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..
| {{{ 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 embolish | 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 | ||||||||||||||||||||||||||||||||||||||||||||||||
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.