Flank Pain Flashcards
Differentials of acute flank pain?
Muscular sprain Nepholithiasis/ureteric colic Leaking/rupturing AAA Spinal pathology (fracture, metastases, disc prolapse) Testicular torsion Pyelonephritis Perforated peptic ulcer Renal cancer Abscess Basal pneumonia
Think gynea aswell
What questions will ask in a patient with presenting complaint of flank pain?
SOCRATES Fever, rigors, night sweats Nausea/vomiting - Visceral Haematuria Lower urinary tract symptoms - UTI/Ureteric obstruction Cloudy or offensive smelling urine Leg weakness - Spinal
What are the surgical emergency in a patient with flank pain ?
Leaking/ruptured AAA
Testicular torsion
Pyelonephritis
Perforated peptic ulcer
What are the important things in someone PMH/DH when they present with flank pain?
Previous kidney stones
Recurrent cystitis - Predisposes to stones of the struvite type
Atherosclerotic disease - AAA
Long standing back pain - MSK
Kidney disease - Polycystic kidneys predisposes to pyelonephritis
DH - Indinavir, aciclovir and acetazolamide
What position do those with ureteric colic tend to adopt?
Unable to sit still and thus tend to writhe in pain
What tests should be performed in someone with suspected ureteric colic?
Urinalysis
Urine microscopy, culture and sensitivity
Bloods - FBC, U&Es, CRP, Serum Ca, phosphate and urate
Imaging - CT-KUB
When should a patient with a kidney stone be admitted?
There is evidence of an upper urinary tract infection (proximal to the obstruction)
Evidence of renal failure
Refractory pain (despite analgesia)
Bilateral obstructing stones (or one if only one kidney)
Elderly, child or otherwise unwell (for closer monitoring)
What is the initial management for kidney stones
Analgesia and encourage fluid intake
Maybe add a medication to relax the smooth muscle of the ureter. Either an alpha-blocker (tamsulosin) or a CCB (nifedipine)
Follow up 2-3weeks
What is the initial management for kidney stones >0.5cm?
Lithotripsy - Extracorporeal shock wave lithotripsy
Ureterorenoscopic removal - Commonly require a post-operative ureteric stent
Percutaneous nephrolithotomy
Stenting
Antibiotic cover
What is the longer term management of individuals with kidney stones?
Increase fluid intake
Which organism most commonly causes pyelonephritis?
E. coli
What is the management for MSK back pain?
Maintaining activity and exercise
Regular analgesia
Build up core muscles
General back care
(Surgery no better than conservative management)
What are the different types of kidney stones? How might you treat them?
Calcium (75-85%) - Oxalate, phosphate or mixed
- Hypercalcinuria (exclude hyperparathyroidism)
- Hyperuricosuria can be be given allopurinol
- Hypocitraturia can be give potassium citrate
Struvite (10-20%)(ammonium magnesium phosphate)
- Most common in women and are secondary to infection with urease-producing bacteria
Urate (5-10%) - Urate crystals from the presence acid urine
Cystine (1%) - Secondary to cystinuria (a rare autosomal recessive disorder)
What are the radiological findings would you look for in a patient with suspected kidney stones?
The stones themselves
Hydronephrosis and/or hydroureter due to obstruction
Perinephritic fluid
Soft-tissue rim - Stone may be surrounded rim of soft tissue
Tail sign - Soft tissue opacity extends away from stone like a tail (Consistent with pelvic phlebolith not ureteric stone)
What are the complications of kidney stones?
Ureteric stricture
Acute or chronic pyelonephritis
Renal failure
Intrarenal perinephric abscess
Xanthogranulomatous pyelonephritis (chronic bacterial pyelonephritis characterised by the destruction of renal parenchyma and the presence of granulomas and abscesses)
Urine extravassation into the pelvic cavity
