Question

A 45-year-old grocery sales clerk has been suffering from bouts of severe pain in his left flank region. He blamed it on prolonged standing for 8 hours straight while working. He was taking over-the-counter pain medications for his pain. One day, he found fresh blood in his urine. He went to a doctor who performed urine tests, CT scans, and x-rays. He was diagnosed with urinary calculi.

• Discuss possible factors that may have been responsible for the development of the stone and use this case to show how the patient's diet and water intake can help analyze the composition of the calculi.
• What would be the test results of his white blood cells, blood calcium levels, CT scan, and x-ray?
• Suggest the best treatment for the patient and a plan to prevent recurrence post-treatment.

Answer 1

Here, factors responsible for urinary calculi to occur are a) due to prolonged straight standing for 8hrs.

b) dehydration due to insufficient water intake and may also be due to sweating.

Fluid intake and dietary assessment are important to analyze the composition of urinary calculi and also to treat and prevent their formation. Both these factors promote or inhibit the stone formation.

The drinking water samples are analyzed for pH, alkalinity, TDS( total dissolved solutes of both organic and inorganic minerals), electrical conductivity (EC) and salinity. Acidic pH and mineral contents by EC indicate the inorganic pollution ( potassium, calcium, magnesium, oxalate, sodium).

Evaluate dietary intake of sodium, oxalate, calcium, protein ( both animal and plant), dietary supplements. Dietary assessment done by 24 hr recall along with 24hr urine collection, food record diet history and food frequency questionnaire.

Based on the food intake and urinalysis, adequate medical and dietary treatments are provided.

Test results: 1.Raised WBC, if calculi formation associated with infection.

2. Raised blood calcium levels, if calculi is due to deposits of calcium.

3. CT scan - It enables precise detection and location of urinary calculi. Common findings- Direct visualization of stones in ureteric lumen with or without ureteral dilatation. Secondary findings: perinephric fat stranding and edema, periureteral edema, hydroureter and hydronephrosis. All these aren't necessarily present.

4.Xray findings: depends on the stone composition. Opaque in Calcium containing stones. Radiolucent in uric acid and cystine stones.

Treatment given here is along with pain relievers, alpha blocker like Tamsulosin given as it relaxes muscle of ureter and allow the stones to pass. As the patient complains of bloody urine, the size of the stones maybe of larger sizes, extensive treatment like ESWL (extracorporeal shockwave lithotripsy) done. But due to its drawback of bleeding, surgery (percutaneous nephrolithotomy which is the BEST TREATMENT for this patient) is done.

Plan to prevent recurrence post treatment:

1.Advice the clerk to drink lots of plain water or citrus juices like lemon, orange, grapes etc. Drinking 1.8- 2.8 lts / day (2 - 3 quartz per day) cause the stones to move and keep them from growing.

2.To avoid standing for a long time.

3. Avoid or reduce animal protein intake.

4. To eat more calcium rich foods, less sodium and less oxalate rich foods.

5.To explore herbal medicines.

6. To avoid vitamin C supplements.