Flank Pain Flashcards
1
Q
What are differentials for acute flank pain?
A
- Muscular spasm
- Nephrolithiasis/ureteric colic
- Spinal pathology (fractures, metastases, disc prolapse)
- Leaking/ruptured AA
- Testicular torsion (very unusual in elderly patients)
- Pyelonephritis (unusual in men)
- Perforated peptic ulcer
- Renal cancer
- Abscess (perinephric, renal)
2
Q
What are gynae differentials for acute flank pain?
A
ectopic preg, ovarian torsion
3
Q
What would unilateral flank pain radiating from loin to groin suggest?
A
kidney stones
4
Q
What would trauma causing the onset of flank pain suggesting?
A
- musculoskeletal pain
2. internal bleeding
5
Q
What would colicky (waxing and waning) flank pain suggest?
A
ureteric stones
6
Q
What would constant flank pain suggest?
A
stones lodged in kidney or inflammatory cause
7
Q
What would cause achey flank pain?
A
musculoskeletal pain
8
Q
What would cause shooting flank pain?
A
nerve impingement
9
Q
What would flank pain radiating to groin suggest?
A
ureteric pain
10
Q
What would flank plain radiating down the leg suggest?
A
lumbar nerve root pain
11
Q
What could be alleviating factors for flank pain?
A
posture/eating/drinking/medications etc
12
Q
What would many weeks of flank pain suggest?
A
muscuskeletal cause
13
Q
How would a leaking AAA go on with time?
A
not persist more 1 day without resolution
14
Q
What are exacerbating factors for peritonitis e.g from perforated peptic ulcer?
A
movement
15
Q
What would flank pain which is excruciating suggest?
A
kidney stones
16
Q
What other questions must you ask about the history of presenting complaint?
A
- fevor, rigors, night sweats
- dehydration
- nausea and vomiting
- haematuria
- lower urinary tract symptoms
- cloudy or offensive smelling urine
- leg weakness
17
Q
What would a raised fever with flank pains suggest?
A
- Inflammatory process e.g. pyelonephritis,
- Sepsis from e.g. psoas abscess
- Rare - malignancy e.g RCC
18
Q
Why is dehydration important to ask about with flank pain?
A
persistent dehydration, predisposes to concentrated urine and therefore to kidney stones
19
Q
What would nausea and vomiting with flank pain suggest?
A
visceral organ pathology e.g. ureteric stones, biliary colic, appendicitis
20
Q
What would haematuria with flank pain suggest?
A
70-90% of patient with kidney/uteric stones have microscopic haematuria
21
Q
What are lower urinary tract symptoms are common in UTI?
A
- urinary frequency
- urgency
- dysuria
22
Q
What lower urinary tract symptoms are more common in uteric obstruction e.g. (enlarged prostate, stones, tumours)?
A
- hesitancy
- reduced flow
- dribbling
- incomplete voiding
23
Q
What would cloudy or offensive-smelling urine suggest?
A
infection
24
Q
What could flank pain with leg weakness suggest?
A
spinal pathology
25
What PMHx is important to ask about with flank pain?
1. Previous kidney stones
2. Recurrent cystitis
3. Atherosclerotic disease
4. Longstanding back pain
5. Kidney disease
26
Why do you ask about previous kidney stones with flank pain?
nephrolithiasis associated with a 50% 10yr recurrence
27
Why do you ask about recurrent cystitis in flank pain?
recurrent episodes of UTI predisposes to stones of struvite type
28
Why do you ask about atheroscloertic disease in flank pain?
strong risk factor of AAA
29
Why do you ask about longstanding back pain with flank pain?
usually due to pathology affecting muscles, ligaments, and bones
30
Why do you ask about kidney disease in flank pain?
PCKD predisposes to pyelonephritis - need to know if only one kidney as obstruction of the only functional ureter is a medical emergency
31
Which medications do you ask about with flank pain?
1. Aciclovir and Indinavir
| 2. Acetazolamide
32
What does aciclovir and indinavir do?
crystallize in urine
33
What can acetazolamide cause?
diuresis and potentially dehydration predisposing to kidney stone formation
34
What FHx do you check with flank pain and why?
- Kidney stones
| - may indicate rare inherited conditions such as cystinuria
35
What signs do you look for on examination in flank pain?
1. Position
2. Tenderness
3. Masses
4. Spine
5. Lower Limb
6. Temperature
36
What would a restless patient unable to sit still suggest with flank pain?
ureteric colic
37
What would a motionless and rigid patient with flank pain suggest?
peritonitis e.g. from ruptured AAA are rigid and motionless
38
What would flank or loin tenderness (esp in costovertebral angles) suggest?
renal or ureteric stones
39
What would abdominal tenderness suggest?
suggests peritoneal cavity problem (e.g. appendicitis, pancreatitis)
40
What would a centrally laterally expansive mass suggest?
leaking AAA - physical examination does not exclude this esp if >55yo
41
How do you exclude spinal pathology in flank pain?
by testing range of movement (e.g. straight leg raise) + feel for tenderness along vertebrae
42
When do you conduct a neurological lower limb exam?
if spinal pathology is suspected from history and examination so far
43
When do you conduct a vascular exam of lower limbs?
- suspect AAA
| - AAA can comprimise blood supply to the lower limb
44
What does it mean if you can easily feel the popliteal pulse?
uspect popliteal aneurysms (50% of patients with a pa also have a AAA)
45
Why do you check temperature with flank pain?
whether an inflammatory process e.g. polynephritis is ongoing
46
What urine tests do you do for flank pain?
1. urinalysis
| 2. urine microscopy, culture and sensitivity (MCandS)
47
What presences are you looking for in urinalysis?
- haematuria
- white blood cells (pyuria)
- leucoyte esterase
- nitrates
48
Why is it important to check urine pH?
1. urate stones - acidic urine
| 2. alkali pH - presence of urease-producing bacteria that can predispose to stone formation
49
When do you do urine MCandS?
if urinanalysis is abnormal and shows blood, leukocytes or nitrates
50
What do you look for in urine MCandS?
1. red cells
2. evidence of infection (WC, bacteria)
3. crystals
51
Why is knowing the type of crystal important?
helps to know cause + secondary prevention of future stones
52
What does the presence of red cell casts or white cell casts suggest?
red or white cells coming from kidney rather than ureters or bladder
53
What condition would red cell casts suggest?
glomerular damage
54
What damage would white cell casts indicate?
pyelonephritis
55
What bloods do you order for flank pain?
1. FBC and CRO
2. Urea, creatinine, electrolytes
3. Serum calcium, phosphate and urate
56
What would a rasied WCC and CRP show?
infection or sepsis
57
Why do you measure urea, creatinine, electrolytes?
asses renal function, as obstruction by renal stone can lead to renal damage - renal failure a medical emergency
58
Why do you measure serum calcium, phosphate and urate?
provide clues to cause of kidney stone
59
What imaging is used in flank pain?
1. Bedside US
| 2. Non-contrast CT-KUB (gold)
60
Why is bedside US useful?
look for AAA >3cm
61
Why is bedside US not that good?
1. Not say if aneurysm is bleeding as will bleed into retroperitoneal space hard to visualise on US
2. Hard if large body habitus or unfasted and have lots of air and peristalsis in transverse colon
3. So if flank/back/abdominal pain and AAA on US need contrast CT abdo if haemodynamically stable
62
Why is a non-contrast CT-KUB great?
1. shows any stones in kidney or ureter
2. shows any rare causes of ureter obstruction causing renal colic e.g. a retroperitoneal tumour
3. IMPORTANT AS DECTECTS AAA
63
When is KUB radiographs used?
following progression of confirmed stones with less exposure to ionizing radiation
64
What imaging is used if pregnant?
MRU
65
What other tests may be considered?
1. If pancreatitis suspected order serum lipase or amylase
| 2. If perforated peptic ulcer concern request CXR to look for air under diaphragm
66
When is a patient with a kidney stone with no hydronephrosis admitted?
1. evidence of upper UTI
2. evidence of renal impairment/failure
3. refractory pain (despite analgesia)
4. bilateral obstructing stone (or one if one kidney)
5. patient elderly, a child or otherwise unwell (e.g. unable to tolerate oral fluids) for closer monitoring
67
What would the evidence of an upper UTI be?
1. cloudy urine ±
2. white cell casts
3. high WCC in blood
4. high CRP
5. fever
- infection proximal to an obstruction is surgical emergency and need drainage
68
What would evidence of renal impairment/failure be?
1. high creatinine
2. high urea
3. high K+
69
What is the acute management of kidney stone?
1. Regular multimodal analgesia (paracetamol + NSAIDs)
2. Encourage fluid intake: oral if possible or IV fluids if admitted
3. Tamsulosin (alpha blocker) or nifedipine (CCB)
4. Active stone removal
70
Why do you use NSAIDs and paracetamol over opiates?
1. additional effect of decreasing ureteric smooth muscle tone
2. lack some of the adverse effects of opiate (respiratory and CNS depression vomiting and disorientation)
71
Why do you prescribe Tamsulosin (alpha blocker) or nifedipine (CCB) for kidney stones?
1. both relax smooth muscle in ureters
2, increase chances of spontaneous passage of a renal tract stone with T being superior to N
3. mainly beneficial in distal ureteric stones <10mm
72
If a kidney stone is <5mm what is the chance it passes spontaneously?
50%
73
What is the treatment for a kidney stone <5mm?
1. if no reason for admission patients discharged and asked to strain their urine to recover stone for analysis
2. follow up in 2-3 weeks
3. plain KUB radiograph before discharge to compare to one at follow up - to see if stone moved (better than repeat CT-KUB as less dose of radiation)
74
How is stones >5mm treated?
- less likely to pass spontaneously esp if >7mm
| - should be discussed with urologist for consideration of removal
75
What are the options for treatment for renal Tract stones >5mm or smaller ones that haven't passed spontaneously after 4-6 weeks?
1. Lithotripsy
2. Ureterorenoscopic removal
3. PCNL
4. Stenting
5. Antibiotic cover
76
What is Lithotripsy?
1. ESWL if small enough (renal stones <2cm and ureteric stones <1cm)
2. . Uses shock waves to break down stone into smaller fragments that more likely to pass spontaneously
77
What is ureterorenoscopic removal (using a fine telescope inserted via the urethra)?
- with a dormia basket, holmium laster, mechanical lithotripsy etc
- if too large for ESWL
- usually requires post-operative ureteric stent as it can cause ureteric stricture
78
What is PCNL?
percutaneous nephrolithotomy (PCNL) - rarely used nowadays as invasive
79
What is stenting?
1. (using a JJ stent) or percutaneous nephrostomy
| 2. performed to prevent hydronephrosis - if obstruction cannot be resolved surgically
80
When is antibiotic cover used?
if invasive procedure
81
What is the LT management of stones post removal?
1. Increase fluid intake
2. Further testing for cause to avoid recurrence if:
- Strong FHx
- Multiple stones at first diagnosis
- Recurrent stone formation / passage
