Emergency Department Case Study: Ureteral Calculi Treatment

This case study examines the diagnosis and treatment of ureteral calculi in a 25-year-old female presenting to the emergency department with severe flank and abdominal pain. The patient's history includes previous kidney stone attacks and a lifestyle involving outdoor work with inadequate water intake, which are identified as risk factors. The case study explores diagnostic procedures, including the use of intravenous pyelogram (IVP) and alternative radiological examinations for patients allergic to contrast dye. It details the types of kidney stones, potential complications of untreated renal stones, and various treatment interventions such as ureteroscopy and shock wave lithotripsy. Furthermore, the study outlines discharge instructions, including medication, dietary recommendations, and fluid intake guidelines to prevent recurrence. The immediate plan of care includes surgical interventions like pyeloplasty, with a concluding emphasis on the importance of dietary, lifestyle, and fluid intake habits for long-term prevention.

Running head: URETERAL CALCULI: CASE STUDY
URETERAL CALCULI: CASE STUDY
Name of the Student:
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Introduction
The following set of questions and answers demonstrate key treatment and screening
components to be considered for the treatment of ureteral calculi in a 25 year old female, SR.
Question 1
A number of health issues and conditions can cause a female patient to urinate blood,
namely, urinary tract infection (UTIs), kidney stones or ureteral calculi, cancer and
endometriosis. While UTIs are largely associated with pelvic, as observed in the given case
study, this cause can be ruled since SR does not demonstrate UTI-like symptom like urgency to
urinate, foul smelling or cloudy urine or prevalence of microbial colonies in her urine analysis
(Bolenz et al., 2018). There is no presentation of endometriosis symptoms of dysmenorrhea or
observed structural abnormalities like cysts in SR’s pelvic examination findings. The patient SR
also does not present renal cancer symptoms of lumps, anemia, sudden weight loss or cancerous
cells in her pelvic, physical and urine examinations (Subak & Grady, 2017).
The most accurate diagnosis for SR will be ureteral calculi or renal stones, due to her
demonstration of prevalent symptoms like uncontrolled and extreme pain in the abdominal flank
radiating to the groin region and red blood cell (RBC) content grossly higher than the standard
number of four in the urine. Additionally, inadequate water intake and dehydration are key risk
factors of ureteral calculi – as demonstrated by SR in her history of renal stone incidences during
summer as well as her habits of taking minimal water breaks (Scotland et al., 2018).
Question 2
The process of intravenous pyelogram (IVP) comprises of an X-ray examination
involving administration of contrasting substances for the purpose of evaluation of organs like

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the urinary bladder, ureters and the kidney and is prevalently used to identify underlying cause of
hematuria. Before conducting an IVP, the key questions to ask to SR include: whether she is
allergic to seafood, iodine or contrast dye and whether she is pregnant. Individuals with
dehydration or diseases like diabetes, cardiovascular disorders, and hypertension are susceptible
to acquire kidney failure due to IVP. To prevent the same, individuals like SR may be need to
perform a creatinine blood tests which the practitioner and nephrologist must evaluate prior to
IVP administration (Rosenkrantz et al., 2019).
Question 3
Since patient SR is allergic to contrast dye, alternative radiological examinations which
she can participate in place of IVP, include: ultrasound, magnetic resonance imaging and
computed tomography of her pelvic region. These alternatives are safe for SR since they do not
require in contrast dye for producing radiological images.
Question 4
The most common types of kidney stones are calcium oxalate (a) and calcium phosphate
(b). In the case of SR, struvite (c) uric acid (d) and cystine € stones are rare since they are found
prevalently in UTI, males and in individuals with cystinuria – a genetic disorder (Nyman, Sterner
& Aspelin, 2018).
Question 5
It has been evidenced that the dehydration and a personal medical history of kidney
stones are some of the key risk factors of kidney stones. As per the case study, it is known that
the patient SR engages in long hours of outdoor work and drinks very little water in between her
occupation – all of which, are likely to cause dehydration during summers and thus pave the way

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of ureteral calculi. Indeed, such clinical assumptions can be confirmed in SR’s personal history
of three renal stone incidences occurring during late summer (Öğreden et al., 2019).
Additionally, renal stones of the calcium oxalate type are largely associated with the high
consumption of oxalate containing foods like beetroot, potato crisps, spinach, chocolate and
peanuts. While SR’s diet is not known, most of the above foods are convenience items which
busy employees like SR are likely to consume. Thus, diet along with personal history and
dehydration, are key causes of ureteral calculi in SR (Legemate et al., 2017).
Question 6
If not remove, renal stones like the one in SR can cause long term complications. When
not removed for a prolonged period of time, renal stones are likely pass and travel to the ureters
– the delicate, smooth muscle tubes responsible for transporting urine to the urinary bladder from
the kidneys. Often ureters may be too narrow to allow the smooth passage of renal stones
towards the bladder, thus resulting in painful spasms and hematuria – as observed in SR’s
ureteral vesicle junction stone. Additionally, large renal stones are likely to cause urinary
obstruction where the normal passage of urine is blocked. Such a phenomenon can cause adverse
complications like toxic waste accumulation, renal damage, renal infection and a fatal state of
kidney failure (Modai et al., 2019).
Question 7
Two interventions which are can be used to treat SR’s ureteral vesicle stone are:
ureteroscopy and shock wave lithotripsy. In ureteroscopy, a long tube or an ureteroscope in
inserted into the patient’s urethra, which is then fed to the ureter. The stone is then extracted and
removed by the urologist or destroyed using lasers. In shock wave lithotripsy, shock waves are

4URETERAL CALCULI: CASE STUDY
used to damage the stones – rendering them small enough to be able to pass outside the body via
urine (Barozzi et al., 2017).
Question 8
As a part of specific discharge instructions, SR maybe be requested to take medications
like thiazide diuretics which assist in the reducing blood calcium levels, and thus calcium stone
formation. To prevent medication side effects as well as future stone formation, SR will be
instructed to strictly restrict salt consumption to 2300 mg or one teaspoon per day. To prevent
dehydration, SR needs to be instructed to drink water in amounts high enough to product 2.5 ml
of urine – which is approximately 3 liters of water. She may be required to consume more water
as compared to the given value considering that it is a hot summer day (Vaughan et al., 2019).
Special instructions are to be taken when she is straining her urine using a urine strainer.
This will include instructing her to urinate in a strainer, which comprises of a funnel and a wire
mesh at the base. For convenience, she may urinate in a glass jar, carefully pour the same
through a strainer and make sure to collect all stone fragments (Jendeberg et al., 2017).
Question 9
SR’s immediate plan of care, since her stone has not passed, would include surgical
interventions such as open surgery or pyeloplasty comprising of surgical removal of the ureter
pelvic junction and reattachment of the ureter a the renal pelvis to ease and widen the passage of
urine and drainage of stones. Laparoscopic pyeloplasty may be used as a less invasive option
with less likelihood of pain (Modai et al., 2019).

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Conclusion
To conclude, despite the range of surgical options available, dietary, lifestyle and fluid
intake habits ensure long term prevention of ureteral calculi.

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References
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Ultrasonography in Urology, Andrology, and Nephrology (pp. 67-72). Springer, Cham.
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investigation of hematuria. Deutsches Ärzteblatt International, 115(48), 801.
Jendeberg, J., Geijer, H., Alshamari, M., Cierzniak, B., & Lidén, M. (2017). Size matters: the
width and location of a ureteral stone accurately predict the chance of spontaneous
passage. European radiology, 27(11), 4775-4785.
Legemate, J. D., Wijnstok, N. J., Matsuda, T., Strijbos, W., Erdogru, T., Roth, B., ... & Jean, J.
(2017). Characteristics and outcomes of ureteroscopic treatment in 2650 patients with
impacted ureteral stones. World journal of urology, 35(10), 1497-1506.
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of surgical intervention for distal ureteral stones. Journal of endourology, 33(9), 750-754.
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