kidney stones in the adolescent patient

8/13/2019 Kidney Stones in the Adolescent Patient

1/16

Morning Report

Erin Fuchs

PGY2January 15, 2014


2/16

Case/History 15 year old female who presents with acute

onset worsening abdominal pain Had initially begun around 11am at school

Ate lunchnot all of it, but some, but pain

continued to worsen Mom picked up after school, brought home, and

pain has since continued increasing

Presents to the ED at approximately 6-7PM with

10/10 right lower quadrant abdominal pain thatradiates to her back.

Since coming home from school she has hadnausea and vomiting x2 secondary to pain


3/16

ROS: Positive for abdominal pain radiating toback, nausea/vomiting x2. Otherwise negative

MEDS: Synthryoid, Advil (400mg day before),Excedrin Migraine

ALL: NKDA

PMH: Hypothryoidism, otherwise negativeIMMS: UTD

FHx: Negative for GI disorders or other chronic

illnessesSHx: Not currently or ever sexually active; noconcerns about STI or pregnancy; Regularperiods; denies tobacco, alcohol, or illicit drugs


4/16

Physical Exam

WT: 41.9 kg, T 36, HR 80, RR 20, SpO2 RA GEN: Writhing on bed, cannot appear to find a

comfortable position, occasionally crying

HEENT: NCAT, PEERLA, EOMI, TMs clear, OP pink

w/o exudate or erythema, MMM NECK: FROM, (-)cervical LAD

CV: RRR, S1, S2, (-)murmur, 2+ radial pulses

RESP: CTAB, (-)wheeze, rhonchi, crackles

GI: BS+, soft, nondistended, negative HSM. TTPesp in RLQ and LLQ

BACK: +Right flank pain

EXT: WWP


5/16

15 year old female with acute onset

right quadrant abdominal pain


6/16

DDxInfectious Disease:

Gastroenteritis Viral Illness

Appendicitis

Pneumonia

Hepatitis

Pharyngitis

Gastrointestinal: Constipation

Intraabdominal abscess

Cholecystitis

Pancreatitis

Perforated ulcer

Abdominal migraine

IBD

Primary Bacterial Peritonitis

MeckelsDiverticulum

CV:

Myocarditis

Pericarditis

MISC:

Trauma Adhesions

Sickle cell syndromevasoocclusive crisis

Familial Mediterranean fever

ENDO/RENAL: UTI

Urolithiasis

DKA

Henloch SP

HUS

OB/GYN:

Ovarian torsion

Ruptured ovarian cyst

Ectopic pregnancy

Labor

Pelvic Inflammatory Disease


7/16

Studies

CBC: WBC 5.7 (N65%, L26%, M7%), Hgb 12.2, Hct35, Plts 185

CRP:


8/16

Imaging US Appendix: Tubular structure projecting in right lower

abdomen. This is believed to represent the distal rightureter rather than appendix, given dilatation of right renalcollecting system and proximal ureter. No distal ureteralstone seen.

-> increased bladder distention

US Pelvis: Normal of uterus and ovaries; probable dilatedright ureter. Suspicious for renal stone

CT without contrast: Mild pelviectasis of right kidney and ureterectasis of proximal

right ureter. No renal or ureteral stone

3 calcifications in region of cecum and terminal ilium -> likelyfecaliths. No dilated appendix.

No etiology for abdominal pain seen.


9/16

Kidney StonesDefinitions:

Urolithiasis: renal stones at

any location within the

urinary tract

Nephrolithiasis: stones

formed exclusively in the

kidneyNephrocalcinosis:

deposition of calcium salts

in the renal parenchyma,

including the tubular lumen,

tubular epithelium, and

interstitium

Deposits usually are

either calcium oxalate

or calcium phosphate


10/16

Epidemiology

Ages 10-19 = 4% of total episodes of

nephrolithiasis

Boys more affected at younger ages (up to 10

yo)

More common in Caucasians

Most common stone:

Calcium oxalate (45-65%)

Calcium phosphate (14-30%)

Struvite (13%)


11/16

Presentation

Depends on age:

Younger kidsdont often see radiating flank pain

Inverse relationship between age and pain (60, 40, 20%

in adolescents, school-age,


12/16

Evaluation/Diagnosis Good History Previous renal stone, family history,

abnormalities, metabolic conditions,medications, recurrent UTIs

PE Labs

UA

Ucx

Serum Creatinine Imaging

Abdominal X-rayRadiopaquestones

Ultrasoundlimited to radiolucentstones and urinary obstruction

Noncontrast CTmost sensitive


13/16

Acute Management

Pain management NSAIDs

Opiods

Passage Most


14/16

Prevention

2/3 patients developed 1 or more additionalstones within 5 years

Evaluate underlying risk factors: Stone analysis

Metabolic evaluation Serum tests: Ca, Phos, HCO3, Cr, Mg, Uric Acid

Urine tests 24-hour urine collections

Interventions: Fluid Intake

Metabolic


15/16

References

Barr, Ronald. "Abdominal Pain in the Female Adolescent." Pediatrics in Review. 4.9(1983): 281-289. Web. 15 Jan. 2014.

Ferry, George. "Causes of acute abdominal pain in children and adolescents."UpToDate. Wolters Kluwer Health, 19 Aug 2013. Web. 15 Jan 2014.

Fishman, Mary, Mark Aronson, and Mariam Chacko. "Chronic abdominal pain inchildren and adolescents: Approach to the evaluation." UpToDate. Wolters

Kluwer Health, 19 Dec 2013. Web. 14 Jan 2014. Lendvay, Thomas, Jodi Smith, and F Bruder Stapleton. "Acute management of

nephrolithiasis in children." UpToDate. Wolters Kluwer Health, 18 Jun 2013.Web. 15 Jan 2014.

McKay, Charles. "Renal Stone Disease." Pediatrics in Review. 31.5 (2010): 179-188.Web. 15 Jan. 2014.

Smith, Jodi, and F Bruder Stapleton. "Clinical featurs and diagnosis of

nephrolithiasis in children. UpToDate. Wolters Kluwer Health, 03 Jun 2013.Web. 15 Jan 2014.

Smith, Jodi, and F Bruder Stapleton. "Epidemiology of and risk factors fornephrolithiasis in children." UpToDate. Wolters Kluwer Health, 29 Aug 2013.Web. 15 Jan 2014.

Smith, Jodi, and F Bruder Stapleton. "Prevention of recurrent nephrolithiasis inchildren. UpToDate. Wolters Kluwer Health, 03 Jun 2013. Web. 15 Jan 2014.


16/16

The EndThink Happy Thoughts .

kidney stones in the adolescent patient

Documents