Flank Pain Flashcards
List the differential diagnosis for flank pain.
Muscular sprain Ureteric colic Spinal pathologies (fractures, metastases, disc prolapse) Leaking/ruptured AAA Testicular torsion Pyelonephritis
List some gynaecological diseases that could cause flank pain.
Ectopic pregnancy
Ovarian torsion
List some other abdominal pathology that could present atypically with flank pain.
Pancreatitis
Diverticulitis
Appendicitis
Describe the type of pain caused by ureteric colic.
Unilateral (almost always)
Waxing and waning (colicky)
Extremely severe
Loin to groin
Describe the type of pain caused by nerve impingement.
Shooting pain that radiates down the legs
What does pain that radiates down the leg suggest?
Lumbar nerve root compression
Which surgical emergency can present with acute flank pain?
Leaking AAA
What type of pathology tends to be associated with nausea and vomiting?
Visceral pathology (e.g. ureteric colic, biliary colic, appendicitis)
Why is it important to check for signs of persistent dehydration on examination?
Persistent dehydration predisposes to concentrated urine and the formation of kidney stones
Why is it important to perform a urine dipstick test in patients with ureteric colic?
70-90% of patients with ureteric colic have microscopic haematuria
List some symptoms of UTI.
Urgency
Frequency
Dysuria
List some common ureteric obstruction symptoms
E.g. enlarged prostate, or (more unusually) stones or tumours
Hesitancy
Reduced flow
Dribbling
Incomplete emptying
What does cloudy, offensive-smelling urine suggest?
Infection
State another symptom that may indicate that spinal pathology is the cause of the flank pain.
Leg weakness
List some key features of the past medical history.
Previous kidney stones Recurrent cystitis Atherosclerotic disease Longstanding back pain Kidney disease (e.g. polycystic kidney disease predisposes to pyelonephritis)
List some drugs that predispose to the formation of kidney stones.
Aciclovir
Indinavir
Acetazolamide
Name an inherited condition that increases the risk of forming kidney stones.
Cystinuria
Describe the appearance of a patient with:
Ureteric Colic
Peritonitis
- Ureteric Colic
Writhing in pain and unable to stay still - Peritonitis
Rigid and motionless
What can you do during the examination to figure out whether spinal pathology is the cause of the flank pain?
Test range of movement and feel for tenderness over the vertebrae
What examination should be performed if spinal pathology is suspected?
Lower limb neurological examination
What examination should be performed if AAA is suspected?
Peripheral vascular examination
Why is the finding of a popliteal artery aneurysm significant?
50% of patients with popliteal artery aneurysms also have AAA
Why is it important to perform urinalysis in patients with flank pain?
Microscopic haematuria is a common feature of kidney stones
What clues may the pH of the urine suggest?
Acidic – urate stones can cause urine to be acidic
Alkaline – suggests the presence of urease-producing bacteria (e.g. Proteus, Pseudomonas)
What are red cell casts and what do they suggest?
Sausage-shaped clumps of red cells found on urine MC&S
They suggest that the red cells are coming from the kidneys rather then the ureters/bladder)
The presence of red cell casts suggests that there has been glomerular damage
What do white cell casts suggest?
Pyelonephritis
Why should patients be told to try and retain the stones if they pass them?
They can be send for analysis, which could reveal clues about the aetiology of the kidney stones
List some blood tests that would be performed in a patient with suspected ureteric colic.
FBC CRP (infection or sepsis) U&Es and Creatinine (kidney function) Serum calcium, phosphate and urate (for aetiology of kidney stones)
Why is it important to check the serum calcium, phosphate and urate levels in a patient with ureteric colic?
It can give information about the aetiology of kidney stones
List two types of imaging that are useful for investigating patients with flank pain.
Bedside ultrasound
Non-contrast CT-KUB
What is a disadvantage of using bedside ultrasound to investigate flank pain?
It shows AAA but it does not show whether the AAA is leaking or not
List some reasons for admitting patients with kidney/ureteric stones.
Evidence of upper urinary tract infection Evidence of renal impairment/failure Refractory pain Bilateral obstructing stones Elderly/child
Which drugs can be used to ease the passage of kidney stones?
Tamsulosin (a-blocker)
Nifedipine (CCB)
Management of kidney stones is largely dependent on its size. What size kidney stones have a good chance of passing spontaneously?
< 5 mm
List some surgical methods of removing stones.
Ureteroscopic lithotripsy (URS)
Percutaneous nephrolithotomy (PCNL)
Extracorporeal shockwave lithotripsy (ESWL)
JJ Stenting
Describe the typical presentation of acute pyelonephritis.
Dull flank pain, high fever and urinalysis suggestive of UTI
Pyelonephritis can occur secondary to what other urinary tract pathology?
Secondary to obstruction caused by a kidney stone
What organism most commonly causes pyelonephritis?
Escherichia coli
List the sepsis 6 guidelines.
High-flow oxygen Take blood cultures Broad-spectrum antibiotics IV fluid challenge Measure serum lactate and haemoglobin Monitor urine output
What symptoms and signs would suggest that an intrarenal or perinephric abscess has developed?
Persistently high fever, bacteraemia, very high WCC, severe tenderness on examination or failure to improve with therapy
Describe the typical presentation of an AAA.
Elderly with a past medical history of hypertension
Presents with sudden-onset, sharp flank pain
Describe the management of an AAA.
Urgent CT abdomen to confirm the bleed Large bore IV access X-match 10 units of blood Insert a urinary catheter Notify vascular surgeon
