By Tedler D. Depaynos, MD
It was just after midnight when the 34 years old female patient from La Trinidad was brought to the ER because of severe abdominal pain. After a brief work-up, the diagnosis of a stone in the right kidney was confirmed. It reminded us of a similar case we encountered 2 months earlier. Both were with super severe abdominal pain and were rushed to the hospital at a very unholy hour.
The other patient was a 29 years old male patient from Itogon. He was twisting with severe abdominal pain radiating to the right lumbar area. It started suddenly 2-3 hours earlier when he was about to lie down to sleep after a hard tiring work in their private tunnel digging continuously for the precious and evasive gold ore. Actually, it was his second pain attack. The first attack occurred two weeks earlier and although it was also severe, it just lasted less than an hour receding very fast. When he went back to his usual hard work, his companions even cracked jokes that he was just malingering and wanted to go home suddenly because his wife just arrived after a two months vacation visiting her parents in their province.
He originally refused to be brought to the hospital hoping that the attack would also be transient. Besides, it was already nearly midnight and the trip to the hospital would take an hour or more. The pain became so severe and unbearable however so that he practically started begging to be brought to the ER. His distant neighbor who was already in deep slumber agreed readily to drive them to the hospital despite his sleepy eyes after seeing the pathetic condition of the patient.
That is how painful the attacks of kidney stones. Experienced doctors always include this medical condition in their differential diagnosis when they encounter patients suffering from this kind of pain. The sudden excruciating pain usually occurs when the stone moves or travels down the ureter, the urine tube pathway from the kidneys to the urinary bladder. In general, the pain also stops when the stone stops moving. Because the moving stone may erode the walls of the ureter, blood may be admixed with the urine. In most cases, the blood is just microscopic because of the urine coming also from the other kidney. Although the patient mentioned that in his first attack he noticed an episode of apparent blood stained urine, he did not have it in this second attack.
If the stone is small (around .4 cm. in diameter), it may pass the whole length of the ureter into the urinary bladder and finally excreted thru the urethra. These patients are then advised to observe their urine because the small stone may be excreted. Urinating thru a gauze which will act as a filter may catch the passed stone.
A larger stone may get stuck in the kidney or ureter and may block the passage of urine. This may not be apparent because of the urine coming from the other functioning kidney. However if this is left as is, the dammed urine may eventually destroy the involved kidney. The pressure inside the kidney and ureter will gradually increase and will cause their eventual dilatation and destruction if not relieved. The felt pain will be vague but increasing in severity as the organs gradually dilate.
Actually, this is the main danger of kidney stones – obstruction of the passage of urine. Kidney stones even though plenty provided they do not cause urinary obstruction may be left alone.
Urologists who specialize in this surgical field, however, study individual cases meticulously and advise removal of the stones not only because of actual obstruction but for other indications. The visualized stones may cause inevitable or potential occurrence of obstruction. Why wait for obstruction to occur? Being foreign bodies, they may be the cause of non responsive or chronic urinary tract infection. Patients with stones may chronically have repulsive foul smelling urine despite the increased intake of fluids. Lately after several studies, they may be the cause of malignancy especially in the urinary bladder.
The patient underwent ultrasound of the kidneys, ureters and urinary bladder and although both of the kidneys appeared normal, the right proximal ureter looked dilated implying that there was obstruction distal to it. The stones probably originated from the kidney. With special x-ray procedures, a stone was visualized causing obstruction hence the dilatation.
Previously, the only option to remove the stone is surgery. Nowadays, a Lithotripter machine which creates “shock waves” is employed by highly trained urologists to break the stones into small particles which may then easily be excreted in the urine. With the use of ultrasound or x-rays to pinpoint exactly the location of the stones, adjoining tissues are left undamaged making the procedure highly safe. In general the size of the stone should be around 2 cm or less for a single session of shock wave therapy. Bigger stones may require several sessions or outright surgery depending on the expert assessment of the attending urologist.
Patients are sedated or anesthetized during the procedure so that they will just be asleep and feel nothing. It usually lasts for an hour and when patients are awakened, they may immediately be discharged and not confined. A lawyer coffee mate of ours even invited us for bottles of alcoholized water immediately after he successfully undergone the procedure to celebrate.
The patient was back to his usual work in no time at all.
Kidney stones are small hard deposits of mineral and acid salts usually found on the inner surfaces of kidneys. Normally the deposits may be diluted and dissolved in the urine. When urine is concentrated however mainly due to inadequate fluid intake, the minerals with time may crystallize, stick together and solidify. With the presence of calcium, they harden and become non-dissolvable despite the many prescribed “herbal” medicines that are supposed to dissolve the stones.
Incidentally, my clinic roommate is a young Urologist who had extensive training at the Veterans Medical Center. Majority of their patients were elderly “veterans”, hence most of the cases they handled were diseases of the “elderlies” especially the males.**
