Kidney Stones

The kidneys continuously create urine to remove excess water, minerals and waste products from the blood. Kidney stones are hard deposits of minerals that grow slowly over months or years. Some may pass from the kidneys and become lodged in the ureters or bladder. The most common kidney stones are formed from excess calcium or uric acid in the urine. People who tend to form stones can usually prevent them by following specific recommendations from their physicians.


Diagnosis

The urogram and the CT scan are the preferred ways at Mayo to diagnose kidney stones. Ultrasound is an option but may not detect small stones.

Intravenous Pyelography (Excretory Urogram)
A contrast dye is injected into the patient's vein, and a series of X-rays is taken as the dye moves from the bloodstream into the kidneys, ureters and bladder. If abnormalities are seen, the doctor may follow up with a CT scan — a series of thin X-ray beams that produce two-dimensional images of the organs.

Spiral CT Scan
This high-speed imaging test is used for patients who cannot tolerate contrast dye. A CT scan checks the abdomen in three minutes, and can reveal the presence of very small kidney stones that do not appear on conventional X-rays.

Ultrasound
These high-frequency radio waves allow physicians to look at a patient's internal organs. This test is painless and noninvasive, but it may not detect small stones, especially those outside the kidneys.


Treatment

Waiting and Watching
In about 85 percent of cases, kidney stones are small enough to pass during urination, usually within 72 hours of symptom onset. The best treatment for these stones is to drink plenty of water (as much as 2 to 3 quarts per day), stay physically active and wait. Painkillers may be prescribed to help alleviate the discomfort associated with passing a stone.

For patients who can pass a stone without medical intervention, urinating through a strainer may be recommended so that the stone can be recovered and analyzed. The mineral composition of the kidney stone will dictate appropriate treatment and future preventive measures.

Stones that are too large to pass on their own or that may cause bleeding, kidney damage or ongoing urinary tract infection may need surgical treatment.


Minimally Invasive Treatments:

Extracorporeal Shock Wave Lithotripsy (ESWL)
This procedure is the usual treatment to remove stones about 1 centimeter or smaller.

Patients lie on a cushion during the procedure. In many cases the stone will begin to crumble after 200 to 400 shock waves. The sandlike particles that remain after treatment are easily passed in the urine.

The shock waves are painful, so the procedure is performed with sedatives, local anesthesia or general anesthesia.

Some side effects of extracorporeal shock wave lithotripsy include blood in the urine for a short time after the procedure and minor bruising on the back or abdomen. Some patients may also experience discomfort as the stone fragments pass through the urinary tract. Others may need another treatment if the stone doesn't shatter completely. Most patients resume normal activity in a few days, but it may take months for all stone fragments to pass.

Parathyroid Surgery
Some calcium stones are caused by overactive parathyroid glands, which are located on the four corners of the thyroid gland. Usually, a small benign growth in one of these glands causes it to be overactive. As a result, the body's level of calcium becomes too high, which can lead to kidney stone formation. Removing the growth on the parathyroid gland will cure the kidney stone problem. This operation is performed by a general surgeon, not a urologist.

Atrial Fibrillation

Atrial fibrillation is the most common arrhythmia, affecting about 2 million Americans, primarily the elderly. In atrial fibrillation, the electrical signals in the atrial (upper) chambers of the heart are chaotic. In addition, the atrial electrical impulses that reach the ventricles (lower heart chambers) often arrive at irregular intervals. An irregular and, often, rapid heart rate results.


Diagnosis

In atrial fibrillation, the electrical signals in the atria (upper chambers of the heart) are chaotic and the electrical impulses reach the ventricles (lower heart chambers) often at irregular intervals, causing a fast and irregular heartbeat.

To diagnose atrial fibrillation, the patient may be asked about or tested for conditions that may trigger the fibrillation, such as heart disease or a thyroid gland problem. Several tests may be given to better understand the cause of the arrhythmia.

Stress Test
Atrial fibrillation may be triggered or worsen when the patient is exercising. During a stress test, the patient may exercise on a treadmill or stationary bicycle, with close monitoring by an ECG of heart activity. The test is intended to actively induce an irregular heartbeat while the patient is being monitored. The test may involve use of a drug to stimulate the heart instead of exercise. This may be particularly helpful to patients who have difficulty exercising. The stress test can also be used to detect coronary artery disease.

Electrocardiogram (ECG)
In this test, electrodes (sensor patches with wires attached) are placed on the patient's skin to measure the electrical impulses given off by the heart. The ECG measures the timing and duration of each electrical phase in the heartbeat.

Echocardiogram (Doppler Echocardiogram)
This test uses sound waves to produce detailed images of the patient's heart. Through a handheld device (transducer) on the patient's chest, sound waves bounce off the heart and are reflected to produce video images of the heart's size, structure and motion. The echocardiogram can also be used to measure the heart's blood volume and the speed and direction of blood flow through the heart.

Blood Tests
These may help rule out thyroid problems or other blood chemistry abnormalities that may lead to atrial fibrillation.

In addition, the heart may be monitored during regular activity.

Holter Monitor
A Holter monitor is a portable ECG device that the patient wears for a day or more to record the heart's electrical activity during the patient's daily routine.


Treatment

Nonsurgical Procedures

Cardioversion
To correct atrial fibrillation — reset the heart to its regular rhythm (sinus rhythm) — the physician will often perform cardioversion. This can be done with drugs or electrically.

Cardioversion with drugs
Medications (anti-arrhythmics) are used to stop the atria's quivering and restore normal (sinus) rhythm. The medications effectively maintain sinus rhythm for at least one year in 50 percent to 65 percent of people. However, they can cause side effects such as nausea and fatigue, as well as some long-term risks. In rare cases, the medications may actually increase the heart rate.

Electrical cardioversion
A patient under light anesthesia receives an electrical shock through paddles or patches on the chest. The shock stops the heart's electrical activity for a split second. When the heart's electrical activity resumes, the rhythm may be normal.

Cardioversion is not always effective. It may successfully restore regular heart rhythm in more than 95 percent of patients, but more than half of patients eventually go back into atrial fibrillation. In many instances, anti-arrhythmic medications are needed indefinitely.

Catheter Radiofrequency Ablation
For atrial fibrillations caused by abnormal heart tissue, catheter radiofrequency ablation can be used to destroy the abnormal tissue. In the procedure, catheters (thin, flexible tubes) are threaded through the patient's blood vessels to reach the abnormal heart tissue. The cardiologist then uses a small cutter or radiofrequency energy to remove the abnormal tissue.

Types of ablation for atrial fibrillation include:

• Pulmonary vein isolation ablation (PVI ablation or PVA) — This procedure electrically isolates "hot spots" in the pulmonary veins that trigger atrial fibrillations. Pulmonary vein isolation eliminates atrial fibrillation in 60 percent to 80 percent of patients who are treated. In addition, medications that did not help patients prior to ablation are now effective.
• AV node ablation with pacemakers — In AV ablation, a catheter is placed near the atrioventricular (AV) node (the electrical connection between the atria and ventricles). Radiofrequency energy is applied through the catheter to destroy a small area of tissue. The radiofrequency energy prevents the atria from sending too many electrical impulses to the ventricles. In 98 percent of patients, this procedure completely blocks the heart's electrical impulses and eliminates atrial fibrillation. Once the AV node is destroyed, doctors then implant a pacemaker to establish normal rhythm. Anticoagulation medication (blood-thinning medication) is required after the procedure to reduce the chance of developing blood clots.

Surgical Procedures

Pacemakers
A pacemaker is a medical device that helps regulate the heartbeat. The device, smaller than a matchbox, is placed under the skin near the collarbone. A wire extends from the device to the heart. If a pacemaker detects an abnormally slow heart rate or no heartbeat, it emits electrical impulses that stimulate the heart to speed up or start beating again. A pacemaker is used most often if medications to prevent atrial fibrillation or control the heart rate result in excessively slow heartbeats, and after AV node ablation.

Open-Heart Maze Procedure
For surgical Maze procedures, surgeons create multiple cuts into the muscle of the atria and then stitch them together. These incision lines interfere with stray electrical pathways and circuits. The lines reduce the size of atrial tissue sections needed to maintain atrial fibrillation. Due to its complexity, only a few medical centers in the United States perform the surgical Maze procedure.

Acoustic Neuroma

An acoustic neuroma (sometimes termed a vestibular schwannoma or neurolemmoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. This nerve has two distinct parts. One part is associated with transmitting sound, and the other sends balance information to the brain from the inner ear. These pathways, along with the facial nerve, lie adjacent to each other as they pass through a bony canal called the internal auditory canal. This canal is approximately 1-inch long. Acoustic neuromas originate in this canal from the sheath surrounding the eighth nerve.


Diagnosis

Magnetic resonance imaging (MRI) is the preferred diagnostic test for identifying acoustic neuromas.

Other tests used to diagnose acoustic neuroma and to differentiate it from other causes of dizziness or vertigo include:

* Computed tomography (CT) scan of the head
* Audiology (a test for hearing)
* Caloric stimulation (a test for vertigo)
* Electronystagmography (a test of equilibrium and balance)
* Brain stem auditory evoked response (BAER, a test of hearing and brain stem function)


Treatment

Observation
Acoustic neuromas are sometimes discovered by physicians while evaluating a patient for another medical condition, or when the tumor is very small with subtle symptoms. Because the tumors are slow-growing, if discovered when they are very small, careful observation over time may be appropriate for some patients.

A small tumor diagnosed in an elderly patient may require only observation of its growth rate, if disabling symptoms are not present. If the tumor likely will not need to be treated during the patient's normal life expectancy, treatment and its potential risks and complications can be avoided. Some tumors don't appear to grow at all.

Observation also may be the preferred therapy for those who have a tumor in their only hearing ear or better-hearing ear. In such cases, growth is monitored and treatment is considered only if hearing is lost or the tumor size becomes life-threatening.

In these patients, magnetic resonance imaging (MRI) of the head is done periodically to monitor tumor growth. If there is no growth, observation is continued. If the tumor is growing, however, treatment may become necessary.

Microsurgical Removal
The goal of surgery is to remove the tumor and avoid any new neurologic deficits such as facial weakness or hearing loss. Success in achieving these goals depends a great deal on the tumor's size and configuration and the patient's hearing status prior to surgery.

Microscopic surgery for acoustic neuromas is done under general anesthesia. Usually, patients stay in the hospital four to five days after surgery.

Several surgical approaches can be used to remove acoustic neuromas. The choice depends on the location, tumor size, the patient's hearing level and the surgeon's skill and experience.

Each approach has advantages and disadvantages, but excellent results have been achieved in all approaches. The surgeon and patient should have a thorough discussion before selecting the approach.

Partial Tumor Removal
Some patients and their surgeons prefer partial removal of an acoustic neuroma, especially if the tumor is large. This decision includes the understanding that more surgery or stereotactic radiosurgery may be needed in the future.

Gastroesophageal Reflux Disease (GERD)

GERD, also known as acid reflux, is a condition in which stomach acids or bile salts back up into the esophagus (the tube that connects the mouth to the stomach) producing a burning sensation behind the breastbone and esophageal irritation or inflammation. Normally, acid is trapped in the stomach by a circular band of muscle called the lower esophageal sphincter (LES), which remains closed except when swallowing. If the sphincter relaxes abnormally or becomes weakened, stomach acid tends to back up, causing symptoms of heartburn. This can also be exacerbated by the presence of a hiatal hernia (when part of the stomach is protruding through the diaphragm and into the chest).

An estimated 17 million Americans currently suffer from heartburn and other symptoms of GERD. For many people, it can be treated with the correct combination of lifestyle changes and medication. For others, surgical intervention can help to eliminate the symptoms and prevent further damage to the esophagus.


Diagnosis

Highly trained gastrointestinal specialists work with thousands of patients each year to diagnose mild to severe cases of GERD. A doctor should be consulted about any of the following symptoms of GERD:

* Frequent heartburn, or a burning pain behind the breastbone, often accompanied by a sour taste and the sensation of food coming back into the mouth. It often gets worse when a person eats, bends over or lies down.
* Chest or upper abdomen pain, especially pain that disrupts sleep
* Regurgitation (backflow of stomach fluids into the mouth)
* Difficulty swallowing
* Belching, especially belching that is acidic or sour-tasting
* Chronic sour or bitter taste in the mouth
* Hoarseness, especially in the morning
* Sore throat
* Coughing, wheezing or repeated need to clear the throat


Treatment

The easiest way to treat reflux symptoms is to block acid production in the stomach. In most cases, acid irritation causes the symptoms. Acid can be blocked by several medications. More than half of all patients get better with acid-suppression therapy. Many physicians will treat a reflux patient with acid suppression for about two months before pursuing other treatment.

Lifestyle Changes and Medication
For cases of mild heartburn, a doctor may suggest over-the-counter or prescription medications that block acid production in the stomach — as well as lifestyle changes.

GERD has an excellent prognosis; 80 to 90 percent of patients improve after treatment with medication. However, these remedies may offer only temporary or partial relief from GERD symptoms. Additionally, severe GERD sometimes causes serious complications, including esophageal ulcer, strictures and Barrett's esophagus.

Surgery
Anti-reflux surgery (laparoscopic nissen fundoplication) offers an alternative to medication for GERD. This procedure strengthens the sphincter by wrapping part of the stomach around the lower esophagus to prevent reflux and maintain the position of the stomach and lower esophagus in the abdomen.

Minimally Invasive Techniques
Endoscopic treatments offer an alternative for patients who are not candidates for surgery or for those patients who don't want lifelong medication treatment or surgery. The following endotherapies are outpatient procedures.

Wolff-Parkinson-White Syndrome

Wolff-Parkinson-White syndrome describes when the heart beats rapidly as a result of abnormal, extra electrical pathways between the heart's two upper chambers (atria) and two lower chambers (ventricles).

Why the extra electrical pathways develop in the heart is not known. In some cases, WPW syndrome is present at birth, and WPW syndrome is the most common heartbeat disorder among infants and children. But WPW can occur at any age and develops symptoms more frequently among adults, usually between ages 30 and 40. More males than females are affected.


Diagnosis

The most common form of life-threatening heart rhythm in patients with WPW syndrome is atrial fibrillation, a condition in which the electrical activity in the heart's upper chambers (atria) becomes chaotic and very fast (300 to 400 impulses per minute). When atrial fibrillation occurs in patients without WPW, the heart's conduction system allows only a fraction of these beats to reach the ventricles.

In some cases of WPW syndrome, as many as 350 of the electrical impulses can reach the heart's lower chambers (ventricles). This interferes with the heart's ability to effectively pump blood, a life-threatening heart rhythm abnormality.

To diagnose Wolff-Parkinson-White syndrome, the patient may be asked about or tested for conditions that may trigger the abnormally fast heartbeat, such as heart disease or a thyroid problem. The patient may have two heart monitoring tests: active and passive.

Medications
Several medications can be used to manage WPW syndrome. The medications are usually taken two or three times daily.

When these medications are effective, they can prevent the need for catheter procedures or open-heart surgery. However, the medications may need to be taken for many years and can have side effects, which cause the patient not to feel well. In addition, the medications do not work for all patients and, in 2 to 8 percent of patients, aggravate rather than reduce the fast heart rate.

Open-heart Surgery
Open-heart surgery is the most effective treatment for WPW syndrome. It eliminates the extra electrical heart pathways in 96 to 99 percent of cases. However, open-heart surgery involves a seven- to 10-day stay in the hospital and four to 10 weeks of recovery at home.

Nonsurgical procedures - Atrial Fibrillation Ablation
A less-invasive alternative to open-heart surgery is catheter radiofrequency ablation. In the procedure, catheters (thin, flexible tubes) are threaded through the patient's blood vessels to reach the abnormal heart tissue. The cardiologist then uses radiofrequency energy (heat) to destroy the extra pathway.

Atrial fibrillation ablation usually requires only one to two days in the hospital. Patients usually return to normal activities within one to 10 days. The procedure is about one-third to one-half the cost of open-heart surgery.

Aortic Aneurysm

An aortic aneurysm is an abnormal bulge in the wall of the aorta, the body's largest artery. Roughly the diameter of a garden hose, this artery extends from the heart down through the chest and abdominal region, where it divides into blood vessels that supply each leg. Smaller arteries branch off to supply blood to the vital organs. Aneurysms can develop anywhere in the aorta, but most occur in the abdominal area.

Aortic aneurysms may be caused by the wear-and-tear processes of aging, especially among people who smoke or have high blood pressure; by inherited conditions that weaken the aorta, such as Marfan syndrome or familial thoracic aortic aneurysm disease; or trauma. One type of aneurysm (aortic dissection) is caused by a splitting of the wall of the aorta.

Diagnosis

In some cases, aortic aneurysms are diagnosed from a routine chest X-ray or chest CT scan taken to evaluate another condition, such as lung disease. Some abdominal aortic aneurysms are noticed by a physician who feels a pulsating bulge in the abdomen during a physical exam.

Abdominal aortic aneurysms may be evaluated further by ultrasound or CT scanning. Thoracic aortic aneurysms are typically evaluated by echocardiography, CT scanning or magnetic resonance imaging (MRI). Occasionally, a test called an aortogram is required. Test results are generally available within 24 hours in Mayo's state-of-the-art electronic medical record.

Treatment

Monitoring
If the aneurysm is small and there are no symptoms (for example, if the aneurysm is found during a routine physical examination or discovered in tests for another condition), a physician may recommend watching and waiting. An ultrasound or echocardiogram, CT scan, or MRI scan once or twice a year is a common monitoring strategy.

Medication
If the aneurysm is small, medication may be recommended to prevent enlargement or complications. Anti-hypertensives such as beta-blockers may be used to lower blood pressure.

Surgery
Surgery becomes an option when an aneurysm enlarges enough that the danger of rupture exceeds the risks to the patient from surgery.

Open Abdominal or Open Chest Surgery
An accepted standard surgical treatment for aneurysm is replacement of the damaged portion of the aorta with an artificial graft. Typically, the graft is made from Dacron, a material that will not wear out. The graft is sewn in place with permanent sutures.

Endovascular surgery
The operation, including the incision, depends on the location of the aneurysm. If the aneurysm is confined to the abdomen, then an incision either in the abdomen or on the side or flank may be used. If the aneurysm is in the chest close to the aortic valve, an incision in the front of the chest, such as a median sternotomy, may be used. If the aneurysm is in the aortic "root" and involves the valve, the aortic valve may have to be repaired or replaced. Surgery on the aortic arch is also usually done from the front. If the aneurysm involves the descending thoracic aorta, which lies in the left chest, or the thoracic and abdominal aorta, an incision on the left side of the chest will likely be required.