Transcript of Nephrolithiasis ashmari
- 1. Nephrolithiasis - Ashmari
- 2. Etiology 1. Low urine volume 2. Hypercalciuria 3.
Hyperoxalouria 4. Hyperuricosuria 5. Low fluid intake 6. Fluids
such as apple juice, grape fruit, sodas increases the risk 7. High
NaCl intake 8. High protein intake 9. Low calcium intake 10. H/o
prior kidney stone 11. Hyperoxalouria (enteric hyperoxaluria, short
bowel syndrome) 12. Type I Renal Tubular Necrosis Patients may be
occassionally diagnosed on radiology of abdomen done for other
cause.
- 3. pathophysiology Normally soluble solutes (e.g-calcium)
supersaturates in the urine(site like end of collecting
ducts)crystallization occurscrystal aggregatesbecomes large in
shape and sizeanchoring of crystals occurs at epithelial cell
injury site caused by crystal itself or by infection acting as
Nodus(charged particle)attracts unsoluble solutes towards it
calculi formation
- 4. Types 1. Calcium oxalate (more common) 2. Calcium phosphate
(less common) 3. Uric acid, struvite (Mg, Ammonium Phosphate) 4.
Cystine stones 5. Combination of different stones can exist in
single stone
- 5. Clinical features Pain in the lumbar region (kidney stones),
Renal Punch test postive Pain radiating from Loin to Groin
(ureteric stone) Pain onset when stone descends in the ureter
Spasmodic pain occuring in waves or paroxysm, mostly at night
Nausea and vommitting Hematuria- microscopic or gross or
absent
- 6. Investigation Urine routine and Microscopic- shows crystalls
USG abdomen & Pelvis Xray KUB IVP Non contrast enhanced
CT/MRI
- 7. Treatment Acute colic-IV hydration Nonnarcotic analgesics
(eg, Acetomenophen) PO/IV narcotic analgesics (eg, codeine,
butorphanol, morphine sulfate, oxycodone/APAP, hydrocodone/APAP,
meperidine, nalbuphine) NSAIDS (eg, ketorolac, ketorolac
intranasal, ibuprofen) Uricosuric agents (eg, allopurinol)
Antiemetics (eg, metoclopramide) Antidiuretics (eg-desmopressin
acetate) Antibiotics (eg, ampicillin, gentamicin,
ticarcillin/clavulanic acid, ciprofloxacin, levofloxacin,
ofloxacin) Alkalinizing agents (eg, potassium citrate, sodium
bicarbonate): For uric acid and cysteine calculi Corticosteroids
(eg, prednisone, prednisolone) Calcium channel blockers (eg,
nifedipine) Alpha blockers (eg, tamsulosin, terazosin)
- 8. Surgery Stones that are 7 mm and larger are unlikely to pass
spontaneously and require some type of surgical procedure, such as
the following: Stent placement Percutaneous nephrostomy
Extracorporeal shockwave lithotripsy(ESWL) Ureteroscopy
Percutaneous nephrostolithotomy (PCNL) Open nephrostomy
- 9. Ashmari- ayurvediya concept 1. s // (..) 2. / s // (..) Due
to improper purification of the body and by following the Apathya,
kapha dosha gets vitiated in the urine and reaches in the basti to
form ashmari. According to charakacharya- the shukra dhatu in the
basti gets dried up along with Pitta or Kapha dosha by Vata forms
Ashmari like how Gorochana forms in Gallbladder of cow.
- 10. 1. s / s// 2. / // 3. s / / (..-) Vata-Pitta-kapha dosha
enters into basti like how mutra enters into basti from Pakwashaya
and with Upasneha nyaya Ashamari is formed in Basti. When clear
water is placed in a new mud pot, after sometimes some particles
precipitates into the water, similarly in the basti ashmari
develops- this explains the stagnation of the urine in the bladder
due to bladder outlet obstruction like BPH etc can form calculus in
the bladder.
- 11. Third shloka explains the crystallization process- when dry
air along with the static electricity in the clouds forms the
crystalls of water present in the cloud, similarly ashmari
develops.
- 12. Purvaroopa - // Pain and discomfort in the bladder,
urethra,testicles/external genital organs. Anorexia, dysuria,
fever, debility, smell of goats urine. Colour of urine appears like
that of individual doshas and pain accordingly. urine appears
non-clear, increased specific gravity.
- 13. Types 1. Kaphaja 2. Vataja 3. Pittaja 4. shukraja
- 14. Samanya lakshana Pain in the umbilicus,bladder, perineum,
external genitals eithr in any one of them while passing urine.
Obstruction to the urine stream Hematuria Urine appears clear as
Gomeda or some crystals can be seen in urine. Discomfort or pain
while performing the activities like running, swimming, hanging,
swimming,riding on back of horse,camel.
- 15. Vataja Ashmari Vata and kapha dosha after combining
together obstructs the urine and causes pain as a result person
bites his teeth, presses navel, external genitals,anus and shouts
due to pain. Has to pass urine after putting force. The ashmari
formed is Shyava, hard, irregular,rough, it contains thorny
structures like of kadamba Pushpa.
- 16. Pittaja Ashmari Kapha dosha along with Pitta dosha attends
compactness and obstructs the urine and produces discomfort like
burning sensation in the basti- medhra, feeling of hot air coming
out of bladder. Ashmari appears like red,yellow, dark in colour and
appears like seed of Bhallataka
- 17. Kaphaja ashmari The Kapha dosha attends compactness and
increases in size and obstructs the urine and produces features
like tearing type of pain in bladder, heaviness in the bladder and
feeling of cold. Ashmari appears like hens egg, pale-white colour,
unctous to touch, large in size and like madhuka flower.
- 18. Madhuka pushpa kukkutanda
- 19. Shukrashmari Causes = shukraveghdharan or excessive coitus.
The vitiated vata causes vimargagaman of shukra into medhra or
vrushana and after drying it up forms the shukrashmari. The
resultant ashmari obstructs flow of urine and causes dysuria, pain
in bladder and external genitals, oedema in legs. On pressing the
ashmari it gets broken into pieces easily.
- 20. Ashmari in children Due to kapha avastha more chances of
forming ashmari Occurs in those children who follows life style and
diet which increases and vitiates kapha Ashmari can be of any 3
doshas Due to thin bladder wall and under developing basti, ashmari
is small in size and can be easily removed with instruments Due to
non development of shukra dhatu, there are no chances of forming
shukrashmari
- 21. chikitsa Newly formed ashmari can be treated with medicines
Chronic- surgical removal
- 22. Medicinal treatment Vataja ashmari-
pashanbheda,vasuka,shatavari,gokshura,bhru hati, kantakari etc
drugs should be used in form of kshaar, yavagu,kwatha,milk,food
etc. Pittaja- kusha-kasha-sara-gundra-itkata- morata(sugarcane
root),pashanbhedh,vidaari- varahkanda-
shaalimoola,gokshura,shyonaka,punarnava,shi risha,lotus seed,
evaru(cucumber) etc
- 23. Kaphaja ashmari- varunadi gana,guggulu,ela,kushtha,
devdaru,haridra,maricha,chitraka etc drugs in form of kshar,
peya,kshira,yavagu,kwatha. Kshara prepared from
tila,apamarga,kadali,palasha and yava kalka with sheeps urine
prevents sharkara formation
- 24. Use of Ghrita, Kshara,kashaya, kshira and Uttarbasti are
advised. If no relief with above medications then surgical
extraction of calculus should be performed.
- 25. Surgical extraction Purvakarma- consent from the king,
snehan- swedan-vaman-virechana, food should be given to the
patient. Mangala-swastik vachan Collection all required instruments
and medicines required during surgery
- 26. Pradhana karma This technique is Perineal Vesicolithotomy
Position is lithotomy postion, head resting in lap of attendant
Sneh is applied on nabhi and pressure massaging in done on left
lateral region till ashmari decends into Basti. Lubricated middle
and index finger is inserted into anal canal of the patient.
Calculus is then pushed with those fingers in upward direction
towards in between guda and external genital. Ashmari can be seen
as nodule
- 27. While performing this procedure if patient becomes
unconscious or goes into shock, in such condition procedure should
be hold and extraction shouldnt be done. Site of incision-
vamaParshwa (left lateral) 1 yava(grain) distance from the
sevani(perineal raphe). Incision should be adequate to remove stone
While extracting the calculus, it should be brought out without
crushing it. Otherwise it can cause recurrence. Instrument used is
(curved forcep)
- 28. In case of female uterus should be protected,incision
shouldnot be too deep otherwise it causes vrana through which urine
oozes out. Avoid damaging important structures like
mutravaha,shukravaha,mutrapraseka,sevani,y oni,guda,basti.
- 29. Damage to- 1. Mutravaha srotas and Basti-death due to
extavasation of urine 2. Shukravaha srotas-death or infertility 3.
Mushkasrot- dhwajabhanga (erectile dysfunction) 4. Mutraprasek-
vesical fistula urine discharge 5. Sevni and yoni- severe pain 6.
Guda and basti- death
- 30. Paschat karma Patient should be kept in hot water tub, this
prevents collection of blood in bladder. If blood gets collected in
bladder then Uttarbasti of kshirvruksha kwatha should be
administered, it removes the collected blood out of bladder
(bladder wash) For mutramargavishodhana rice mixed with jaggery
should be given. After removing from tub, apply honey+ghrita on the
incision wound
- 31. For diuresis- trunapanchamoola,gokshura etc drugs in the
form of yavagu is given 2-3 times a day. For rakta-mutra shodhan
and vrana kledanartha- jaggery mixed milk along with cooked rice is
given in small quantity for 10 days. After 10 days- sour fruit like
dadima and jangala mamsa rasa is given. Carefully snehan and drava
swedan is performed. Clean wound with kshiravruksha decoction.
Apply lepa of rodhra,madhuka,manjishtha,prapaundarika kalka
- 32. If urine doesnt come through its normal route and comes out
from incision site (vrana), then it should be thermally cauterized
( agnikarma). After urine comes out via normal route, uttarbasti,
anuvasan and niruha basti are given prepared from kakolyadi gana or
Kshiravrukshadi gana.
- 33. Obstructed shukrashmari or sharkara should be removed with
badisha yantra Avoid coitus, horse-elephant-camel ride climbing
mountain, riding chariots, swimming, heavy to digest food for 1
year after healing of the wound.