Question

Chief Complaint: 52-year-old male with abdominal pain and nausea.  

History: The patient was woken up by abdominal pain located in his right lower quadrant, in the right groin and radiating into his right testicle. He was transported to the hospital. He reports that his pain is a “10” on a 1 to 10 scale. He is nauseated but has not vomited. The patient is normal weight and otherwise healthy. Upon palpation his abdomen is soft with mild tenderness in the right lower quadrant. Following the discovery of blood in his urine he is diagnosed with a ureteral obstruction, a computed tomography scan shows a calcified stone in the right ureter at the ureterovesical junction.

Guiding Questions

1. The ureterovesical junction (where the ureter passes through the wall of the bladder) is a common site for kidney stones to become impacted. Can you propose two additional sites within the ureter where kidney stones are likely to become impacted based on the anatomy of the ureters?

2. This patient was advised to increase his water intake to prevent subsequent kidney stones. Why would an increased fluid intake lower his chances for a repeat incident?

3. Assume that the kidney stone in question has reached the bladder. What is the pathway of exit for this stone (i.e. what anatomic structures must the stone still pass through)? Based on the anatomy of those structures, do you predict this to be difficult or easy? Defend your answer.

4. Propose a possible treatment for the patient in this case study. How does this treatment improve conditions for the patient? Are these improvements seen at the cellular, tissue, organ or systemic level?

Answer 1

1. The 2 sites other than the ureterovesical junction are uteropelvic junction and ureteral crossing of the iliac vessels.The stone lodged on the ureteropelvic junction will be having the larger diameter compared to that at the ureterovesical junction, thus chance of expulsion rate of the stone from the ureterovesical will be high. The stone lodge in these areas is because of the narrowing of the ureter is found at these regions
2. kidney stone are formed due to the accumulation of the wastes in the kidney due to the low level of fluid volume in the blood.The waste filtrated from the blood should be eliminated from the kidney , this will not occur in condition in which in the lack of fluid volume.That is for example if we take food with high salt content it will sodium content in the blood , so inorder to eliminate this high soadium content we must drink more water otherwise there will be hypertension and also the risk for the formation of kidney stone. The water intake help in the clearence of the waste from the kidney so that they will not accumulate in the kidney and excretory system , thus reducing the chance of kidney stone
3. the stone after reaching bladder has to urethra to the exterior.The lodging of the stone at the external orifice of the bladder can cause feeling of urination.This will happen if the stone is of larger diameter otherwise it will easily pass through the bladder , as it has transition epithelium which help in the stretching of the of te urinary bladder and urethra which help in the easy expulsion of small stones with the patients having high water intake. Thus in such patients with the expulsion of the water in the urine stone is also carried out.But if it is of larger diameter i will get stuck in the urethra.In this case endoscope removal should be done to break the larger stones inorder to facilitate its expulsion or manually remove it
4. treatments can be

• surgery - in this case, surgically remove the stone by making a cut in the ureter and then taking away the stone. So the block is removed, thus the function of organ will be replenished in the normal way
• extracorporeal shock - wave lithotripsy - it is done to break large stone so that they can be naturally expelled by the natural urination
• percutaneous nephrolithotomy - this help in the breaking of the stones larger than 2cm thus in smaller size they can be expelled
• this all technique facilitate the starting of normal function of the urinary system.Thus improvement can be seen in the systemic level with normal functioning of the system
• to prevent further chancs of occurence advise to drink more water and reduce intake of diet which has high salt content
• Also avoid cola and beer as it can increase phosphoric acid
• also reduce tea,coffee intake also try to avoid grape and orange juice