hold the
aggregation, and other interesting material so that it becomes larger crystals. Although the
size is large enough, aggregate crystals are fragile and not quite able clogs up the urinary
tract. For the aggregate crystals stick to the urinary tract epithelium (shape retention crystals)
and from other materials deposited on aggregate to form stones that are large enough to block
the urinary tract.
Metastable condition is influenced by temperature, pH, presence of colloids in the urine, the
concentration of solute in the urine, urine flow rate in the urinary tract, or the corpus alienum
in the urinary tract that acts as the core stone.
More than 80% of urinary tract stones composed of calcium stones, both of which bind with
oxalate or phosphate, forming calcium oxalate stones and calcium phosphate, while the rest
comes from uric acid stones, magnesium ammonium phosphate stones (infection stones),
stone xanthyn, cysteine stones, and other types of stone. Although the pathogenesis of stone
formation in the almost same, but the atmosphere inside the urinary tract that allows the
formation of the rock types are not the same. In this simple example uric acid stones form in
acidic conditions, while the magnesium ammonium phosphate stones form because the urine
is alkaline.

D. COMPOSITION STONE


Urinary tract stones in general contain the following elements: calcium oxalate or potassium
phosphate, uric acid, magnesium ammonium phosphate (MAP), xanthyn, and cystine,
silicates, from other compounds. Data regarding the content / composition of substances
contained in rocks is very important for prevention efforts against the possibility of stone
residif.

Calcium stone
Stones of this type most often found, which is approximately 70-80% of all urinary tract
stones. The content of this type of rock composed of calcium oxalate, calcium phosphate, or
mixtures of the two elements.
Factor of calcium stones are:
A. Hiperkalsiuri, the levels of calcium in the urine is greater than mg/24jam 250-300.
According to Pak (1976) there are three kinds of causes of hiperkalsiuri, among others:
- Hiperkalsiuri absorptive occurring due to an increased absorption of calcium through the
intestines.
- Hiperkalsiuri occur because of impaired renal reabsorption of calcium through the ability of
the kidney tubules.
- Hiperkalsiuri resorptif is due to the increase in bone calcium resorption is the case with
primary hyperparathyroidism or parathyroid tumors.
2. Hiperoksaluri, the excretion of urinary oxalate in excess of 45 grams per day. This
situation is often found in patients with disorders of the intestine after undergoing intestinal
surgery and patients who consumed foods rich in oxalate, among which are: tea, instant
coffee, soft drinks, cocoa, strawberry, lemon, and green vegetables, especially spinach.
3. Hyperuricosuria, the levels of uric acid in urine in excess of 850 mg/24jam. Excessive uric
acid in the urine acts as a core rock / nidus for calcium oxalate stone formation. Source of
uric acid in the urine comes from the foods that contain lots of purine or derived from
endogenous metabolism.
4. Hipositraturia, in the urine reacts with the calcium citrate form of calcium citrate, thus
blocking the binding of calcium with oxalate or phosphate. This is possible because the
binding of calcium citrate is more soluble than calcium oxalate. Therefore, citrate can act as
an inhibitor of calcium stone formation. Hipofosfaturi can occur in renal tubule acidosis
disease or malabsorption syndrome, renal tubular acidosis, or the use of thiazide diuretics
group in the long term.


5. Hipomagnesuria, as well as the citrate, magnesium acts as an inhibitor of calcium stone
incidence, because the magnesium in the urine reacts with oxalate to magnesium oxalate thus
preventing the binding of calcium with oxalate. The most common cause is hipomagnesuria
inflammatory bowel disease (inflammatory bowel disease) followed by malabsorption
disorders.

Uric acid stones
Uric acid stones is 5-10% of all urinary tract stones. Between 75-80% of uric acid stones
composed of uric acid and the remainder is a mixture of pure calcium oxalate. Uric acid stone
disease affects many patients with gout disease, myeloproliferative disease, patients receiving
anti-cancer therapy, and a lot of drug use among the sulfinpirazone urikosurik, thiazide, and
salicylate. Obesity, alcohol consumption, and high-protein diet have a greater opportunity to
get this disease.
Source of uric acid from purine-containing diet and endogenous metabolism in the body.
Degradation of purines in the body through inositat acid converted into hipoxanthyn. With
the help of xantyhn oxidase enzyme, hipoxanthyn which eventually turned into xanthyn
converted into uric acid. In mammals other than humans and dalmation, have enzymes that
can alter urikase uric acid into allantoin which is soluble in water. In humans because it does
not have that enzyme, uric acid is excreted into the urine in the form of free uric acid and
urate salts are more likely to bind to the sodium to form sodium urate. Sodium urate more
soluble in water compared with uric acid-free, making it impossible to hold a crystallization
in the urine.
Relatively insoluble uric acid in the urine so that in certain circumstances is easy to form
crystals of uric acid, and subsequently form uric acid stones. Factors that led to the formation
of uric acid is; urine is too acidic (pH urine <6), with small amounts of urine volume (<2
liters / day) or dehydration, hiperurikosuri or high uric acid levels.
Uric acid stone size ranged from small to large sizes so as to form staghorn stones that fill the
entire pelvikalises kidney. Not like a rock that looks kind of jagged calcium, uric acid stone is
smooth and rounded shape so it often came out spontaneously. Pure uric acid stones are
radiolucent, so that the examination of PIV appears as a shadow filling defect in the urinary
tract so often be distinguished by a blood clot, the formation of renal papillae necrosis, tumor
or fungal bezoar. On ultrasound examination gives an acoustic shadow (acoustic shadow).
To prevent recurrence of uric acid stones after treatment, is, drinking a lot, alkalanisasi urine
to maintain pH between 6.5 to 7, and keep not going to prevent the occurrence of


hyperuricemia hyperuricosuria. Every morning, patients are encouraged to check the pH of
the urine with paper nitrazin, and guarded so that no urine production less than 1500-2000 ml
per day. Uric acid levels examined periodically, and if there is hyperuricemia should be
treated with drugs xanthyn oxidase inhibitor, which is allpurinol.

E. EXAMINATION
Plain photo abdomen
Making a plain photo abdomen aims to look at the possibility of a radio opaque stones in the
urinary tract. Types of calcium oxalate stones and calcium phosphate is radio opaque and
most often found among the other stones, while the uric acid stone is non opaque (radio
lusen).

Intra Pielografi veins (PIV)
This examination aims to assess the anatomy and renal function. In addition it can detect the
presence of PIV semi-opaque stone or non-opaque stone that can not be seen by plain photo
abdomen. If the PIV can not explain the state of the urinary system due to a decrease in renal
function, as a successor is pielografi retrograde examination.

Ultrasonography (USG)
Ultrasound may be performed if the patient does not undergo PIV, which is in the state;
allergy to contrast material, decreased renal physiology, and in women who are pregnant.
Ultrasound examinations can examine the stone in the kidney or bladder shown as echoic
shadow, hydronephrosis, renal pionefrosis or shrinkage.

F. MANAGEMENT
Stones that have caused problems in the urinary tract should be removed as soon as possible
so as not to cause more severe complications. Indications for therapeutic action in the urinary
tract stones if the stone has caused: obstruction, infection, or should be taken as an indication
of the social.
Obstruction due to urinary tract stones that have caused hidroureter or hydronephrosis and
stone that has been causing a urinary tract infection, should be released. Sometimes urinary
tract stones do not cause complications such as above, but suffered by a person for the job (eg
stone suffered by an aircraft pilot) have a high risk can lead to blockage of the urinary tract in


question was at the time of their profession, in which case the rock must be expelled from the
urinary tract.
Stones can be removed by ESWL Medical solved through action endourology, laparoscopic
surgery or open surgery.



Medical
Medical treatment intended to rock the size of less than 5 mm, because the stone is expected
to come out spontaneously. Given therapy aims to relieve pain, facilitate the flow of urine by
administering diuretikum, and drink a lot in order to push the stone out of the urinary tract.

ESWL (Extracorporeal Shockwave LITHOTRIPSY)
ESWL is a rock-breaking tool that was first introduced by Caussy in 1950. This tool can
break up kidney stones, stones proximal ureter, or bladder stones without invasive and
without anesthesia. Stone broken into small fragments that easily excreted through the
urinary tract. Not infrequently the rock fragments that induce a feeling of being out of colicky
pain and cause hematuria.

Endourology
Endourology action is minimally invasive techniques to remove urinary tract stones are
composed of rock breaking, and then remove it from the urinary tract through a device that is
inserted directly into the urinary tract. The device is inserted through the urethra or through a
small incision in the skin (percutaneous). Stone-solving process can be done mechanically, by
means of hydraulic energy, the energy of sound waves, or with laser energy. Some of
endourology action are:
A. PNL (Percutaneous Nephro Litholapaxy), which issued the stone inside the kidney
channel by inserting an endoscope into the system calices instrument through an incision in
the skin. Stone is then removed or broken down into tiny fragments advance.
2. Lithotripsy, which breaks the rock or stone bladder urethra by inserting a rock-breaking
tool (litotriptor) into the jar. Rock fragments removed by evakuator Ellik.
3. Ureteroskopi or uretero-renoskopi, which include peruretram ureteroskopi tool to see the
state of the ureter or renal system pielo-Calix. By using a particular energy, the stone inside
the ureter and the system can be broken down through the guidance pelvikalises ureteroskopi
/ ureterorenoskopi this.
4. Dormia extraction, which issued a ureteric stone with Dormia basket menjaringnya through
the tool.

Laparoscopic Surgery
Laparoscopic surgery to take urinary tract stones are currently being developed. This method
is most often used to take the ureter.



OPEN SURGERY
In the clinics that do not have adequate facilities for the action endourology, laparoscopy, or
ESWL, stone retrieval is performed through open surgery. Open surgery include:
pielolitotomi or nefrolitotomi to pick up stones in the bile duct, and for stones in the ureter
ureterolitotomi. Not infrequently the patient must undergo nefrektomi action or decision
because the kidneys are not functioning kidneys and contains pus (pionefrosis), korteksnya is
very thin, or experiencing shrinkage due to urinary tract stones that cause obstruction and
chronic infection.

BLADDER STONE
Stone bladder or vesikolitiasis often occurs in patients suffering from micturition disorders
or there is a foreign object in bladder. Micturition disorders occur in patients with prostatic
hyperplasia, urethral strictures, bladder diverticular, or neurogenic bladder. Catheter attached
to bladder for a long time, the presence of other foreign objects that accidentally inserted into
the bladder is often a core for the formation of bladder stones. Besides bladder stones can be
derived from the kidney or ureter stones are dropped into a jar. In developing countries are
still common in endemic stone jars are often found in patients suffering children who are
malnourished or suffer from dehydration or diarrhea.
Typical symptoms of bladder stones is a form of irritation symptoms include: pain when
urinating (dysuria) to stranguri, uneasy feeling when urinating, and urinate all of a sudden
stop and then smoothly return with changes in body position. Pain during micturition is often
perceived (Referred pain) on the tip of the penis, scrotum, perineum, waist to toe. In children
often complain of eneuresis nokturna, in addition to frequently pulling his penis (in boys) or
rub the vulva (the girls).
Often the composition of bladder stones composed of uric acid or struvit (if the cause is an
infection), so it is not uncommon on a plain abdominal examination did not appear as an
opaque shadow in the pelvic cavity. In this case the PIV investigation on cystogram phase
gives a negative image. Ultrasound can detect radiolucent stones in a bladder.
Bladder stones can be solved by lithotripsi or if too large requires open surgery
(vesikolitotomi). It is no less important is to make corrections to the causes of urinary stasis.



LITERATURE

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