Flank pain resident survival guide

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.

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.

• 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:

• 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.

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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.

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

Obstraction 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.
• 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

• Fail to evaluate elder patients in the presence of overt clinical signs.
• 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.
• Don’t delay resuscitation or surgical consultation for the ill patient while waiting for imaging.

References