URETEROLITHIASIS (ureteral stones)

DEFINITIONS
Ureterolithiasis is a state of the accumulation of oxalate, calculi (kidney stones) in the ureter or in the kidney area. Ureterolithiasis occurs when a stone is in the urinary tract. The stone itself is called calculi. Rock formation began with crystals trapped somewhere along the urinary tract grows as the originator of the urine solution. Calculi vary in size and of a microscopic focus to a few centimeters in diameter large enough to fit within the renal pelvis. Symptoms of excessive pain in the waist, nausea, vomiting, fever, hematuria. Turbid urine color like tea or red. (Brunner and Suddarth, 2002: 1460).
Ureteral stones are generally derived from kidney stones down into the ureter. Ureteral stones may be passed down to the bladder and then come out with urine. Ureteral stones could also get into the bladder and then form a nidus into a large bladder stones. Stone can also remain in the ureter while clogging and causing chronic obstruction with hidroureter that may be asymptomatic. Not uncommon hematuria were preceded by an attack of colic. (R. Sjamsuhidajat, 1998 Page. 1027).
Urolithiasis is calcification with urinary calculi system, often called kidney stones. Stone can be moved into the ureter and bladder (Black, Joyce, 1997, p. 1595).
Urolithiasis is a solid object formed by the precipitation of various solutes in the urine in the urinary tract. Stone can be derived from calcium oxalate (60%), as a mixture of calcium phosphate, ammonium, and magnesium phosphate (triple phosphate rock as a result of infection) (30%), uric acid (5%), and cystine (1%). (Pierce A . Grace & Neil R. Borley, 2006, SURGICAL SCIENCE, p. 171).
Urolithiasis is a disease diamana obtained stone in the urinary tract, which starts from Calix to the anterior urethra. (DR. Nursalam, M. Nurs & Fransica BB, urinary system, p. 76).

B. Etiology
Till now cause stone formation is not known with certainty. Some of the factors predisposing to stone:
1. Kidney
Tubular damaged the nephrons, the majority of stone formation
2. Immobilization
Less movement of bone and musculoskeletal causes the accumulation of calcium. Increased calcium in the plasma will increase the formation of stones.
3. Infection: Urinary tract infections can lead to tissue necrosis and become the core of the formation of kidney stones.
4. Lack of drinking: the emergence of a potential occurs stone formation.
5. Work: with plenty of seating more than the rock formation allows the employment of a worker or farmer.
6. Climate: a cold temperature (room air conditioning) causes dry skin and lack of fluid intake. Place in warm climates such as in the tropics, in the engine room caused a lot of sweat, will reduce the production of urine.

7. Diuretics: potentially reduce the volume of fluid to improve the condition of the formation of urinary tract stones.
8. The food, the habit of eating foods high in calcium such as milk, cheese, peas, peanuts and chocolate. High in purines such as: fish, chicken, meat, offal. High oxalate such as: spinach, celery, coffee, tea, and vitamin D.


C. CLASSIFICATION
Theory of renal stone formation:
1. Theory Intimatriks
Stone formation Urethral require any organic substance as the core. The substance is composed of mucopolysaccharides and mukoprotein A which facilitate crystallization and aggregation substance of stone formation.
2. Theory Supersaturation
Saturation occurs in the urine of stone-forming substances such as cystine, santin, uric acid, will facilitate the formation of calcium oxalate stones.
3. Precipitation-Crystallization Theory
Urine pH changes will affect the solubility of the substance in urine. Urine acidic precipitates cystine, uric santin and salt, alkaline urine will precipitate phosphate salts.
4. Theory of Diminishing Obstacles
Obstacles such as peptides reduced phosphate, pyrophosphate, polyphosphate, magnesium citrate, acid mucopolysaccharides will facilitate the formation of Urethral Stone.

D. Clinical manifestations
Clinical manifestations of stones in the urinary tract depend on obstruction, infection and edema.
1. When the stones obstruct the flow of urine, obstruction, causing an increase in hydrostatic pressure and distention of the kidney and ureter proximal cup.
Infection (pyelonephritis and cystitis accompanied by chills, fever and dysuria) can occur from continuous irritation stone. Some stones causes few symptoms but slowly damages the functional units (nephrons) kidney
Tremendous pain and discomfort.

2. kidney stones in cup
a. Pain in and constantly in the area kastovertebral.
b. Hematuria and pyuria may be found.
c. Pain comes from the renal area spreads anteriorly and in women approaching pain down the bladder, while the man approached the testes.
d. When the pain suddenly became acute, accompanied by tenderness in the area kostoveterbal, and appeared Nausea and vomiting.
e. Diarrhea and abdominal discomfort may occur. The gastrointestinal symptoms as a result of reflex renoinstistinal and kidney anatomic proximity to the stomach pancreas and colon.
3. Stone who are stuck in the ureter
a. Causing a wave of tremendous pain, acute, and colic that spread to the thighs and genitalia.
b. Micturition curiosity but little urine comes out
c. Hematuria due to the action of the rock abrasion.
d. Usually stones may come out spontaneously with a diameter of 0.5-1 cm stone.
4. The stone that got stuck in the bladder
a. Usually cause irritation and symptoms associated with urinary tract infections and hematuria.
b. If the stones cause obstruction in the bladder neck will happen urinary retention.

E. Pathophysiology
The mechanism of stone formation in the urinary tract, known as urolithiasis not known with certainty. But there are several factors predisposing stones include: Increased concentration of urine due to lack of fluid intake and also an increase in organic materials due to a urinary tract infection or urinary stasis presents a nest for stone formation.
Supersaturation of urine elements such as calcium, phosphate, oxalate, and other factors favor stone formation include: pH of urine which turns into acid, the amount of solute in the urine and the amount of liquid urine. Problems with purine metabolism affects the formation of uric acid stones. Urine pH also supports the formation of stones. Uric acid stones and cystine stones can settle in acidic urine. Calcium phosphate stones and struvite stones are common in alkaline urine. Oxalate stones are not affected by pH of urine.
Immobilization of time will cause the movement of calcium into the bones will be hampered. Increased serum calcium will add fluid to be excreted. If the incoming fluid is inadequate then the buildup or deposition of this growing and increasingly complex deposition resulting in stone.
Stones that form in the urinary tract varies greatly, there is a small stone and a large stone. Small stone can come out through the urine and would cause pain, trauma of the urinary tract and blood in the urine will appear. While the large stone can cause urinary tract obstruction that causes dilation structure, as a result of dilatation urinary reflux will occur and fatal consequences may arise hydronephrosis due to renal dilatation.
Damage to the structure of the old kidneys will cause damage to organs in the kidneys, causing chronic renal failure because the kidneys are not able to perform its function normally.
Then it can happen CRF disease that can cause death.

F. EXAMINATION DIAGNOSTIC
1. urinalisa: yellow, dark brown, bloody. Generally showed red blood cells, white blood cells and crystals (cystine, uric acid, calcium oxalate), as well as fragments, minerals, bacteria, pus, urine pH acidic (increase cystine and uric acid stones) or alkaline improve magnesium, ammonium phosphate , or calcium phosphate stones.
2. Urine (24 hours): creatinine, uric acid, calcium, phosphate, oxalate or cystine increases.
3. Urine culture: indicate a urinary tract infection (stapilococus aureus, Proteus, klebsiela, pseudomonas).
4. Survey biochemistry: increased levels of magnesium, calcium, uric acid, phosphate, protein and electrolytes.
5. BUN / creatinine serum and urine: Abnormal (high in serum / low in the urine) secondary to high okkstuktif stones in the kidneys leading to ischemia / necrosis.
6. Levels of chloride and bicarbonate serum: increased levels of chloride and bicarbonate levels indicate a decrease in the occurrence of renal tubular acidosis.
7. Complete blood count: white blood cells may increase indicates infection / septicemia.
8. Red blood cells: usually normal.
9. Hb, Ht: abnormal when a patient with severe dehydration or polycythemia occurred (push presipitas compaction) or anemia (bleeding, renal dysfunction).
10. Parathyroid hormone: may increase when there is renal failure. (PTH stimulates the reabsorption of calcium from bone improve circulation serum and urine calcium).
11. X-ray: showed calculi or anatomical changes in the kidney area and along the ureter.
12. IVP: provides quick confirmation urolithiasis, such as the cause of abdominal or pelvic pain. Shows abdomen anatomic structures (distention of the ureter) and the outline of calculi.
13. Sistoureterokopi: direct visualization of the bladder and ureters can show stones and obstruction effects.
14. Stan CT: identify / describe calculi and other mass, kidney, ureter, and bladder distension.
15. Renal ultrasound: to determine changes obstruction, stone location.
G. COMPLICATIONS
1. Obstruction: by shards of stone
2. Infection: due to the dissemination of kidney stone particles or bacteria from obstruction
3. Damage renal function: due to blockage of a long pre-treatment and removal of kidney stones

H. PREVENTION
1. Keep adequate diuresis: 2-3 liters of drinking water per day can be achieved diuresis of 1.5 liter / day.
2. Implementation of the diet depends on the type of stone disease (high calcium low residual acid, a diet high in the rest of the base, and a low-purine diet).
3. Eradication of urinary tract infections in particular for struvite stones.

I. MANAGEMENT
1. The reduction of pain, reduce pain until the cause can be eliminated, morphine administered to prevent syncope due to extraordinary pain. Warm bath in the pelvic area can be beneficial. Fluids are given, unless the patient is vomiting or suffering from congestive heart failure or other conditions that require fluid restriction. This increases the hydrostatic pressure in the back room of the stone so that the stone passase pushed down. Fluid intake throughout the day reduces the concentration of crystalloid urine, dilutes the urine and urine output ensures great.
2. Appointment of stone, inspection and passase sistoskopik small ureteral catheter to remove the stone that causes obstruction (if possible), will immediately reduce the back pressure on the kidneys and reduce pain.
3. Nutritional therapy and medications. Nutritional therapy plays an important role in preventing kidney stones. Adequate fluid intake and avoid certain foods in the diet that is the main ingredient of stone formers (mis.kalsium), effective to prevent stone formation or further increase the size of existing stones. Drink at least 8 glasses a day to dilute the urine, unless contraindicated.
a. Calcium stones, reduction of calcium and phosphorus in the diet can help prevent further stone formation.
b. Phosphate rock, low phosphorus diet can be prescribed for patients who have rock phosphate, to cope with excess phosphorus, aluminum hydroxide jelly can be prescribed because this agent mixed with phosphorus, and mengeksikannyamelalui intensial channel instead of the urinary system.
c. Urate stones, urate stones to overcome, patients are required low-purine diet, to reduce the excretion of uric acid in the urine.
d. Oxalate stones, dilute urine oxalate maintained with income restrictions. Foods to avoid include leafy green vegetables, nuts, celery, chocolate, tea, coffee.
e. If the stone can not come out spontaneously or in case of complications, treatment modaritas include extracorporeal shock wave therapy, percutaneous stone pengankatan, or uteroroskopi.
4. Lithotrupsi Extracorporeal Shock Wave, is a noninvasive procedure used to destroy kidney stones Calix. After the stone was broken into small parts such as sand, the rest of the stones are expelled spontaneously
5. Method of Appointment endourology stone, endourology field combines the skills of radiologists and urologists to pick-renal stones without major surgery.
6. Uteroskopi, including visualization and askes ureter by inserting a tool through sistoskop ureteroskop. Crushed stone with a laser, electrohydraulic lithotripsy, or ultrasound and then removed.
7. Dissolution of the rock, fluid infusion kemolitik, to dissolve the stones can be done as an alternative treatment for patients with less risk to other therapies, and rejecting other methods, or those who have a rock soluble (struvite).
8. Appointment of Surgery, prior to lithotripsy, pengankatan kidney stone surgery is the main treatment. If the stone is located in the kidney, surgery is performed by nephrolithotomy (incision to remove the kidney stones or nephrectomy, if the kidneys are not functioning due to infection or hydronephrosis, stones in the kidney trophy diangat with pielolitotomi, while rock is removed with ureterolitotomi, and if the stone is sistostomi in the bladder., stone then been destroyed by the clamp tool. This procedure is called sistolitolapaksi.