Flank Pain

Question 1

List the differential diagnosis for flank pain.

Answer 1

Muscular sprain
Ureteric colic 
Spinal pathologies (fractures, metastases, disc prolapse)
Leaking/ruptured AAA 
Testicular torsion 
Pyelonephritis

Question 2

List some gynaecological diseases that could cause flank pain.

Answer 2

Ectopic pregnancy

Ovarian torsion

Question 3

List some other abdominal pathology that could present atypically with flank pain.

Answer 3

Pancreatitis
Diverticulitis
Appendicitis

Question 4

Describe the type of pain caused by ureteric colic.

Answer 4

Unilateral (almost always)
Waxing and waning (colicky)
Extremely severe
Loin to groin

Question 5

Describe the type of pain caused by nerve impingement.

Answer 5

Shooting pain that radiates down the legs

Question 6

What does pain that radiates down the leg suggest?

Answer 6

Lumbar nerve root compression

Question 7

Which surgical emergency can present with acute flank pain?

Answer 7

Leaking AAA

Question 8

What type of pathology tends to be associated with nausea and vomiting?

Answer 8

Visceral pathology (e.g. ureteric colic, biliary colic, appendicitis)

Question 9

Why is it important to check for signs of persistent dehydration on examination?

Answer 9

Persistent dehydration predisposes to concentrated urine and the formation of kidney stones

Question 10

Why is it important to perform a urine dipstick test in patients with ureteric colic?

Answer 10

70-90% of patients with ureteric colic have microscopic haematuria

Question 11

List some symptoms of UTI.

Answer 11

Urgency
Frequency
Dysuria

Question 12

List some common obstructive symptoms.

Answer 12

Hesitancy
Reduced flow
Dribbling
Incomplete emptying

Question 13

What does cloudy, offensive-smelling urine suggest?

Answer 13

Infection

Question 14

State another symptom that may indicate that spinal pathology is the cause of the flank pain.

Answer 14

Leg weakness

Question 15

List some key features of the past medical history.

Answer 15

Previous kidney stones 
Recurrent cystitis 
Atherosclerotic disease 
Longstanding back pain 
Kidney disease (e.g. polycystic kidney disease predisposes to pyelonephritis)

Question 16

List some drugs that predispose to the formation of kidney stones.

Answer 16

Aciclovir
Indinavir
Acetazolamide

Question 17

Name an inherited condition that increases the risk of forming kidney stones.

Answer 17

Cystinuria

Question 18

Describe the appearance of a patient with:
Ureteric Colic
Peritonitis

Answer 18

• Ureteric Colic
  Writhing in pain and unable to stay still
• Peritonitis
  Rigid and motionless

Question 19

What can you do during the examination to figure out whether spinal pathology is the cause of the flank pain?

Answer 19

Test range of movement and feel for tenderness over the vertebrae

Question 20

What examination should be performed if spinal pathology is suspected?

Answer 20

Lower limb neurological examination

Question 21

What examination should be performed if AAA is suspected?

Answer 21

Peripheral vascular examination

Question 22

Why is the finding of a popliteal artery aneurysm significant?

Answer 22

50% of patients with popliteal artery aneurysms also have AAA

Question 23

Why is it important to perform urinalysis in patients with flank pain?

Answer 23

Microscopic haematuria is a common feature of kidney stones

Question 24

What clues may the pH of the urine suggest?

Answer 24

Acidic – urate stones can cause urine to be acidic

Alkaline – suggests the presence of urease-producing bacteria (e.g. Proteus, Pseudomonas)

Question 25

What are red cell casts and what do they suggest?

Answer 25

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

Question 26

What do white cell casts suggest?

Answer 26

Pyelonephritis

Question 27

Why should patients be told to try and retain the stones if they pass them?

Answer 27

They can be send for analysis, which could reveal clues about the aetiology of the kidney stones

Question 28

List some blood tests that would be performed in a patient with suspected ureteric colic.

Answer 28

``` FBC CRP U&Es Creatinine Serum calcium, phosphate and urate ```

Question 29

Why is it important to check the serum calcium, phosphate and urate levels in a patient with ureteric colic?

Answer 29

It can give information about the aetiology of kidney stones

Question 30

List two types of imaging that are useful for investigating patients with flank pain.

Answer 30

Bedside ultrasound | Non-contrast CT-KUB

Question 31

What is a disadvantage of using bedside ultrasound to investigate flank pain?

Answer 31

It shows AAA but it does not show whether the AAA is leaking or not

Question 32

List some reasons for admitting patients with kidney/ureteric stones.

Answer 32

``` Evidence of upper urinary tract infection Evidence of renal impairment/failure Refractory pain Bilateral obstructing stones Elderly/child ```

Question 33

Which drugs can be used to ease the passage of kidney stones?

Answer 33

Tamsulosin | Nifedipine

Question 34

Management of kidney stones is largely dependent on its size. What size kidney stones have a good chance of passing spontaneously?

Answer 34

< 5 mm

Question 35

List some surgical methods of removing stones.

Answer 35

Ureteroscopic lithotripsy (URS) Percutaneous nephrolithotomy (PCNL) Extracorporeal shockwave lithotripsy (ESWL) JJ Stenting

Question 36

Describe the typical presentation of acute pyelonephritis.

Answer 36

Dull flank pain, high fever and urinalysis suggestive of UTI

Question 37

Pyelonephritis can occur secondary to what other urinary tract pathology?

Answer 37

Secondary to obstruction caused by a kidney stone

Question 38

What organism most commonly causes pyelonephritis?

Answer 38

Escherichia coli

Question 39

List the sepsis 6 guidelines.

Answer 39

``` High-flow oxygen Take blood cultures Broad-spectrum antibiotics IV fluid challenge Measure serum lactate and haemoglobin Monitor urine output ```

Question 40

What symptoms and signs would suggest that an intrarenal or perinephric abscess has developed?

Answer 40

Persistently high fever, bacteraemia, very high WCC, severe tenderness on examination or failure to improve with therapy

Question 41

Describe the typical presentation of an AAA.

Answer 41

Elderly with a past medical history of hypertension | Presents with sudden-onset, sharp flank pain

Question 42

Describe the management of an AAA.

Answer 42

``` Urgent CT abdomen to confirm the bleed Large bore IV access X-match 10 units of blood Insert a urinary catheter Notify vascular surgeon ```