KEYWORDS: ..요로계 결석이란 신장, 요관, 방광, 요도 등에서 발견되는 결석으로, 요로에 발생하는 가장 흔한 질환 중 하나이다. ..Prevalence : 2~3% in the general population, approximately 50% of patients with previous urinary calculi have a recurrence within 10 years. Stone disease is two to three times more common in males than in females.Whites are affected more often than persons of Asian ethnicity, who are affected more often than blacks. ..수분섭취 부족과 이로 인한 소변의 농축이 가장 중요한 요인이며 식이칼슘 의 역할은 불명확하여 식이칼슘제한은 일반적으로 권장되지 않는다. Type Frequency (%) Calcium 70~80 Calcium oxalate 30~70 Calcium phosphate 36~70 Mixed 6~10 Magnesium ammonium phosphate (struvite) 6~20 Uric acid 6~17 Cystine 0.5~3 Miscellaneous 1~5 1. Idiopathic hypercalciuria is the most common cause of renal calculi. 2. Uric acid stone occurs in 10 to 20 percent of cases 3. Absence of crystal inhibitors is a factor in small portion. 4. Systemic disease such as hyperthyroidism occurs only in 5 per cent of cases. Urolithiasis Key etiology 529 The Root of ambulatory care 1. Unilateral severe colicky Pain in the lumbar region or Lower abdomen radiating to groin, labia, testes or penis, Very often with nausea and Vomiting : Stones located in the intravesicle segment of the ureter may cause frequently and dysuria. In some patients, especially children, the only symptom may be hematuria. ..Occasionally the patient may complain of pain in the groin or testes, without flank or abdominal pain. Rarely the only symptom may be painless hematuria. ..Think of hyperparathyroidism if the first episode of renal stone occurs after age 45 years in the absence of infection 1. Urinalysis : Limited pyuria is a fairly common response to irritation caused by a stone and, in absence of bacteriuria, is not generally indicative of coexistent urinary tract infection. 2. Microscopy for crystals 3. Plain radiography (KUB) 4. IVP 5. Noncontrast helical CT ..Diagnostic imaging is essential to confirm the size and location of urinary tract calculi. A diagnosis of renal colic cannot be based on the clinical findings alone. Key symptom Key tests ▶ 우측 신우에 결석과 함께 담석도 보인다. Urolithiasis ..IVP검사시 조영제의 신독성은 잘 알려져 있으며, 검사 시행 전 반드시 혈중 creatinine농도를 확인해야 한다. Creatinine level이 1.5mg/dL이상이라도 검사 의 절대적 금기는 아니며, 검사의 위험성과 효용성을 감안해 임상가가 판단 해야 한다. 적절한 수분섭취와 조영제 투입량의 최소화, 이후 조영제 사용 검 사 시간을 적절히 배치함으로써 위험성을 줄일 수 있다. ..IVP검사시 Metformin을 복용하는 당뇨환자는 치명적인 대사성 산증의 발생 을 막기위해 검사전 약을 중단해야 하며 검사 후 48시간이 지난후 신기능이 정상임을 확인하고 투약재개해야 한다. Imaging modality Sensitivity (%) Specificity (%) Advantages Limitations Accessible Good for Poor visualization of Ultrasonography 19 97 diagnosing hydronephrosis ureteral stones and renal stones Requires no ionizing radiation Accessible and inexpensive Stones in middle section of ureter, phleboliths, Plain radiography 45~59 71~77 radiolucent calculi, extraurinary calcification and nongenitourinary conditions Accessible Provides Variable-quality imaging information on anatomy and Requires bowel preparation Intravenous functioning of both kidneys and use of contrast media pyelography 64~87 92~94 Poor visualization of nongenitourinary conditions Delayed images required in high-grade obstruction Most sensitive and specific Less accessible and Noncontrast radiologic test Indirect signs relatively expensive helical CT 95~100 94~96 of the degree of obstruction No direct measure Provides information on of renal function nongenitourinary conditions 531 The Root of ambulatory care Confirmed radiologically demonstrated Stone Rule out emergency : Urosepsis, Anuria, Renal Failure Consider hospital admission Refractory pain Refractory nausea Extremes of age Debilitated condition Symptoms well response to medical management Renal stone or ureteral Ureteral stone < 5mm stone > 5mm Trial of conservative management Weekly KUB radiographs Stone passes Referral to urologist Urologic consultation Urgent urologic consultation Stone fails to pass within 2 to 4 weeks No Yes Yes Fig 1. Initial management of radiologically confirmed urolithiasis Key treatments Urolithiasis - Ambulatory patient 1. Analgesics ..Codein.. 20mg 1T, 1-3T q 4hrs ..Anyfen.. 300mg 1T, 1T tid-qid ..Brufen.. 200mg 1T, 1T-3T tid ..Pontal.. 250mg 1C, 2C bid 2. Antispasmotics ..Tiropa.. 100mg 1T, 1T bid-tid ..Algiron.. 50mg 1T, 1T tid 3. Restoring fluid ..수분 섭취 격려 2-3L/day ..Anyfen.. - Dexibuprofen ..Pontal.. - Mefenamic acid ..Algiron.. - Cimetropium ..Antispasmotics은 acute colic에 유용하지 못하다는 보고도 있다. ..대부분의 요로 결석은 자연 배출될 수 있는 5mm이하 크기이므로 외래에서 치료를 시도해 볼 수 있다. ..외래에서 효과적인 치료법은 경구용 마약성 진통제와 경구용 NSAIDS를 같 이 사용하는 것이 좋다. ..통증조절이 잘 되면 환자에게 모든 소변을 스타킹, 필터로 걸러 통과 확인해 볼 수도 있다. ..Extracorporeal shock wave lithotripsy를 시행하기 3일전부터는 NSAIDs와 Aspirin을 끊어야 한다. 533 The Root of ambulatory care Stone location and size Probability of passage (%) Proximal ureter > 5mm 0 5mm 57 < 5mm 53 Middle section of ureter > 5mm 0 5mm 20 < 5mm 38 Distal ureter > 5mm 25 5mm 45 < 5mm 74 ..All patients with kidney stones shoud be investigated for the etiology of kidney stones. ..증상이 없는 환자에서도 향후 5년 내 50%에서 증상이 발현될 수 있다고 주지 시켜야 한다. 참고 문헌 Andrew J. Portis, M.D., Chandru P. Sundaram, M.D. : Diagnosis and Initial Management of Kidney Stones. A journal of the American Family Physicains 2001 ; 63 : 1329-1338 P. George John : Hypercalciuria and Renal Calculi, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 706-712 조비룡 : 요로결석, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1385-1391 Margaret S. Pearle, M.D., Ph.D. : Renal Calculi, in Conn's Current Therapy 2004, Robert E. Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004, P 768-774 오창석(ed) : 요로결석, in Complete Guide To Practical Based Prescription Medicine. 서울, 한우리, 2005, P 298-299 김형묵 역 : 복부 CT. 서울, 군자출판사. 2005, P 265