schego time is one of the most
common urologic diseases. Morbidity ICD regions
Russia varies from 25,5% (Urals) to 41,5% (Eastern Siberia), and patients with
various forms of this pathology account for 35 - 50% of hospital beds urological
hospitals. In According to many authors, this disease as a manifestation of metabolic disorders
will tend to increase due to the deteriorating environmental situation
.
why, and why?
unified concept of etiopathogenesis of ICD currently there, because it
development affects the state of many organs and systems - as congenital,
and acquired pathology, as well as poor socio-economic conditions,
pollution of the environment, etc. in connection with which some authors attributes this
disease in so-called diseases of civilization. Modern views on
etiopathogenic process of stone formation are shown in the scheme.
climatic and biogeochemical factors (to the latter include chlorides,
sulfates, pesticides in water and food) have a direct toxic or
an indirect effect on the human body, causing metabolic disorders in
biological environments, and lead eventually to the emergence of tubulopaty,
manifest violation of the purine, oxalic-acid and phosphoric
-calcium exchange. Increasing concentrations kamneobrazuyuschih factors in seasm and urine
leads to crystalluria, which for lack of substance supporting
colloidal stability of urine and contribute to the maintenance of salt dissolved
as well as for changes urine pH leads to adhesion of the crystals and thus
to the formation of microliths, which is the trigger mechanism of stone formation.
to these substances include solubilizers (hippuric acid, xanthine, chloride
sodium citrate, magnesium), as well as inhibitors of crystallization (
inorganic pyrophosphate, zinc ions, manganese, cobalt), whose concentration in the urine of patients with ICD
usually reduced. In chronic pyelonephritis the main role in stone formation
are metabolic products of a number of microbes (phenols , cresols and
volatile fatty acids), which also violate the metastable state
salts in saturated solution. a great role in stone formation are also different
kidney abnormalities, disturbances of urodynamics of upper urinary tract, microcirculation and
other pathologies .
Urinary stones, depending on the type of metabolism or the presence of
infections can be of different chemical composition: some of them have
monostaskturnoe stascture, butmoreoften polymineral, or mixed
buildings, stones. Knowledge stone stascture plays an important role in selecting
treatment and prevention methods. Currently, urologists around the world recognized
Mineralogical classification of urinary calculi.
Peculiarities of the diagnosis of IBC
Diagnosis of IBC is based primarily on complaints of patients, of whom
are the most important bouts of renal colic, especially repeated.
In the period between attacks observed dull pain in the lumbar region, discharge of
stones, hematuria, which usually occurs after physical exertion .
General clinical research methods can detect signs of kidney damage and urinary tract
(positive symptom Pasternatskogo, tenderness on palpation
in the kidney or in the course of the ureter, palpable kidney).
in blood tests taken during time of renal colic or pyelonephritis attack,
complicating the ICD revealed leukocytosis, shift to the left of leukocyte formula,
toxic granulation of neutrophils, increased erythrocyte sedimentation rate.
in the urine detected small amounts of protein, single cylinder, fresh red blood cells and
salt crystals, and pyelonephritis - leucocyturia.
X-ray examination is a leader in recognizing the stones in the kidney
or in the ureter. The most common method is to review
urography. It can be used to determine the magnitude, shape, stone, and
its localization. If necessary, in case coral-stone or doubts in regard to the involvement of
shadow to the urinary paths, make images in two projections.
City urogram should cover the entire area of the kidneys and urinary tract infections with both
parties.
But not all the stones make a shadow on the overview image, and in some cases the shadow,
suspected calculus, may belong to gallstones,
foreign body, calcified lymph nodes, etc. In the projection of small pelvis is often seen
rounded shadows - flebolity, similar to stone. After review
urography excretory urography should be carried out, which allows you to specify whether
applies shadow to the urinary paths, and to identify anatomic and functional status
kidney and localization concrement (in pelvis, ureter). When rentgenonegativnom
stone on the background of X-ray contrast agents can be seen filling defect,
appropriate concretions. As a general asle, excretory urogram
gives a complete picture of the excretory functions of the kidney, but after the attack renal colic
kidney is in a state of blockade and isolation of X-ray
substance on the affected side may be absent. In the study of kidney function
great help to have an isotopic techniques.
a role in the diagnosis of IBC is an ultrasound study of kidneys
and the bladder. indirect symptom of the benefit of having a stone upper urinary tract may serve
extension pyelocaliceal system.
retrograde pyelography with liquid radiopaque substances or oxygen (pnevmopielografiyu)
performed only in cases where doubts remain with respect to diagnosis or shade
stone is not visible, which is usually when rentgenonegativnom stone.
In the differential diagnosis is very important not to miss
acute appendicitis, acute cholecystitis, perforated ulcer, acute intestinal obstasction
, acute pancreatitis, ectopic pregnancy and other diseases.
All means are good ...
Over the past 10 years due to the widespread introduction in urological practice
modern technologies remove kidney stones and Urinary tract
significantly changed tactics and strategy of treatment of this disease. It should be emphasized,
that ICD - is a surgical pathology, and only 5% of patients (their stones are
of uric acid salts) are effective conservative methods, Specifically, litoliz.
most widespread (almost 85% of cases) has been used
distance shock-wave lithotripsy (DLT), which differs the least traumatic
.
As already mentioned, the DLT on the right to take leading role in the treatment of kidney stones and
ureter. This simple, low-impact and cost-effective way
treatment of stones is the method of choice, along with endoscopic and open
surgery. Especially effective application of DLT at
relatively small size stones (up to 2 cm) and stored functions
diseased kidneys. Well-established clinical examination of the population and the application of this method of treatment
can count on a significant decrease in severe forms
ICD complicated by urosepsis and renal failure who are
the main cause of death in this disease.
Today we can confidently say that the DLT
widely introduced into clinical urological practice. Office DLT operate inmorethan 90 cities in Russia
.
Simultaneously mastered and continues to develop new operational methods,
in most cases, avoiding open surgery and to achieve the desired result
with less risk to the patient. Among them are various and
endourological operation. The main criterion for choosing the method of endoscopic
destasction of the stone are the size, shape, position and length of stay
stone in the ureter. currently expanding indications for ICD therapy with
laser.
Algorithm for treatment of patients with ICD is shown in the scheme.
Features pharmacotherapy IBC
Given that any operation to remove the stone, is in fact
symptomatic treatment, we should note the growing role of various
conservative methods of treatment of IBC (dasgs, physiotherapy, and balneotherapy herbal medicine),
aimed at correcting the metabolic disorders and relapse prevention
stone formation.
In our practice we commonly use herbal medicine that improves
urodynamics in the upper urinary tract and amorerapid discharge of stones or fragments
and sand after their destasction by DLT.
Preference is given to easy to use officinal dasgs (avisan, olimetin, marelin,
phytol, Cystone, fitolizin, nieron, urofluks, Ural, tsistenal, rovatineks,
kedzhibelling, etc.), some of which increase the concentration of protective colloids in urine
.
In renal colic due to ureteral stones, shows analgesic and antispasmodic
(baralgin, maksigan, Trigano, etc.) or intramuscular
diclofenac (voltaren, diklorana, etc.). We often assign and so-called lytic
mixtures containing narcotic analgesics or promedol
pentazocine (Fortran), butorphanol (moradol), tramadol (Tramal), etc.
Recent studies have shown that in such cases, especially in renal colic
arising in the first days after the DLT, it is advisable to appoint
nonspecific anti-inflammatory dasgs (indomethacin, diclofenac,
piroxicam, etc.) and antioxidant therapy with dasgs such as essentiale,
phospholipids, lipostabil, vitamins E and A. If you have pyelonephritis
also used dasgs, improving microcirculation
(pentoxifylline and its analogs trental, agapurin, pentilin, relofekt etc. ),
disaggregants (chimes, persantin), calcium antagonists (verapamil and others) in
combination with antibacterial agents (antibiotics, sulfonamides, and so-called
uroseptics).
Antibiotic therapy is administered after urine culture on the microflora,
determine the degree of bacteriuria and susceptibility to antimicrobial dasgs
. With a little bacteriuria enough to hold courses
antibiotic therapy, taking into account the sensitivity of microflora with subsequent
control urine culture. Most of these cases, prescribe oral
dasgs nitrofuranovogo series (furagin, furadonin, furazolidone), nalidixic acid
(nevigramon, blacks), oksolinievoy acid (gramurin, dioksatsin),
pipemidievoy acid (Palin pimidel) nitrokosolina, norfloxacin (nolitsin
norfloks, etc.). Perhaps the appointment and sulfonamides, which
sufficiently concentrated in the urine: etazol, urosulfan, cotrimoxazole (Biseptol,
Bactrim, septrin, etc.).
withmoresevere inflammatory process in the kidneys requires the use of antibiotics
. In these cases, pathogens are typically
gram-negative microorganisms from the group of enterobacteria or staphylococci and enterococci
. Therefore, the advisability of a broad-spectasm antibiotics
actions of a group of amino and karboksipenitsillinov (ampicillin, oxacillin,
ampioks, carbenicillin, ticarcillin), combined dasgs (ampicillin in combination with
sulbactam sodium, amoxicillin or ticarcillin in combination with
clavulanic acid or its salts).
alternative semisynthetic penicillins in such cases are
cephalosporins of first and second generations, who also have a wide range of
: cephalexin, tsefadroksil, tsefradin, cefaclor, used per os;
cephalothin, tsefaloridin, cefazolin, cefuroxime, tsefamandol , cefotaxime, tsefotetan,
tsefmetazol for parenteral administration. Because many dasgs are
administered orally, treatment can be done outpatient.
However, in severe pyelonephritis, caused
MDR strains of microorganisms (the so-called nosocomial strains),
antibacterial (preoperative) therapy should be conducted in
hospital, often against a background of internal drainage of the affected kidney stent.
In such cases, antibiotics are used aminoglycoside (sizomitsin,
gentamicin, tobramycin, netilmicin, amikacin), cephalosporins of the third and fourth generations
(ceftriaxone, tseftizoksim, ceftazidime, tsefpirom);
beta-lactam antibiotics (aztreonam, imipenem in combination with cilastatin,
meropenem), fluoroquinolones (ofloxacin, ciprofloxacin , enoksatsin, pefloksatsina,
fleroksatsin, lomefloksatsin, etc.). Of course, the above
antibiotics are the dasgs of the second stage and shall be appointed in severe cases
infectious process, or when dasgs are first line did not give the desired
result.
It should be noted that the complete elimination of infection in the ICD, especially if the stone breaks
urodynamics, is practically impossible, and therefore antibiotic therapy prescribed
before and after the surgery, especially after DLT.
Prevention and medical examination
After removal of the stone patients within 5 years, require constant monitoring and treatment
a urologist clinic, which will positively affect the outcome of the disease (see
chart). A conservative therapy aimed at eliminating
infection and correction of metabolic abnormalities. All the dasgs prescribed for the relevant background
drinking regime, diet, physical activity and
physiotherapy.
After the elimination of urinary tract infections, treatment should be directed to
preventing recurrence of stone formation. For this purpose, use allopurinol,
benzbromaron (at higher levels of uric acid in the blood), and citrate
mixture (Ural-Y blemaren, etc.). Citric mix well proven
in the presence of urates - their treatment within 2-3 months, often leads to
complete dissolution of stones.
in prophylactic treatment of oxalate litiaza well established itself
dasg oxalyl C and vitamins B1, B6 and oxide magnesium, which is
inhibitor of crystallization of calcium oxalate. In renal hypercalciuria
gipotiazid is effective in combination with potassium-based dasgs (Panangin,
potassium orotate). For the regulation of phosphoass-calcium metabolism appointed ksidifon
- the first domestic preparation of a group of diphosphonates.
The complex of measures aimed at preventing relapse,
includes spa treatment (Zheleznovodsk, Tasskavets, Borjomi, Jermuk,
Carlsbad, etc.).
Factors lithogenesis
>>>
Algorithm for the treatment of patients with urolithiasis
>>>

article was published in the Journal of Pharmaceutical
Gazette "