Flank pain resident survival guide: Difference between revisions
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{{CMG}}; {{AE}} [[User:Qasim Khurshid|Qasim Khurshid, M.B.B.S.]] | {{CMG}}; {{AE}} [[User:Qasim Khurshid|Qasim Khurshid, M.B.B.S.]] | ||
{{SK}} Flank pain work-up, Approach to flank pain, Flank pain management | |||
==Overview== | ==Overview== | ||
Flank pain refers to the discomfort in the upper abdomen or back and sides. It develops in the area above the [[pelvis]] and below the ribs. This is a common [[symptom]] and usually, [[pain]] is worse on one side of the body. Most frequently the cause is [[benign]] and/or self-limiting, but more serious [[causes]] may require urgent intervention. [[Treatment]] of the flank pain depends on the cause, urgent [[surgical intervention]] may be required if the pain is caused by ruptured [[aortic aneurysm]] and some conditions can be treated with [[NSAIDS]]. | Flank pain refers to the discomfort in the upper abdomen or back and sides. It develops in the area above the [[pelvis]] and below the ribs. This is a common [[symptom]] and usually, [[pain]] is worse on one side of the body. Most frequently, the cause is [[benign]] and/or self-limiting, but more serious [[causes]] may require urgent intervention. [[Treatment]] of the flank pain depends on the cause, urgent [[surgical intervention]] may be required if the pain is caused by ruptured [[aortic aneurysm]] and some conditions can be treated with [[NSAIDS]]. | ||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.<ref name="RippelRaman2013">{{cite journal|last1=Rippel|first1=Christopher|last2=Raman|first2=Jay D.|title=Acute Flank Pain|year=2013|pages=19–27|doi=10.1007/978-3-642-28732-9_3}}</ref><ref name="pmid27614885">{{cite journal| author=Jha P, Bentley B, Behr S, Yee J, Zagoria R| title=Imaging of flank pain: readdressing state-of-the-art. | journal=Emerg Radiol | year= 2017 | volume= 24 | issue= 1 | pages= 81-86 | pmid=27614885 | doi=10.1007/s10140-016-1443-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27614885 }} </ref> | ||
Listed below are the life threatening causes: | |||
*[[Ruptured Abdominal Aortic Aneurysm]] | *[[Ruptured Abdominal Aortic Aneurysm]] | ||
*[[Renal abscess]] | *[[Renal abscess]] | ||
| Line 38: | Line 40: | ||
===Common Causes=== | ===Common Causes=== | ||
Common causes of flank pian include: | Common causes of flank pian include:<ref name="pmid25108546">{{cite journal |vauthors=Evan AP, Worcester EM, Coe FL, Williams J, Lingeman JE |title=Mechanisms of human kidney stone formation |journal=Urolithiasis |volume=43 Suppl 1 |issue= |pages=19–32 |date=January 2015 |pmid=25108546 |pmc=4285570 |doi=10.1007/s00240-014-0701-0 |url=}}</ref><ref name="RippelRaman2013">{{cite journal|last1=Rippel|first1=Christopher|last2=Raman|first2=Jay D.|title=Acute Flank Pain|year=2013|pages=19–27|doi=10.1007/978-3-642-28732-9_3}}</ref><ref name="pmid27614885">{{cite journal| author=Jha P, Bentley B, Behr S, Yee J, Zagoria R| title=Imaging of flank pain: readdressing state-of-the-art. | journal=Emerg Radiol | year= 2017 | volume= 24 | issue= 1 | pages= 81-86 | pmid=27614885 | doi=10.1007/s10140-016-1443-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27614885 }} </ref> | ||
*[[strain|Abdominal muscle strain]] | *[[strain|Abdominal muscle strain]] | ||
| Line 57: | Line 59: | ||
==Diagnosis== | ==Diagnosis== | ||
Shown below is an algorithm summarizing the diagnosis of flank pain. | Shown below is an algorithm summarizing the diagnosis of flank pain.<ref name="pmid18853840">{{cite journal| author=Taourel P, Thuret R, Hoquet MD, Doyon FC, Merigeaud S, Delabrousse E| title=Computed tomography in the nontraumatic renal causes of acute flank pain. | journal=Semin Ultrasound CT MR | year= 2008 | volume= 29 | issue= 5 | pages= 341-52 | pmid=18853840 | doi=10.1053/j.sult.2008.06.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18853840 }} </ref> | ||
{{familytree/start | {{familytree/start}} | ||
{{familytree | | | | | | | | |Patient History | {{familytree | | | | | | | | | |A01|A01=Patient History}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|.| | }} | {{familytree | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|.| | }} | ||
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==Treatment== | ==Treatment== | ||
Shown below is an algorithm summarizing the treatment of [[flank pain]]. | Shown below is an algorithm summarizing the treatment of [[flank pain]].<ref name="pmid23430331">{{cite journal |vauthors=Manjunath A, Skinner R, Probert J |title=Assessment and management of renal colic |journal=BMJ |volume=346 |issue= |pages=f985 |date=February 2013 |pmid=23430331 |doi=10.1136/bmj.f985 |url=}}</ref><ref name="pmid26349951">{{cite journal |vauthors=Singh P, Enders FT, Vaughan LE, Bergstralh EJ, Knoedler JJ, Krambeck AE, Lieske JC, Rule AD |title=Stone Composition Among First-Time Symptomatic Kidney Stone Formers in the Community |journal=Mayo Clin. Proc. |volume=90 |issue=10 |pages=1356–65 |date=October 2015 |pmid=26349951 |pmc=4593754 |doi=10.1016/j.mayocp.2015.07.016 |url=}}</ref><ref name="pmid14960744">{{cite journal |vauthors=Teichman JM |title=Clinical practice. Acute renal colic from ureteral calculus |journal=N. Engl. J. Med. |volume=350 |issue=7 |pages=684–93 |date=February 2004 |pmid=14960744 |doi=10.1056/NEJMcp030813 |url=}}</ref> | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | A01 | | | | | |A01=Acute Flank Pain}} | {{familytree | | | | | | | | | A01 | | | | | |A01=Acute Flank Pain}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | B01 | | | | | |B01=History<br>Physical exam<br>Laboratory evaluation<br>non contrast [[CT]]}} | {{familytree | | | | | | | | | B01 | | | | | |B01=History<br>Physical exam<br>[[Laboratory evaluation]]<br>non contrast [[CT]]}} | ||
{{familytree | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }} | {{familytree | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }} | ||
{{familytree | G01 | | | | | | | | | | | | | |G02|G01=Stone is not identified|G02=Stone identified}} | {{familytree | G01 | | | | | | | | | | | | | |G02|G01=Stone is not identified|G02=Stone identified}} | ||
{{familytree | |!| | | | | | | | | | | | |,|-|-|^|-|-|.| }} | {{familytree | |!| | | | | | | | | | | | |,|-|-|^|-|-|.| }} | ||
{{familytree | C01 | | | | | | | | | | | |C02| | | |C03| | C01=Consider alternate diagnois<br>1.Non-urologic<br>2.Alternate GU diagnosis|C02=[[ | {{familytree | C01 | | | | | | | | | | | |C02| | | |C03| | C01=Consider alternate diagnois<br>1.Non-urologic<br>2.Alternate GU diagnosis|C02=[[Obstruction]] present|C03=[[Obstruction]] absent}} | ||
{{familytree | | | | | | | | | | | | | | | |!| | | | | |!| | | | }} | {{familytree | | | | | | | | | | | | | | | |!| | | | | |!| | | | }} | ||
{{familytree | | | | | | | | | | | | | | | D01 | | | | D02 | |D01=Any of the following signs present?<br>[[Fever]]<br>Solitary [[Kidney]]<br>[[UTI]]<br>[[WBC]]>15K<br>Rising Serum [[Creatinine]]<br>Bilateral obstruction<br>Signs of [[sepsis]]|D02=Solitary kidney or uncontrolled symptoms}} | {{familytree | | | | | | | | | | | | | | | D01 | | | | D02 | |D01=Any of the following signs present?<br>[[Fever]]<br>Solitary [[Kidney]]<br>[[UTI]]<br>[[WBC]]>15K<br>Rising Serum [[Creatinine]]<br>Bilateral obstruction<br>Signs of [[sepsis]]|D02=Solitary [[kidney]] or uncontrolled symptoms}} | ||
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| |,|-|^|-|.| }} | {{familytree | | | | | | | | | | | | | |,|-|^|-|.| |,|-|^|-|.| }} | ||
{{familytree | | | | | | | | | | | |E01| |E02| |E03| |E04|E01=Yes|E02=No|E03=No|E04=Yes}} | {{familytree | | | | | | | | | | | |E01| |E02| |E03| |E04|E01=Yes|E02=No|E03=No|E04=Yes}} | ||
| Line 100: | Line 102: | ||
==Do's== | ==Do's== | ||
*The symptomatic [[patients]] of the [[abdominal aortic aneurysm]] with hemodynamic stability should be evaluated with [[abdominal CT]] as an initial diagnostic test. Abdominal CT provides additional details such as a[[ ruptured aneurysm]], [[infected aneurysm]], and anatomical details that are important for subsequent [[management]]. | *The symptomatic [[patients]] of the [[abdominal aortic aneurysm]] with hemodynamic stability should be evaluated with [[abdominal CT]] as an initial diagnostic test. Abdominal CT provides additional details such as a[[ ruptured aneurysm]], [[infected aneurysm]], and anatomical details that are important for subsequent [[management]].<ref name="pmid14960744">{{cite journal |vauthors=Teichman JM |title=Clinical practice. Acute renal colic from ureteral calculus |journal=N. Engl. J. Med. |volume=350 |issue=7 |pages=684–93 |date=February 2004 |pmid=14960744 |doi=10.1056/NEJMcp030813 |url=}}</ref> | ||
*Urgent urologic consultation is warranted in patients with [[urosepsis]], [[acute kidney injury]], [[anuria]], and/or unyielding [[pain]], [[nausea]], or [[vomiting]]. | *Urgent urologic consultation is warranted in patients with [[urosepsis]], [[acute kidney injury]], [[anuria]], and/or unyielding [[pain]], [[nausea]], or [[vomiting]]. | ||
*Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant [[obstruction]], or who have not passed the stone after four to six weeks should be referred to urology for potential intervention. | *Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant [[obstruction]], or who have not passed the stone after four to six weeks, should be referred to urology for potential intervention. | ||
*Patients should be advised to strain their urine for several days and bring in stone that passes for analysis. This will help the physician to take effective measures for [[preventive therapy]]. | *Patients should be advised to strain their urine for several days and bring in stone that passes for analysis. This will help the physician to take effective measures for [[preventive therapy]]. | ||
*The patients of [[APDKD]] with new-onset flank pain should be suspected for [[cyst hemorrhage]] or [[infection]] or [[nephrolithiasis]]. | *The patients of [[APDKD]] with new-onset flank pain should be suspected for [[cyst hemorrhage]] or [[infection]] or [[nephrolithiasis]]. | ||
| Line 108: | Line 110: | ||
==Don'ts== | ==Don'ts== | ||
* | *Do not fail to evaluate elder patients in the presence of overt clinical [[signs]].<ref name="pmid14960744">{{cite journal |vauthors=Teichman JM |title=Clinical practice. Acute renal colic from ureteral calculus |journal=N. Engl. J. Med. |volume=350 |issue=7 |pages=684–93 |date=February 2004 |pmid=14960744 |doi=10.1056/NEJMcp030813 |url=}}</ref> | ||
*Do not delay treatment with [[antibiotics]] for [[pyelonephritis]] while waiting for [[blood cultures]]. | *Do not delay treatment with [[antibiotics]] for [[pyelonephritis]] while waiting for [[blood cultures]]. | ||
*Do not delay the [[intervention]] for life-threatening conditions of [[flank pain]]. | *Do not delay the [[intervention]] for life-threatening conditions of [[flank pain]]. | ||
* | *Do not delay resuscitation or surgical consultation for the ill [[patient]] while waiting for [[imaging]]. | ||
==References== | ==References== | ||
| Line 117: | Line 119: | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category: | [[Category:Up-To-Date]] | ||
[[Category:Nephrology]] | [[Category:Nephrology]] | ||
[[Category: | [[Category:Primary care]] | ||
[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
Latest revision as of 18:39, 13 January 2021
| Flank pain Resident Survival Guide |
|---|
| Overview |
| Causes |
| Diagnosis |
| Treatment |
| Do's |
| Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Qasim Khurshid, M.B.B.S.
Synonyms and keywords: Flank pain work-up, Approach to flank pain, Flank pain management
Overview
Flank pain refers to the discomfort in the upper abdomen or back and sides. It develops in the area above the pelvis and below the ribs. This is a common symptom and usually, pain is worse on one side of the body. Most frequently, the cause is benign and/or self-limiting, but more serious causes may require urgent intervention. Treatment of the flank pain depends on the cause, urgent surgical intervention may be required if the pain is caused by ruptured aortic aneurysm and some conditions can be treated with NSAIDS.
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.[1][2] Listed below are the life threatening causes:
- Ruptured Abdominal Aortic Aneurysm
- Renal abscess
- Perforated gastric ulcer
- Renal artery dissection
- Traumatic splenic rupture
- Acute pancreatitis
- Adrenal hemorrhage
- Pulmonary embolism
- Cholecystitis
Common Causes
Common causes of flank pian include:[3][1][2]
- Abdominal muscle strain
- Acute kidney injury
- Cholecystitis
- Ureteric calculi
- Pyelonephritis
- Renal abscess
- Renal tumor
- Nephrolithiasis
- Post streptococcal glomerulonephritis
- Renal papillary necrosis
- Shingles
- Ureteric blood clot
- Pneumonia
- Acute renal infarction
- APDKD
Diagnosis
Shown below is an algorithm summarizing the diagnosis of flank pain.[4]
| Patient History | |||||||||||||||||||||||||||||||||||||||||
| Pulmonary Symptoms | Urinary Symptoms | colic | |||||||||||||||||||||||||||||||||||||||
| Considor PE or pneumonia | Consider UTI or nephrolithiasis | Consider hepatobiliary cause or nephrolithiasis | |||||||||||||||||||||||||||||||||||||||
| Physical Examination | Physical examination | Physical Examination | |||||||||||||||||||||||||||||||||||||||
| Tachypnea,hypoxia or pulmonary findings | Costovertebral or suprapubic tenderness | Perform ultrasonography of abdomen,if non diagnostic consider nephrolithiasis | |||||||||||||||||||||||||||||||||||||||
| Chest radiography,if non diagnostic, helical CT or D dimer to evaluate for pulmonary embolism | Perform Urinalysis | ||||||||||||||||||||||||||||||||||||||||
| Pyuria | Hematuria | ||||||||||||||||||||||||||||||||||||||||
| Consider uninary tract infection or pyelonephritis | Consider nephrolithiasis | ||||||||||||||||||||||||||||||||||||||||
| Spiral CT scan of abdomen | |||||||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of flank pain.[5][6][7]
| Acute Flank Pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History Physical exam Laboratory evaluation non contrast CT | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Stone is not identified | Stone identified | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Consider alternate diagnois 1.Non-urologic 2.Alternate GU diagnosis | Obstruction present | Obstruction absent | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Any of the following signs present? Fever Solitary Kidney UTI WBC>15K Rising Serum Creatinine Bilateral obstruction Signs of sepsis | Solitary kidney or uncontrolled symptoms | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Inpatient management Prompt surgical drainage(stent vs nephrostomy tube) Consider antibiotics and urine culture | Out patient management Oral anagescis Alpha blockers<Repeat imaging as vindicated | Inpatient management Analgescis (IV or oral) Alpha blockers Consider surgical drainage for solitary kidney | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- The symptomatic patients of the abdominal aortic aneurysm with hemodynamic stability should be evaluated with abdominal CT as an initial diagnostic test. Abdominal CT provides additional details such as aruptured aneurysm, infected aneurysm, and anatomical details that are important for subsequent management.[7]
- Urgent urologic consultation is warranted in patients with urosepsis, acute kidney injury, anuria, and/or unyielding pain, nausea, or vomiting.
- Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant obstruction, or who have not passed the stone after four to six weeks, should be referred to urology for potential intervention.
- Patients should be advised to strain their urine for several days and bring in stone that passes for analysis. This will help the physician to take effective measures for preventive therapy.
- The patients of APDKD with new-onset flank pain should be suspected for cyst hemorrhage or infection or nephrolithiasis.
Don'ts
- Do not fail to evaluate elder patients in the presence of overt clinical signs.[7]
- Do not delay treatment with antibiotics for pyelonephritis while waiting for blood cultures.
- Do not delay the intervention for life-threatening conditions of flank pain.
- Do not delay resuscitation or surgical consultation for the ill patient while waiting for imaging.
References
- ↑ 1.0 1.1 Rippel, Christopher; Raman, Jay D. (2013). "Acute Flank Pain": 19–27. doi:10.1007/978-3-642-28732-9_3.
- ↑ 2.0 2.1 Jha P, Bentley B, Behr S, Yee J, Zagoria R (2017). "Imaging of flank pain: readdressing state-of-the-art". Emerg Radiol. 24 (1): 81–86. doi:10.1007/s10140-016-1443-9. PMID 27614885.
- ↑ Evan AP, Worcester EM, Coe FL, Williams J, Lingeman JE (January 2015). "Mechanisms of human kidney stone formation". Urolithiasis. 43 Suppl 1: 19–32. doi:10.1007/s00240-014-0701-0. PMC 4285570. PMID 25108546.
- ↑ Taourel P, Thuret R, Hoquet MD, Doyon FC, Merigeaud S, Delabrousse E (2008). "Computed tomography in the nontraumatic renal causes of acute flank pain". Semin Ultrasound CT MR. 29 (5): 341–52. doi:10.1053/j.sult.2008.06.010. PMID 18853840.
- ↑ Manjunath A, Skinner R, Probert J (February 2013). "Assessment and management of renal colic". BMJ. 346: f985. doi:10.1136/bmj.f985. PMID 23430331.
- ↑ Singh P, Enders FT, Vaughan LE, Bergstralh EJ, Knoedler JJ, Krambeck AE, Lieske JC, Rule AD (October 2015). "Stone Composition Among First-Time Symptomatic Kidney Stone Formers in the Community". Mayo Clin. Proc. 90 (10): 1356–65. doi:10.1016/j.mayocp.2015.07.016. PMC 4593754. PMID 26349951.
- ↑ 7.0 7.1 7.2 Teichman JM (February 2004). "Clinical practice. Acute renal colic from ureteral calculus". N. Engl. J. Med. 350 (7): 684–93. doi:10.1056/NEJMcp030813. PMID 14960744.